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Mukherjee: Worth Reading and Heeding

By Shlomo Maital

Siddhartha Mukherjee, MD

Who is Dr. Siddhartha Mukherjee? He is a 49-year-old Indian-American, physician, biologist, oncologist, author, TV commentator. His book on cancer won the Pulitzer Prize in 2011.   He is an Associate Professor of Medicine in the Division of Hematology and Oncology, Columbia University Medical Center.

   The Government of India conferred on him its fourth highest civilian award, the Padma Shri, in 2014.  

     His article in The New Yorker, March 26,  on the pandemic is brilliant and clear. Here is a brief summary of his main points. (800 words…).

* Ancient Chinese and Indians, and Arab doctors, knew long ago, that you could ‘vaccinate’: e.g. “taking matter from a smallpox patient’s pustule and applying it to the pricked skin of an uninfected person, then covering the spot with a linen rag.” Healers in China did this as early as 1100 AD.

* Three question deserve attention: 1) “do people exposed to higher ‘doses’ of virus have increased risk of infection? (e.g. healthcare workers). 2) Is there a relationship between the ‘dose’ of virus and the severity of the disease?” 3) “can exact quantitative measures of how the virus behaves in infected patients (peak viral load, patterns of its rise and fall…) predict the severity of the illness, and its infectiousness to others?   We need to start measuring the virus WITHIN people!”

   The fact that we do not have strong proven answers to these questions, show how little we really know about COVID-19 and how we are fighting in the pitch dark!

 For HIV, Mukerjee notes, how much was in a patient’s blood produced a distinct pattern; the virus count in the blood rises to a peak “Peak viremia”, patients with the highest peak viremia “typically became sick sooner, they were least able to resist the virus.” (Same goes for coronavirus? We don’t know). The set point too is crucial (the level to which a virus count settles and stabilizes, after its initial peak. People with a high set point move quicker to actuall AIDS (autoimmune disease). Same for COVID-19? Also, viral load (quantity of the virus in the body) helped predicts (AIDS’) nature, course and transmissibility. (Same for COVID-19?)….

   For kids – could an initial low-level exposure (as the ancient Chinese Indians and Arabs did) lead to a lower set point, (and hence less COVID-19 danger and risk?)….

     Mukherjee cites research showing “the more virus you shed, the more likely you are to infect others” from HIV research. I.e., the R0 number (numbers infected by one infected person) is variable, depending on how much virus the infected person ‘sheds’.

   “Does a large viral dose result in more severe disease?   “For reasons we don’t understand front-line healthcare workers are at greatr risk for serious illness despite their younger age.” Is it because they are exposed to ‘higher doses’? (Correlation between dose and severity varies widely from one strain of flu to the next).   Corona viruses “seem to follow the pattern seen in influenza”. A SARS study showed (in Hong Kong) that “a higher initial load of virus measured in the deep part of your throat above your palate was correlated with more severe respiratory illness”.   For measles, there is proven links between dose and severity.

   Finally, can we track viral load and hence predict the course of the disease? Here’s the catch. Tests are done with oral swabs. But viral dose varies immensely with how the oral swab is administered, and it varies tremendously among doctors and healthcare workers who administer the swab! A study in the Lancet medical journal does show that “viral loads…from patients with severe COVID-19 were 60 times higher on average than loads among patients with a mild form of the disease”!.

     Data. Bring me data. We need to know how much virus COVID-19 patients harbor, not just whether they harbor any.

   “If we had “dosimetry” (viral dose measures), we can quarantine those who are most infectious.”

     Let’s do a two-step procedure. 1. Identify infected patients. 2. Quantify viral loads in nasal or respiratory secretions.   Plan medical care accordingly.

       End Lockdown?   Mukherjee says, we need two criteria: people have no measured viral shedding, and they have signs of persistent immunity in their blood (antibody test).   Healthy immune workers are crucial – they can work with no danger to themselves or others, and they can care of other sick people!

       Why should we listen to an oncologist? “Measurement and enumeration are the mainstays of medicine for people in my field.   We do ‘risk stratification’. “   This should be the case for treating COVID-19 too.

     Mukherjee makes a simple medical point. “To win the (battle) against COVID19, it is essential to trace the coure of the virus as it moves through the populations. But it’s equally essential to measure its course within a single patient. The one becomes the many. Count both; both count.”