No one knew them until they started making us sick. Then some died. Like some unknown enemy out of a Hollywood movie, Coronavirus became an overnight sensation.
Coronaviruses are a large family of viruses that are common in many different species of animals, including camels, cattle, cats and bats. Rarely, animal coronaviruses can infect people and then spread between peoples such as with MERS, SARS and now with 2019-nCoV.
First isolated in 1937, coronaviruses are the second leading cause of colds (after rhinovirus). There are 4 major categories, and they are known by the greek letters – alpha, beta, delta and gamma. Only alpha and beta cause diseases in humans. The 2019-nCoV is a betacoronavirus. Seven (7) human coronaviruses have been identified so far. This includes SARS-CoV, MERS-CoV and the novel coronavirus.
Coronaviruses are zoonotic. Meaning they are transmissible between humans and animals, but most infect only their specific host. SARS killed about 10% of the people it infected. MERS killed around 35% of those that came down with this viral infection. The good news is that SARS has relatively disappeared from the limelight. MERS on the other hand remains an ongoing viral organism to contend with. Transmission of coronavirus is between people who were in close contact with patients. Hence, post a greater risk to the healthcare worker.
Clinically, this virus can manifest with just a sneeze, a cold, or at worse, become complicated enough to cause pneumonia. Whether patients die because of the virus or complications from the viral infection is another story altogether.
They’re called coronaviruses for a reason. Under electron microscopy, they look like halos. They are part of the RNA (ribonucleic acid) viruses family. Typically they are single stranded, 32 kb (kilobases) long, and is the largest known RNA virus genome. In reality, they’re actually dumb viruses. They cannot last on their own and will need to find hosts in order to replicate. Coronaviruses are promiscuous. They mutate and change at a very high rate. Meaning they are bad when it comes to reproduction. While the virus is dumb, evolution is smart. Mutations are random. Thoughtless. This process makes the organism more suitable to survive. And while most of the other viruses die, the few that survive make the virus more successful quickly take over.
Coronaviruses mutate less rapidly than other RNA viruses because they have a genome that’s 2-3x bigger than other RNA viruses. They are more complex. Accuracy in reproduction is more important for them. They are the only RNA virus family with a ‘proofreading’ capability.
Peter Coy, “The Global Battle to Force the Coronavirus Below It’s Tipping Point”, Bloomberg Businessweek, January 30, 2020
What information can be derived from knowing the enemy?
For one, the fact that the viruses mutate and change at a high rate is a dilemma for both diagnostic detection as well as treatment and development of vaccines against them.
Coronaviruses have an unusual replication process, which involves a 2-step replication mechanism. Many RNA virus genomes contain a single open reading frame (ORF) which is then translated as a single polyprotein that is then catalytically cleaved into smaller functional viral proteins, but coronaviruses can contain up to 10 separate ORFs. Most ribosomes translate the biggest one of these ORFs, called replicase, which alone is twice the size of many other RNA viral genomes. The replicase gene encodes a series of enzymes that use the rest of the genome as a template to produce a set of smaller, overlapping messenger RNA molecules, which are then translated into the structural proteins – the building blocks of new viral particles.
Rodney Rohde, “2019 Novel Coronavirus (2019-nCoV) Update: Uncoating the Virus”, American Society for Microbiology, January 31, 2020
Dr. Mark Denison, director of the division of pediatric infectious diseases at Vanderbilt University School of Medicine points out that the effort at slowing down this virus can only succeed not on what people do, but on how successful science is at addressing the virus. Because Coronavirus are dumb and cannot reproduce on their own, they hijack the reproductive machinery of the cells they attack. Man vs. Microbe scenario.
Remember the ‘proofreading’ capability of coronaviruses? That function seems to be able to be switched off if the virus is under evolutionary pressure. Here is where antiviral drugs theoretically can be useful. The antiviral that targets RNA will allow disruption in proofreading. Locking in that function makes the virus unadaptable, mutate faster, and essentially fall apart. Drug development takes into consideration knowing the enemy in order to eliminate them. An adenosine analogue that incorporates into nascent viral RNA chains resulting in premature termination is Remdesivir. Interesting is the potential of an old friend in Chloroquine. Chloroquine is used for the treatment of malaria and some diseases of the autoimmune system. Some data have shown that it also has potential as a broad-spectrum antiviral agent. The antiviral activity of chloroquine works by increasing endosomal pH for viral/cell fusion and interfering with glycosylation of cellular receptors of SARS-CoV. Chloroquine in addition has immune-modulating activity that can synergistically enhances its antiviral effect in vivo. [Manli Wang, Ruiyuan Can, Leike Zhang, Xinglou Yang, Jia Liu, Mingyue Xu, Zhengli Shi, Zhihong Hu, Wu Zhong, & Gengfu Xiao, “Remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-nCoV) in vitro:, Cell Research, 04 February 2020, as Letter to the Editor].
These are difficult times between man and microorganism. Science has come a long way. Technology and modern scientific and laboratory tools have paved the way at treating various infectious diseases using a more scientific approach. Gone are the days of hit and miss. Now we know the enemy, our next move is to destroy it expeditiously and precisely. Because in the end, only one can survive.
The Novel Coronavirus (NCoV) that has caused concern among people and the health experts has overtaken all other causes of global calamity (natural and political).
What started out as a a “potential” SARS-like illness from Wuhan, China in December 2019, has, as of this writing, become a story that looks like it was written for a Netflix series.
