How Unique Regional Factors Collided to Create the Black Fungus Crisis in India—A Hypothesis

We forget history at our own peril.

In the 1980s, more than two lakh newborn babies used to die every year in India due to a dreaded infection. This, when that preventable disease was already only of academic interest in the developed world. WHO and the Indian government worked together to address the factors leading to the disproportionately high rates of this infection and neonatal fatalities in India, as compared to the rest of the world. Those efforts paid handsome dividends: in 2015, India announced that the country had successfully eliminated the disease.

The condition referred to is Neonatal Tetanus. Caused by a bacterium that is present all around us, especially in the soil and animal manure—in India and the rest of the world. But what caused the disproportionately high numbers of infections in India? Studies identified that low vaccination rates in India, in conjunction with the high rates of home deliveries under unhygienic conditions, as the predominant causes. In relation to the latter, the presence of cow dung in the immediate vicinity of childbirth —especially the application of cow/goat dung on the newborn’s umbilical cord stump was identified as a main factor. The reason: the abundant presence of tetanus spores in animal dung.

Fast-forward to 2021:

The devastating effects of the COVID-19 pandemic in India have been exponentially exacerbated by a baffling explosion of mucormycosis (black fungus) cases. India has an alarmingly disproportionate number of this comparatively rare infection—a whopping 71% of all the global cases in Covid patients even prior to the devastating second wave – significantly higher than even our subcontinental neighbours. What is it about India that accounts for these high numbers? This hypothesis grapples with the question, and ultimately posits that cow excrement is a major factor—that, during this COVID wave, cow excrement, steroids, diabetes and untested remedies collided to create the perfect storm of mucormycosis in India.

My conclusions are drawn from the following facts and suppositions:

1. Cow excrement is rich in the spores of Mucormycetes, the fungus causing mucormycosis. In its inactive form, the fungus is pervasive, present everywhere around us in the form of spores. The spores enable the fungus to survive adverse conditions and to disperse, and then to grow and reproduce when the conditions are right – similar to seeds in the plant kingdom. But, notably, these fungi have a particular affinity for herbivore (grass eating animals) dung, and are called ‘coprophilous fungi’ meaning ‘dung-loving fungi’. (see Section 3.3 of this publication.)
2. There is a longstanding tradition in large parts of India of incorporating cow excreta into multiple facets of daily life—significantly and disproportionately more so than in most other parts of the world. Examples include applying cow dung on bodies, imbibing cow urine, and using cow dung for fuel and housing. Panchagavya, for instance, ingested as an Ayurvedic medicine by many Indians, contains cow dung, cow urine, milk, ghee and curd. Naturally, any population that engages in such practices will harbour a heavy load of mucor spores in their bodies and environment.
3. To bolster the above point, it merits note that the personal use of cow excreta amongst Indians increased manifold during the COVID pandemic. Under the patronage of political and religious leaders, many Indians actively utilized cow dung and urine regularly and in copious amounts, in the hopes of preventing and treating COVID, despite warnings from the scientific community. This possibly paved the path for unusually large fungal loads, and, syllogistically, atypically and markedly elevated chances of systemic fungal infections among Indians.
4. The fungal spores, though present in and around humans in soil, decaying matter, compost, manure, animal excreta and bird droppings, do not usually cause systemic illness, since they are opportunistic pathogens. Such pathogens normally lie dormant inside a host, and cause illness only when circumstances are conducive for their proliferation. One such conducive circumstance is an immunocompromised host, a patient whose immune system is weakened due to varied reasons, including infections like COVID, diseases like cancer, or the use of drugs that suppress immunity, like steroids (technically called glucocorticoids. Examples of commonly used steroids in medicines include dexamethasone, prednisone, budesonide and hydrocortisone). Such an immunocompromised patient is significantly vulnerable to developing a systemic fungal infection.

5. Steroids are among the most important drugs used in the medical treatment of advanced Covid. COVID infection can cause a deranged inflammatory response in the body, called a cytokine storm, that can lead to significant organ impairment, including serious damage to the lungs . This can result in the patients becoming breathless and requiring supplemental oxygen, and sometimes assisted ventilation. Thus, paradoxically, the immune system of the body (which is typically critical in warding off infections), in this case, actually harms the body through this inflammatory response. Hence, in the treatment of COVID, steroids are commonly used when signs of inflammation are present clinically, and also as evidenced by specialized blood tests, in order to suppress the harmful immune reaction. Thus, the patient, with their immune system already weakened by the Coronavirus infection, now becomes further vulnerable to developing a systemic fungal infection.
6. Anecdotal reports suggest there has been overuse of steroids in the treatment of COVID in India: rendering patients uniquely vulnerable to systemic fungal infections.
7. Another conducive circumstance for fungal proliferation—and hence systemic fungal infection—is high blood sugar levels in the patient, as in diabetics, especially those with uncontrolled diabetes. India has an enormous caseload of diabetes spanning the spectrum of blood sugar levels—controlled, uncontrolled, and poorly controlled. Many patients with diabetes in India are still undiagnosed.
8. As part of their biochemical actions, steroids elevate blood sugar levels by opposing the action of insulin and stimulating the production of glucose in the liver. This can lead to massive surges in blood sugar levels, especially in diabetic patients, which in turn, can make the patient more vulnerable to systemic fungal infections.