Less than a month into the lockdown in Wuhan (and expanded to other cities in the central province of Hubei), the Chinese authorities have now, according to the New York Times, “resorted to increasingly extreme measure on Thursday to try to halt the spread of the deadly coronavirus, ordering house-to-house searches, running up the sick and warehousing them in enormous quarantine centers. The urgent, seemingly improvised steps come amid a worsening humanitarian crisis in Wuhan, one exasperated by tactics that have left this city of 11 million, with a death rate from the coronavirus of 4.1% as of Thursday – staggeringly higher than the rest of the country’s rate of 0.17%”.
In early December, Dr. Li Wenliang, a physician at Wuhan City Central Hospital had warned of the outbreak – but was reportedly silenced by the police for it. In a country whose government is known to be shrouded in secrecy in order to keep social and political norms at bay, public anger is simmering and unrest and disorder at the brink of concern for the Communist Party, who are reportedly trying to stifle news organizations and local social medial platforms on criticisms related to how the government in general and President Xi Jin Ping in particular are handling this medical crisis. The death of Dr Li from this novel coronavirus was likewise shrouded in so many speculations before the news was finally released that he had indeed died from the viral infection.
While there are now 31,481 confirmed cases, 635 deaths, and 28 countries affected (as of this post) giving an overall case fatality rate of 2.01%, the numbers may not reflect the actual case fatality rate of the disease (worldometers.info/coronavirus). That’s because all except for 2 deaths are concentrated in China. The epicenter Wuhan has the most number of cases – 22,112 (72% of all the cases in the world) and the most number of deaths – 470 (of the 633 deaths in China alone, or 74% of all deaths). According to the National Health Commission of China (based on a press conference last February 4, 2020):
The national mortality rate is 2.1% of CONFIRMED cases,
Mild cases are usually not reported
97% of the total deaths in China were in Hubei Province. Mortality rate in Wuhan was 4.9%, while the fatality rate in other provinces at 0.16%.
Most of those affected are males (around 70%) and the elderly with co-morbid conditions have higher fatality rate.
Infectivity period can be anywhere between 2-14 days (average is around 5.2 days), ASYMPTOMATIC transmission is possible (hence the rationale for a 14 days quarantine or medical observation period for the pathogen).
While this global medical problem isn’t going to go away anytime. It comes at a time when the cooler temperatures and viral upper respiratory infections are common complaints seen in the various clinics, making managing respiratory problems a more difficult and fearful one.
The graph below shows the data culled from worldometers.info/coronavirus on the trend of daily new cases. While preliminary data is encouraging on the present statistical trend, the health authorities should not keep their guard down on this pathogen.
At the pinnacle of the outbreak is a country whose leadership and culture are being tested and challenged. China should change its paradigm on its approach to novel diseases and outbreaks emanating from a region whose 1.4 Billion people are at the forefront of travel, migration and economy. The SARS story in 2003 must have made China learn its lesson – that diseases like these cannot be swept under the rug. Seventeen years ago, social media and travel driven by advances in technology evolved dynamically into an industry in itself. Not even a highly restricted state media can control how people provide accurate information and react to life and death situations in the real world. We begin to realize that no one individual is worth protecting – even if he is the anointed president for “life”. No one is worth the sacrifice, if only to keep the notion that “business is as usual” and the “economy” of the world’s number 2 nation is at risk. This kind of mindset is archaic and the hierarchical type of governance is detrimental to the health of a nation.
We are not at that point in medicine where man will ever be ready for the microorganisms that roam the same planet we live in. Only fools would make that conclusion. Even as new threats emerge (they’re called emerging diseases in infectious medicine), the old scourges like TB, polio, cholera, the plague, to name a few, are still very much around and flare up with disturbing regularity. Former US adviser on public health emergencies Richard Hatchett nails it in his opinion that “we’ve created an interconnected, dynamically changing world that provides innumerable opportunities to microbes. If there’s weakness anywhere, there’s weakness everywhere.”
The coronavirus (or any infectious disease pathogen for that matter) will not distinguish a head of state from a common citizen. It knows no nationality or boundaries. Hence, it is the mandate of every leader to make sure that none of its citizens suffer or die because he/she prioritized personal, political and economic gains for the lives of a few.
Muhammad Ali Pate, global director for health, nutrition and population at the World Bank, correctly points out that “the foundation for better preparedness is investing in stronger primary health care systems which provide surge capacities that can be mobilized for effective response to contain outbreaks.”
It takes political will to go out in front of an epidemic. Yes. At some point, the outbreak will end. And that’s the problem. We mourn, grieve and bury the dead. And the world will move on. And so will the microbe. They stay quiet. Mutate. Resurge while we’re sleeping.
(Updates have been moved to a new blog entitled COVID-19: The Brief for easy reference. Thank you.)
At the heart of every epidemic, is a story that is told wrong.
Technology and social media, the very tools in disseminating proper, legitimate, and timely information is the same ticking bomb that sows disinformation, fake news, and fear.
An international outbreak of respiratory illness due to a novel coronavirus has thrusted China in the limelight in recent weeks. And the global community has sounded the alarm bells.
What we know
The outbreak apparently began in Wuhan, China at a market that sold live poultry, seafood and wild animals. The virus has turned up in 28 countries to date. Travel to Wuhan and contact with people who were positive for the viral infection put people at risk for developing the disease.
The Philippines has reported the first death in a 44 year old patient who turned out positive for NCoV. His partner is the 38 year old female who was the first positive NCoV case in the country. Both had traveled from Wuhan to the Philippines, via HongKong, then through Cebu. According to the Department of Health, the tourists had gone to Dumaguete before traveling to Manila. The death of the patient in the Philippines is the FIRST REPORTED DEATH OF A PATIENT WITH NCoV outside of China.
Coronavirus can infect both animals and people. Clinical illness can range anywhere from a common cold to severe acute respiratory disorders (remember the 2003 SARS outbreak that killed almost 800 people?). The incubation period is quite disturbing. At the start of this infection, we thought that it would range from 8-14 days. There are unverified clinical data coming out from China that point to 2-24 days! Nevertheless, with all data gathered to date, the median incubation period is possibly 5.2 days.
Health authorities are alarmed because we don’t know how bad this novel coronavirus will manifest in the long term as it is just evolving. It is possible that because it is an emerging infection, most (if not all of us) have not developed any antibodies to this infectious disease yet and that makes us all vulnerable to coming down with an infection – whether it is mild or severe. What we do, however, know is that the current case fatality rate for the novel coronavirus ranges between 2-3%. SARS had a case fatality rate of 11%. Measles has a case fatality rate of 15%. And MERS has a case fatality rate of 35%.
The Wuhan coronavirus is most likely transmitted through respiratory secretions. Evidence also points to human-to-human transmission. As to HOW easily it is transmitted is another story in itself. While the medical journal The Lancet, suggested “that the virus was passed from one ill relative to six others; only two had contact with the initial patient.” This is not a complete history because all the patients actually came from Wuhan and may have had some other zoonotic exposure to some degree, not necessarily from ONE market alone. As to whether some of these patients become “super-spreaders” later on (they infect a large number of people) remains a mystery. What we do know is that the the estimated infectivity of the Wuhan/novel coronavirus is 2.5 (for every index case, there is the potential to spread it to 2-3 people). Note, how pale this compares to measles that has an infectivity of 15 (for every index case with measles, there is the potential to spread it to 15 people!).
The main treatment is supportive care. There are currently no drugs approved for any coronavirus diseases. And megadoses of vitamin C (I read somewhere people advocating this) isn’t really going to help. There is also no evidence that the virus does not survive tropical climate weather. The mere fact that countries like Singapore, Thailand, Vietnam, Malaysia, and Cambodia (and the Philippines) have cases is proof that this virus will survive anywhere.
The Chinese authorities have “locked-down” Wuhan and other affected cities – limiting travel to and from areas of the infection. The Chinese government has built two new hospitals for these patients alone. Shanghai and HongKong Disneyland were closed (and remain to be closed) in anticipation of millions of guests for the Chinese Lunar New Year. Many governments worldwide have begun intensive screening of passengers from Wuhan at entry ports. (That would mean that if you have no important or urgent matters to attend to in China, I would suggest that you defer your travel in the meantime until such time that we know the real scenario. Common sense dictates that if the local authorities are concerned, why do you even want to travel going there?) Several airlines (British Airlines was the first) have canceled or downscaled their flights TO and FROM China. Incidentally, all of the provinces of China now have reported coronavirus cases.
On February 8, the total number of deaths of 813 had surpassed the final total deaths due to SARS (774) in 2003. With 910 deaths (as of February 10, 2020), the number of deaths has surpassed the deaths with MERS (853) in 2012.
The disease is evolving and for accurate information on statistics, I suggest that the reader refer to http://www.worldometer.info/coronavirus for up-to-date details.
The WHO has provided a formal name to the disease caused by the novel Coronavirus and will henceforth be referred to as COVID19. SARS-CoV-2 is the suggested viral taxonomy for the novel coronavirus.
How bad will the Coronavirus get? Here are 6 key factors by Knvul Sheikh, Derek Watkins, Jin Wu, and Mika Gröndahl (New York Times 1.31.2020)
What we don’t know
Are the Chinese authorities being fully transparent with the number of infections and deaths? (It becomes suspicious that the numbers suddenly double in number each day like replicates from a factorial equation. The sudden knee-jerk reaction of locking down a whole city is an overkill.) If you look back at history, the SARS outbreak of 2003 began November 2002. The Chinese authorities did not report this to the WHO until 3 months later.
While the authorities claim that ONE market in Wuhan is the epicenter of the disease, and that medical scientists feel that the most likely primary source of the outbreak are animals, there are hundreds of markets all over Wuhan. This undermines the theory that the epicenter is in ONE specific market. It is most likely that IF animals are the likely source, identifying which animal it is may be important. And whether only ONE market in Wuhan was the source of the outbreak.
Is there going to be a vaccine soon? It’s everyone’s guess. While vaccine development sounds fairly easier today than a few decades ago, there’s still a lot to learn about this novel virus before we get to the drawing board. And I refer everyone to the blog post on “COVID-2019: Numbers that matter” for a discussion on this.
On a side note, the novel coronavirus is an emerging infection and emerging infections may be difficult to handle because we have very little information (YET) of the enemy at hand. The information out there is based on data that is the tip of the iceberg.
While there are increasing number of cases already, there has been NO report of a pediatric casualty. In fact, the demographic data being provided are simply number of cases. A breakdown according to age, sex, co-morbidities, etc. are direly lacking. The youngest confirmed case is a 30 hours old baby from Wuhan (Tribune.net.ph in an article from Agency-France published February 5, 2020) delivered to a NCoV positive mother. This is a clear case demonstrating the likelihood of vertical transmission of the virus. With these scant information, it is possible that children may have milder forms of the disease (if they get the infection) and that the lack of more severe presenting respiratory symptoms in this group may make us miss having them routinely tested unless they have exposure to a source case.