So, in our context, we could say that for a fungal infection to happen, there should be:

• Presence of the fungal spores, ideally in conjunction with:
  • Presence of an immunocompromised patient,
  • And/or the presence of a patient with diabetes/uncontrolled sugar levels.

In sum, the following overlapping elements came together to create the perfect conditions for systemic fungal infections in India over the past few months:

1. Lavish, widespread use of cow dung and urine providing heavy loads of fungal spores, in, on and around the vulnerable population. Just as a baby whose umbilical cord stump was smeared with tetanus bacteria rich cow dung was at a disproportionately higher risk of developing neonatal tetanus than one who was not subjected to that ritual, Indians who actively bathed in, ingested, drank, breathed in, or topically applied Mucor-spore rich cow dung and urine are by any epidemiological logic at a disproportionately higher risk of developing mucormycosis.
2. Steroid treatment of COVID (particularly if it was more than the recommended dose), increasing the risk of immune suppression and thus infection by the opportunistic mucor spores on the already vulnerable COVID patient.
3. Steroids also cause elevation of blood sugar levels, especially among diabetics, adding another risk factor for systemic fungal infection to the mix. In such a scenario, diabetics – already a known high-risk demographic for Covid complications – bearing the brunt of Mucormycosis infections is no surprise.
4. 2-Deoxy D-Glucose is used exclusively in India for the treatment of COVID. While some reports suggest that it has the potential to cause increased blood sugars, further studies are needed to confirm these findings.
5. Coronil, widely used in India as an “alternative cure/prophylactic” for COVID, has been variously marketed as an “immunity booster”, a “herbal supplement” and a drug that “can kill coronavirus”. It is supposed to be an immunomodulator and anti-inflammatory agent—in other words, its actions are similar to those of steroids. Does this mean that it can “clandestinely” add to the administered steroid dose in patients? Do the herbal constituents have unknown side-effects? We certainly need more information on this drug so widely used during this critical time. The “research paper” provided by the makers, Patanjali, is not peer-reviewed, and its claims are dubious, at best. Similarly, the potential presence of steroid-like components and/or cow excreta in the various other indigenous remedies used in India cannot be excluded without further studies.

To return, once again, to the critical issue of fungal spores: While experts and journalists are blithely harping on the role of steroids and diabetes – and even that of iron, zinc and the Delta strain variant – for the disproportionately high rates of mucormycosis cases in India, they are completely, shamelessly, silent on the source of the fungal spores that seem to be so abundant around these patients.

Here is the crucial point: Without the spores, there won’t be any fungal infections—even in the most immunocompromised patient or the most uncontrolled diabetic.

And large numbers of Indian patients were exposed to an extremely high load of Mucor spores through their intimate use of cow excreta – that is an undeniable fact.

Consider this presence of abundant, widespread fungal spores in close proximity to the Covid ravaged, steroid treated, immunocompromised Indian patients who likely also have high blood sugar levels – and we get a pretty complete picture explaining the possible reason behind the disproportionately high number of mucormycosis cases in India. (More research into Coronil and 2-DG could further clarify the picture.)

An important corroborative evidence is the distribution of cases within India itself: The cases are highest in states likely to use cow excreta extensively, like Gujarat, Maharashtra and Andhra Pradesh, while they are relatively much lower in states likely to abstain from such practices, like Kerala and West Bengal.

To summarise, we need to focus on these two unique Indian factors to solve the mystery of the unique caseload of Mucormycosis in India:

1. The widespread use by Indians – especially so during the Covid pandemic – of cow excreta (dung and urine) that we know harbour mucor spores, thus exposing vulnerable, immunocompromised, and diabetic patients to heavy loads of the fungus in their immediate environment.
2. The widespread use by Indians of untested and poorly tested remedies such as Coronil and 2-DG, that may add to the immunosuppression and elevated blood sugar levels, thus increasing their susceptibility to fungal infections.

To be absolutely clear, this is just a hypothesis, and detailed research is needed to conclusively prove or disprove the same. Studies that look at these and other factors in depth will undoubtedly benefit current and future patients – and that certainly should be our ultimate aim.

But the catch here is that detailed research takes time—time that patients suffering from this debilitating disease right now do not have. (We have already crossed 31,000 cases and 2,100 deaths!) It is therefore incumbent upon the medical community in India to ask pertinent questions, carry out informal cause-effect analysis, and, in the meantime, send strong medical advisories to the public to stop all practices that are not globally, scientifically approved, while we fight the dual crises of the COVID pandemic and endemic mucormycosis. Until that clear message goes to every Indian, we are failing in our duties as physicians, scientists and leaders. I sincerely hope that we learn from lessons of our past, that good sense prevails, and additional loss of life—due to a potentially preventable condition—is averted. Learning from the successful template used in the elimination of neonatal tetanus could go a long way towards achieving this goal.

Dr Jessy Skaria is a medical doctor

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