The youngest person to die from this virus is the 34 years old ophthalmologist who first reported the SARS-like illness outbreak in early December 2019. The report on how and when Dr. Li got the infection is sketchy. The information available on social media is that in early January 2020, Li had treated a woman with glaucoma without realizing she had NCoV. On January 10, Li had cough, then fever and two days later was in the hospital. He became seriously ill after a few weeks and passed away on February 7, 2020 (almost ONE MONTH after his clinical illness). (The Guardian, Feb 6, 2020). The course of illness of Li is perplexing and troublesome and requires more transparent data on the length of illness on the untimely demise of the doctor.
If patients recover from the disease (become negative after being positive in a test), how long will immunity last? Does bringing them back to a community with ongoing infection provide protection from getting reinfected and how severe (or mild) will it be the second time around?
How accurate are the test kits that are being used for the diagnosis of the infection? At what day of the illness do patients test positive and what are the limitations of the testing kits? Is there a correlation between illness and positive test results?
What can we do to protect ourselves
An ounce of prevention is worth a pound of cure. Wash your hands. Don’t put your dirty hands on any oral orifice. Don’t rub your eyes. In short, watch your personal hygiene. When you need to wear masks, make sure you have the right one and wear it correctly.
When you have a bad cough – practice cough etiquette and cover your nose and mouth by wearing a mask. This is especially true when you’re getting into an enclosed space (like an elevator). If you’re sick, please, do the world a favor and stay at home.
Avoid crowded places. Don’t bring your smaller kids with you when you need to run an errand or visit the sick. You will need to take care of yourself first. Very young children are a handful and they are difficult to care for especially in crowded places.
Reconsider your travel plans. It may take a few months before this tides over as we don’t know a lot about the virus and how the disease will evolve. YET.
For pediatric patients that need to have their routine immunizations, please make sure your kids get them ON TIME. You don’t want them getting sick with a different, more severe, preventable infection just because of the ongoing fear of the novel coronavirus. The vaccine-preventable diseases carry a far heavier mortality rate and disease burden.
Stay vigilant and update yourselves with correct information from the health authorities and verifiable news. Use social media to create a positive health environment and not as a platform for becoming “viral”. PUIs (or person under investigation) ARE NOT confirmed cases of novel coronavirus infections.
If you are residing in the Philippines, the Department of Health has provided a link on its website for local data, information, and guidances on the current NCoV issue.
Take home message
Be part of the population that use their brains during times of crisis. Don’t be part of the wild, noisy, no-brained, confusing disorder that creates pandemonium. No one benefits from dysfunction.
Update 14 February 2020 (as of 0800H)
1. There are now 1,489 deaths and 65,246 confirmed cases. The cumulative case fatality rate is at 2.28%. China has the bulk of cases and deaths (1,486 [99.85%] of the deaths are in China).
2. Japan has reported its first death in an 80 year old woman. Two additional cases in Japan include a taxi driver who had driven a Chinese passenger and a surgeon at a hospital in Yuasa-cho.
3. Outside of China, Japan has the most number of cases (251 from 247), followed now by Singapore with 58 cases (+11). In third is Hong Kong with 53 cases (+4) cases. Thailand is third with 33 cases. The sudden surge in the number of cases in Japan is due to an additional 44 confirmed cases on the Diamond Princess. The Japanese government is set to allow some of the passengers on the ship to recover on shore. Taiwan has had no additional case for over a week and remains at 18 positive cases for COVID-19.
Additional cases in other parts of the world (after 3pm today) are: Vietnam (1), Hong Kong (2), Singapore (8), the UK (1), the US (1), Malaysia (1), and India (2) as of this writing. The case in the UK is the first case in London.
3. In Hong Kong, a building’s piping system is being investigated as a potential source for airborne transmission through feces after after the 42nd case who lives 10 floors below the 12th confirmed case. It is hypothesized that an airborne route through vents not properly blocked may be the source of the transmission. Could this explain also the increase in cases on board the Diamond Princess? Through unblocked vents and thereby affirming the airborne route? (This will need further investigation and is hypothetical for now.)
3. The Philippines remains to report 3 confirmed cases with one death. The remaining 2 cases have recovered and are now NCoV negative. There are 441 cases considered PUI (persons under investigation). The good news? NO NEW CONFIRMED CASES HAVE BEEN REPORTED as of this post. More good news? More than half of those tested are negative (253 have tested negative and 186 have pending results). This website of the government is highly informative: https://ncovtracker.doh.gov.ph
4. ALL of China’s provinces and territories are affected by this outbreak.
5. The first death outside of China was in the Philippines. The cluster of fatalities remain in China and among the elderly and those with co-morbidities. Hong Kong reported its first death from the outbreak. A 39-year old man with history of travel to Wuhan on January 21, 2020 and returned to Hong Kong 2 days later presented with symptoms on January 31, 2020. The third death outside of China is an 80 year old Japanese woman.
6. The countries and territories with confirmed cases for the novel coronavirus: Thailand, Japan, Hong Kong, Singapore, Taiwan, Australia, Malaysia, Macau, Russia, France, the United States of America, South Korea, Germany, the United Arab Emirates, Canada, Britain, Vietnam, Italy, India, the Philippines, Nepal, Cambodia, Sri Lanka, Finland, Sweden, Spain and Belgium.
7. The World Health Organization has declared the coronavirus infection a global health emergency.
8. Several countries have issued a “DO NOT TRAVEL” to and from China advisory. Airlines have cancelled flights to and from China, with a couple of countries repatriating their citizens.
9. Is it likely to become a pandemic? A pandemic is declared when an ongoing epidemic is observed in two or more continents. What we do know is that it’s highly transmissible and spreading like influenza. Whether it is catastrophic is unknown at the moment. But the effects of a pandemic would definitely burden countries with less resources and fragile health care systems than wealthier nations.
*Disclosure: The author of this article is the Chief, Section of Pediatric Infectious Diseases, University of Santo Tomas Hospital, Manila, Philippines
**This part of the blog will be updated daily based on relevant and verifiable information. The author is disclosing that all information on this blog site is referenced appropriately and that all gathered information have been verified. Some of the comments provided are personal opinions posted as part of scientific discussion on the coronavirus.
In his book “The Emperor of All Maladies: A Biography of Cancer“, published in November 2010, Dr. Siddhartha Mukherjee weaves an ironically beautiful story of the life and times of one of health’s greatest adversary – cancer.
It is no wonder that this book won the Pulitzer Prize for General Non-Fiction, is on magazine TIME as one of the most influential 100 books in the last century and the New York Times magazine as among the 100 best works of non-fiction.
The sad truth is, we all have one immortal illness. From the day we are conceived, there is an interplay of existence between normal and abnormal cells in our body. “Cancer is not one disease but many diseases. We call them all ‘cancer’ because they share a fundamental feature: the abnormal growth of cells.” Both normal and abnormal cells reside in each and everyone of us. Like good and evil, they both co-exist. The dichotomy in the opposites of life. Yin and Yang. Black and White. Justice and injustice. Heaven and earth. Cancer cells are part of us. When abnormal cells proliferate, they take over the cellular regeneration of other cells in our body. The normal cells are eventually replaced by abnormal ones. Because life is one real battlefield. And survival, is that of the fittest.
Cancer, we now know, is a disease caused by the uncontrolled growth of a single cell. This growth is unleashed by mutations – changes in DNA that specifically affect genes that incite unlimited cell growth. In a normal cell, powerful genetic circuits regulate cell division and cell death. In a cancer cell, these circuits have been broken, unleashing a cell that cannot stop growing.
Cancer is built into our genomes: the genes that unmoor normal cell division are not foreign to our bodies, but rather mutated, distorted versions of the very genes that perform vital cellular functions. And cancer is imprinted in our society as we extend our life span as a species, we inevitably unleash malignant growth (mutations in cancer genes accumulate with aging; cancer is thus intrinsically related to age). If we seek immortality, then so, too, in a rather perverse sense, does the cancer cell.
“The Emperor of all Maladies: A Biography of Cancer” by Siddhartha Mukherjee
As early as almost five thousand years ago, the Egyptian physician Imhotep had reference to the disease, in his writings that describe and affliction characterized by “bulging of the breast”, and resistant to any known therapies. From Bennett to Virchow to Farber…this history of cancer is by far a deep and perplexing. Several thousand years down the road and we have barely notched the iceberg of neoplastic diseases. As various therapeutical modalities are developed to address what we do now know of certain cancers, the cancer cells seem to adapt for their own survival as well. No matter how we look at any form of disease wrought by cancer, all were deeply connected at the cellular level. They had one characteristic – an uncontrollable pathological urge to cell divide.
In a National Geographic article, it notes that the likely reason “cancer is a relative newcomer in the historical record is that it commonly afflicts those 65 years and older, and for a long time, few people lived long enough for cancer to be a concern.” While this may not be exactly good news for those growing older, it is inevitably the disconsolate painful truth. As Susan Sontag puts it bluntly, “Now it is cancer’s turn to be the disease that doesn’t knock before it enters.”
As Mukherjee puts is succinctly, “Civilization did not cause cancer, but by extendinghuman life spans, civilization unveiled it.” The longer we live, the more likely that we will all have some form of cancer. Which will be our most likely exit from this world.
In the biography of cancer, Mukherjee takes us to a labyrinth of medical history, so graphically written and accurately detailed it makes one feel like part of the explorative journey to the root of the emperor. And like a Netflix series, his story telling ability will keep you mesmerized. A page-turner in every sense of the word, his graphic and dramatic description of cancer as an omnipotent lord of maladies will make even a layperson understand the history, physiology, pathology, treatment and outcome of cancer.
Cancer is not simply a clonal disease; it is a clonal evolving disease. If growth occurred without evolution, cancer cells would not be imbued with their potent capacity to invade, survive, and metastasize. Every generation of cancer cells creates a small number of cells that is genetically different from its parents. When a chemotherapeutic drug or the immune system attacks cancer, mutant clones that can resist the attack grow out. The fittest cancer cell survives. This mirth, relentless cycle of mutation, selection, and overgrowth generates cells that are more and more adapted to survival and growth. In some cases, the mutations speed up the acquisition of other mutations. The genetic instability, like a perfect madness, only provides more impetus to generate mutant clones. Cancer thus exploits the fundamental logic of evolution unlike any other illness. If we, as a species, are the ultimate product of Darwinian selection, then so, too, is this incredible disease that lurks inside us.
“The Emperor of all Maladies: A Biography of Cancer” by Siddhartha Mukherjee
The fundamental science of oncology has nothing to do with the evolution of cancer. These abnormal cells are with us in some strange way. From the air we breath, the food we eat, the living conditions or even some viral infection (Hepatitis B, Human Papilloma Virus, Ebstein Barr Virus, to name a few) that has triggered the transformation of normal cells to atypical ones and eventually to a cancerous disease has remained perplexing, mysterious, and a formidable foe to medical science.
The turn of the 20th century saw vaccines as the biggest contributor to preventing infectious diseases from eliminating the human population. The discovery of vaccines has dramatically averted morbidity and mortality from microorganisms that once upon a time had practically eradicated a nation. Drug discovery programs addressed treatment for chronic non-communicable illnesses, thereby improving the outcome and prognosis for diseases that used to have debilitating consequences.
The 21st century together with the rapid advances of science and technology changed the landscape of medicine. While the environment we live in has become more livable and human survival is at an all time high (70 is the new 60), living up to a century old has now become the goal. The search for immortality is at a frenzy. We all want to live forever. But forever will always have a price tag to pay.
The laws of medicine are really laws of uncertainty, imprecision, and incompleteness. They apply equally to all disciplines of knowledge where these forces come into play. They were laws of imperfection.
Law One:
A strong intuition is much more powerful than a weak test.
Law Two:
“Normals” teach us rules; “outliers” teach us laws.
Law Three:
For every perfect medical experiment, there is a perfect human bias.
“The Laws of Medicine” by Siddhartha Mukherjee
In spite of the rapid developments in the diagnosis and treatment of various diseases affecting human health, the scourge and challenge of cancer has remained a tough “cookie” to crack.
The formidably beautiful writing style engrosses the reader to a beautiful story on medical history; discovery of preventive medicine and epidemiology; of pharmacology, physiology, anatomy and biochemistry; of science being ensconced in myths and finally the realization of an entangled labyrinth of why a disease as terrible as cancer is the face of an enemy that has remained an enigma since time immemorial.
Mukherjee has masterfully immortalized the story of why cancer deserves to be the Emperor of All Maladies.
One of the most difficult obstacle course in track and field is the hurdles.
These obstacles are set at a fixed distance and runners must be able to overcome them as part of the race.
I thought of writing this blog post with the aforementioned title as my central theme. As the year comes to a close, and we’re almost near the finish line, my family and I are holed up together, recalling how 2019 had been one challenging year.
Life has a way of being either beautiful or ugly. Sometimes painfully both. If there was a streak of bad luck for health issues, this was how our story began.
But our story is but one of billions of lives that intertwined in the lives of other people in 2019. And while most of us have seemed to breeze the year unscathed, the rest of us barely made it out with our sanity intact.
2019 was a difficult one. Many of my friends had seen their loved ones on the departure platform. At our age, we need to face the reality that life comes to an end. And that closure will be a disappointing truth.
But like every hurdle we go through, there will be people rooting for you to make it to the finish line. Before this year formally closes, I’d like to thank family, friends, strangers – even those I have only met recently – for their words of encouragement and never say die attitude.
2019 saw the year of the pig come to a close. The animal pig is the last of the animals in the Chinese calendar. It marks the end of the 12 year cycle. January 25, 2020 will usher in the beginning of a new animal cycle with the year of the metal rat. A new cycle of hope.
Ironically, like many other things in life, we greet another year with renewed hope and prayers for better beginnings. Fresh starts provide us with new aspirations, plans, goals…yes…resolutions.
Thank you 2019. You’ve made me stronger. More positive. And realize that somehow, not only does hope spring eternal. But daily miracles are worth praying for.
And I am grateful of the four letter word called LIFE.
And they show up more frequently now more than ever.
When information technology reshaped the way social media and online news has collaborated with us, some took the shorter road to being a dolt in record time. Oh, I’m not talking about a fundamental political divide here. I’m talking about plain and simple vapid minds who share an obsession with non-intelligent discussion on the “comment” section of a published article – whether it is news or an opinion.
They say that everyone is entitled to make a comment or two. Or an opinion or two. And there is no question about that. Even I, provide a personal opinion or two to socially relevant issues. Nevertheless, when you read the news online, you’ll notice those who practically claim these places as their place of residence. They have a comment for every write-up whether it is OR is not favorable to the administration. Self-opinionated, arrogant, pointless cretins who evoke monosynaptic neuronal discharges have abundantly replicated. They are either die-hard fanatics whose idolatry is beyond comprehension OR they are contemptible keyboard warriors whose fixation on reverence for income is why they do what they do and write what they write.
I don’t agree to everything that is written in the newspapers. Absolute fairness in journalism is a myth. I have encountered paid columnists (and don’t make me go that path because I can single you out) who actually dive into writing for their daily bread. I refuse to call them professionals because they have thrown out the window the very profession of unbiased journalism. They write for the sake of destroying the truth, promote dissent and divisiveness, encourage harassment and violence, and should be ashamed of what they do. There are media outlets whose objectivity in a story is slanted to what they believe is correct, in spite of lapses in accuracy. Their practice is called “envelopment journalism”, due to the fact that they receive money envelopes in exchange for the “Public Relations” promotion they do. I don’t know how and why newspapers even retain them (it’s definitely not due to political advantage. Some news outlets simply need clueless baits.) Yes. Every single newspaper has one or a multitude of them. Bias, after all, is relative.
If there is one thing I have learned in writing, it is how to tell a story. It’s the same when delivering a talk, a lecture, a speech, a campaign…and so on. The master story teller is the one that convinces the audience, which is the more captivating storyline.
When a young boy is diagnosed with leukemia, and his family had to borrow millions to sustain his treatment, the story can be told in a way that tugs at your hearts. A family in need. A suffering that is unnecessary. A miracle in the home.
Yet the same story of the boy with leukemia can be written differently. One from a place of abhorrence and grudges. A broken family due to drugs and poverty. Karma or comeuppance whose time had come.
You can choose the details to fill-in the plot. Because that’s the way the story will sell.
And so, no matter how stories are written, there will always be the feckless belligerent whose values have been eroded by blind veneration. Whose only comment when posted online are self-serving and thoughtless. Whose existence is meaningless because no ounce of kindness is good enough for them. Whatever story is written – good or bad – they only have one agenda. To disrupt social norms.
Feckless belligerence should be attacked head on instead of ignored. There is no place in civil society for them. In the age of information technology, we should learn to educate the impressionable lot who access the internet without the ability to discern what is precise from fraudulent. With so many unskilled at comprehension, the battle is real.
Social media has amped the vitriolic die hards – whether you’re talking about those for or against any administration. Some call them trolls. Others tag them as keyboard warriors.
The art of trolling was unheard of until the Cambridge Analytica scandal created a geopolitical storm. It was fabricated into social media – to generate likes, hates, discordance, disruptive behavior. Originally defined as an ugly mythical figure, the troll now means an “intentionally disruptive person on the internet”. Baiting people on the internet became known as trolling. They live in a world of lecherous anonymity. More than half are paid hard-liners who provide comments and arguments that are disturbingly biased. Any form of comprehension, reading or reasoning is thrown under the bus. The other half, well, they’re staunch supporters who simply refuse to recognize the truth. Almost 75% are aliases or fake accounts.
The fanatic will always be irrationally argumentative. Their mindsets are fixated only on the person or cause they support instead of the issue(s) being tackled. Like rabid attack dogs, logic is lost in any argument from zealots who oppose any change (either pro- or anti-administration) even when an issue is blatantly being mishandled. Culpability is not in their vocabulary. But neither is a sense of reasoning. BASTA! That’s their motto.
If you follow the arguments of these indomitable people, it is perplexing how they are able to jump from one argument to another sans a thought process nor logic, each argument nullifying the previous. Most, if not all of their reasoning is based on an interconnection of concocted fake news, unverifiable reports, and opinions from other reactionary influencers who know nothing but have personal agenda.
For the record, I have never been a fan of ANY president in my lifetime. They are titular heads, and are voted into power by people like me who hope for authentic palpable change that trickles down to the grassroots. We need to support whoever is voted into office, as long as the agenda is inclusive and serves the greater good of its citizen. There will always be issues that hound every elected government official – good or bad. But because taxpayers pay for their salaries they should provide authentic public service. Each Juan has the right to cheer every success, or to jeer every failure. There is nothing personal with calling out government officials for their lapses in judgements. Yet politics is the biggest game changer of human personality. Power and money have the ability to maneuver us into rationalizing wrong into right.
Past presidents had defining moments as well as gaps in governance. PNoy is credited for the Mamasapano tragedy. Gloria will always be remembered for Hello Garci. Erap is enshrined in plunder and perjury with the Jose Velarde accounts. Ramos was hounded by the Clark Expo Centennial scandal. Cory had coups too many to count, and the transition from the Marcos years had the Philippines literally rising from the ashes.
Yet from all these major political faux pas, many of them (and their relatives and friends) are still entrenched in the political arena and/or have taken various roles in government – because POLITICS HAS BECOME A WAY OF LIFE! It has been sadly transformed into a family business enterprise. They eventually believe that doling out favors translates to a legitimate form of helping those in need. By being deeply rooted in a dynasty, they stay buoyant, at times to the point of being shameless.
Critical thinking is at its lowest today. And I’m not talking just about the Philippines. It’s a global social disease, fueled by the internet and social media, engaging with the gullible hapless halfwits of society. The internet has found the weakest link in the world of trolls.
Overnight, the capacity to verify facts became direly lacking. People are unable to discern reliable and correct information from disinformation because they’re too lazy to cross-reference what is being dished out.
My friends and relatives tell me that in order to achieve “peace and less stress”, we need to limit our interaction with trolls because no one wins an argument with them. As my sister would say, we just need to “let things be”.
The idiom “let sleeping dogs lie” means to leave things as they are, not rekindle or even start arguments, and not discuss the matter any further. Personally, it’s a defeatist attitude. And wrong. When a spade should be called a spade, we need to stand up to what is morally, ethically and justifiably correct. We cannot slant the truth to accommodate a warped sense of entitlement by certain sectors of society for their personal gain. We cannot look the other way because we are cowered by fear of expressing personal opinions on what is wrong. Wrong is wrong and no matter how you spin wrong, it’s like a dead carcass – it will eventually stink.
A healthy intelligent debate is sorely lacking these days as a barrage of cuss words have become defining engrams as the norm. The saddest part? Even those supposedly well or better educated have come crumbling down in exchange for pieces of silver.
Good or bad, all things come to an end. History will be the ultimate judge of how a government brought the brightest light to its people or how grim those years of governance was. We need to rise beyond personal proclivity as a people whose love for a nation should be far greater than the adulation to one man or his/her band of thieves. I know we don’t live in a perfect world. It wouldn’t hurt to keep wishing on that we did.
Final food for thought.
If you think lying for people will help you, think again. The world is round.
One lazy evening, my mom and I talked about how quickly time flew. “It’s December already,” I said. She faked a smile and said, “yes, another year is about to end.”
She looked at me with a sad glaze in her eyes, and forced a smile across her face and shed her usual tears. Tears of loneliness and fears or happiness and joy? I couldn’t tell.
The conversation was a difficult one for me. I watched her beautiful face now blanketed with the wrinkles that bespoke of wisdom and hardship, of love and courage, of hope and joy, as she reminisced her younger days and our growing up years.
I held her wrinkled hands and remember how these once lovely soft hands had become callused by trials and pain.
She was feeling both sad and happy. It’s not everyday that we get to have a decent conversation, but today was one of those difficult days when you had to hear and accept some truths.
To say that 2019 was one helluva challenging year is an understatement. No one ever thought that we’d be ready for radical changes in both her life, and ours. Oftentimes we forget that we are not invincible. Reality is often a painful teacher. The unshakeable truth is, when we are aroused by the inevitable fact that we live on borrowed time, fear grips us to our very core when we come face to face with mortality.
The truth is – we cannot turn back time. No room for regrets and what ifs. Just painful, difficult, purposeful, prayerful and hopeful days ahead.
There is no equalizer to circumstances that were. They will always be disquieting reminders on how well we cared, lived and loved.
We can only make better days ahead…not in words, but in deeds.
If you knew your parent(s) or loved one had a terminal illness, would you let them know?
The movie “The Farewell” an American drama-comedy writtten and directed by LuLu Wang starring Awkwafina (of Crazy Rich Asians fame) is a beautiful story that tests the emotions, ethical pragmatism and reality of concealing a painful truth or telling the glamorous lie.
Caring for the elderly, more especially with they are sick, is challenging. And complicated. Decisions on health care, quality of life, and family responsibilities are dependent on multiple factors that interplay on who, what, why, when, where and how these decisions are arrived at.
“The Farewell” is a heartbreaking melodramatic film that enmeshes cultural and societal beliefs against the modern day ethical discourse of autonomy.
In the movie, the children and grandchildren of Nai Nai travel back to Changchun China after finding out that the matriarch is recently diagnosed to have stage IV lung cancer and has 3-6 months left to live.
A wedding for Billi’s cousin to be held in China is used as a platform for the ‘final’ homecoming. Throughout the movie, the clash between Billi and the rest of the family over the “deliberate dishonesty” on her grandmother’s illness becomes the central theme of the story.
When the lie is a good lie, and allows the family to carry the emotional burden of the diagnosis rather than Nai Nai, the values one learns to grow up to actually make one reflect on what is good versus what is right.
Ethicists will always argue that patients have the right to know and the right to make personal decisions in matters pertaining to their health. This movie makes one pause long enough to agree, or disagree with decisions we make as healthcare providers and as patients.
After all, the care provided beyond measure should never always be measured on our yardstick of what we feel is morally correct. There is always a good lie…
Literally and figuratively speaking, the health of the people of this nation since the turn of the millennium is now at it’s all time low. And if you were in my shoes, you’d be cursing too.
This country kicked off 2019 with a measles outbreak, followed by Dengue when the rainy season began. After 19 years, polio is back! And we’re only in the third quarter of the year! If shit didn’t hit the fan with this medical nightmare, then I don’t know how you can claim that we’ve made strides at progress in medicine. At all.
If there’s a caveat in science that people don’t understand, it’s the old adage that “prevention is more effective than cure”. Or as our elder mentors would say, “an ounce of prevention is worth a pound of cure”.
We have many factors to blame. The underpinning one rests on how the government handled the misinformation (and disinformation) campaign of Dengvaxia in 2017. True, that it’s not a perfect vaccine. Program implementation for this had lapses as well. With a frenzy media that did not know right from wrong, personalities that rode the bandwagon of sensationalism including government officials who grandstanded on this issue – the perfect storm for relegating preventive medicine to the 1900s was put in place. And we have to acknowledge the fact that there are people responsible for the stinking mess that we are in today.
Which begs answers to the question – HOW THE HELL DID WE GET TO THIS POINT?
I’ll park that issue because it’s a long discussion. And I’m sure there will be people who will play the blame game. Moving on, knowing how and why we even got to this lowest ebb in our public health program should make us realize that we need to work at how to get out of this rut before another outbreak occurs and more innocent lives are lost.
The outbreaks we’re experiencing will require a concerted effort by all sectors to work with the Department of Health at restoring vaccine confidence and averting more crisis from vaccine-preventable diseases.
The other challenge in this day and age is addressing the rise of anti-vaxxers who use social media as their platform for fomenting fear and tragedy over vaccine safety. Let’s get one fact straight – there is no perfect vaccine OR medicine for that matter. Because science is unlike a bolt or screw coming out of a factory. We are all individually different. How we respond to medicines for our illness or even how a disease evolves in each of us differ from patient to patient. As a general rule, the art and science of medicine rests on how physicians are able to weigh benefit over risk. Some may develop an allergic reaction or adverse effect to drug X, while the majority get better from it. It takes years of training and knowledge before one can master the clinical acumen at being a good physician. Unlike those who simply cut and paste information from Dr. Google, and argue based on what is drawn from their first ping on the internet, the real doctor will make sure that they first DO NO HARM in any decision that involves our road to recovery or preventing diseases from occurring.
During these outbreaks, I saw how scared parents scrambled for answers to questions on how and why their children got sick or are now seeking for vaccines to avert getting the disease. Sadly, until coming down with the illness or death hits home, these children will only remain a statistic in the battles we lose due to dubious news and rumor mongers. And we will simply be spectators to the crisis in our midst.
It is time we put all our acts together. For the sake of our children and a generation ahead. Preventing an illness is not a personal one. Preventive medicine is everyone’s business. It’s a personal responsibility not only to our family but to our neighbors, friends and nation. If there is one lesson from this chaos – POLITICS and HEALTH should never be mixed – unless you have plans of annihilating a race.
It’s embarrassing that polio has resurrected in our nation. It’s a major setback in healthcare and speaks volumes on how fragile and gullible many Filipinos are when discerning between truth and lies.
Finally, after we clean up all this shit, let’s not forget the people who are accountable in bringing us to how all this shit reeked so foul! Justice may be delayed. But justice should not be denied. For the sake of those who became simply a statistic in this charade.
Relative Joy 