When a Pandemic Hits Your Homeland

Don S. Dizon and Hina Khan

Although I left my island home of Guam a long time ago – to follow my ambition to become an academic oncologist – and ultimately settled on the East Coast, I have never forgotten my roots. Guam will always be home: family, friends from elementary school, and colleagues in the oncology community still reside there. As such, my ears perk up every time Guam is in any national headline. I imagine this must be the case for all who chose to leave home, whether for opportunity or for freedom.

Recently I was talking with my colleague, Hina Khan, MD, here at Brown. Dr. Khan is a thoracic oncologist in our group with interests in environmental exposures that increase lung cancer risk and in addressing equity and diversity issues in lung cancer prevention and in clinical trials. We had met to discuss grant opportunities at a point in time when the pandemic in India was exploding. Sensing an opportunity to talk about it, we decided to collaborate on this column.


Hina, where did you grow up, and when did you come to the US?

I grew up in one of the northern states of India called Uttar Pradesh. I completed my school education there and after premedical, I moved to stay on campus at the Jawaharlal Nehru Medical School. My parents, siblings, and extended family members live within a few hours of each other in the state. My father, a civil engineer, and my mother, a science teacher, saw that we received a good education. We lived in the capital city of Lucknow, an urban area. Most of my immediate family, aunts, and uncles lived a few minutes from us. It felt like one big family campus. We were in each other’s homes every day…..so much love and sharing. Our cousins were like our siblings.

After medical school, my husband and I decided to move to the U.S. in 2009 to pursue our career interests. We ended up staying here, leaving behind all our family back in India. We traveled back home every year but the COVID-19 pandemic has changed that; we haven’t seen anyone in over 1 year. Thank god for social media that has kept us connected during this difficult time.

 

What’s the background on the COVID-19 pandemic in India?

On the evening of March 24th 2020, a mandatory national lockdown was imposed by the central government of India towards the 1.38 billion population. The case count on that day for India was 37, with no deaths reported (JHU COVID-19 data). The entire nation remained in lockdown for the next 9 weeks. This response to the first wave in India was described as “timely, robust and far sighted,” by the WHO

 

After the country “re-opened” we saw a surge in cases again over the summer of 2020, which peaked into September 2020 at about 1,300 cases/day. Over the next few months, life went on usual and case counts seemed to be well controlled. During the winter months, I would hear of -full scale weddings and birthday parties among my acquaintances, friends, and family. Earlier in the year 2021, the Indian Health minister declared that “India has successfully contained the pandemic” with the notion of “herd immunity”. It was hard to try to convince my family to continue social distancing and avoid large gatherings, when there were absolutely no state regulations or mask mandates. My parents and siblings stayed safe, socially distant and eventually were vaccinated in March 2021.

2021 was an election year and the political parties were poised for victory during the months of March and April. An analysis done by Associate Professor Deepankar Basu, in the Department of Economics at the University of Massachusetts Amherst, showed that the five states that witnessed assembly elections and political rallies reported a much higher rate of increase in infections than the “non-election states.” We watched in disbelief and panic as we saw visuals of political rallies and social media images of social events in India. It’s simple: We have known that large unmasked gatherings that are not physically distanced will transmit the SARS-CoV2 virus. And it did!

When did you become concerned about the pandemic?

In February 2021, we started hearing about COVID-19 cases on the rise in the community back home. About 10,000 new infections were being reported in India on an average day. Over the next 3 months, we saw (and heard about) a rapid uptick in COVID-19 cases. The month of May started off with > 400,000 new cases in one day (May 1st, 2021). Nearly 7 million new cases were reported in India in April 2021 and over 200,000 deaths (Source: Johns Hopkins University, as of May 3rd, 2021). According to the Indian SARS-CoV-2 Genomic Consortium (INSACOG), there are at least 2 variants causing infection in India: the U.K strain B.1.1.7 and the “Indian” variant, B.1.617 (now referred to as the alpha and delta variants, respectively).

It is believed that the statistics are grossly undercounted due to crematoriums/burial grounds being overwhelmed, home deaths due to lack of hospital beds, etc. Thousands dying as they wait outside hospitals for a bed or oxygen, while unable to access care. Many estimate that the actual numbers in India are likely 5-10 times higher.

Experts have said that our best shot at scaling down this wave would have been stepping up vaccination efforts, state-mandated lock downs, and reinforcing masks. According to Reuters, India is the world’s largest producer of COVID-19 vaccines, yet only 2% of the total population in India has completed their vaccination. Dr. Anthony Fauci the NIAID director, who recommended a lockdown for India back in April at the peak of the second wave, has said; “This virus has shown us that if left to its own devices, it will explode in society. If you don’t respect its ability to cause serious damage, you are going to get into trouble.”

The states and central administration have been criticized for not acting sooner to limit the spread of COVID-19 by mandating masks or limiting political rallies and religious/festival gatherings. It may be too late now. As we saw the world’s biggest surge in COVID-19 infection unfold in India, hospitals and health care infrastructure has collapsed. Medical schools have pulled trainees into the medical work force to keep up with the overwhelming numbers.

Physician colleagues that I went to medical school with are working 24 hours, 7 days a week, caring for patients, while alternating shifts with family members to care for their sick parent, sibling, etc. who also have COVID-19. Those in the clinical field (regardless of the specialty) are all operating as internists caring for patients while on their hospital shifts and caring for their family and neighbors when home. Many have lost a loved one and yet return to work the next day to help others. As we entered April, all hospitals ran out of beds and we were facing a critical oxygen shortage.

A pathology colleague who practices in the Indian capital city, New Delhi reports that his day starts with making 100-200 calls in a day looking for leads on an empty bed. He then posts the leads on our medical school alumni page for those who are desperately in need. Within seconds the beds are occupied. We didn’t hear from him for a few days, only to find out his mother passed away from COVID-19. We have no words of comfort to offer.

The medical diaspora of those with Indian origins is trying to contribute in many ways. My husband, an internist, spends his evenings answering calls and messages from family, friends, and colleagues with COVID-19 infections seeking medical advice. Another pediatrician colleague here in the U.S. tells me he logs into Skype every evening for hours at a stretch as he virtually examines and manages his parents, siblings, and other family members sick with COVID-19. Eight in a household sick! His 24-year-old niece who is a medical student was managing the sick members of the family at home based on his recommendations; giving IV hydration, IV steroids and Remdesevir. A week later she fell ill and unable to care for herself.

Collective efforts from my medical school alumni organization have raised enough funds to start building a new Medical Oxygen Plant for the area. It is the only tertiary level hospital in the area, housing about 1300 beds, and catering primarily to lower socioeconomic population in the region. With the rapidly growing case numbers and the anticipated disproportion with healthcare infrastructure and oxygen availability, many of us have privately shipped oxygen concentrators to our family members should they get sick with COVID-19 and need to be managed at home

Have you been personally impacted?

The pandemic has touched each of our lives in different ways. Everyone in India seems to have lost a friend, loved one, or a colleague. Each story brings out the painful reality that exist.

Among the many front liners that we have lost, one story hit too close to home. He was a young interventional cardiologist with a promising career ahead. He was my senior in medical school, who had taught us along the way. He had the most tranquil smile and his academic achievements were par excellence. A young doctor with much humility and passion to help others. Earlier in April 2021, he noted that he lost his sense of taste. He tested positive for COVID-19. While he was quarantining at home, he worked tirelessly to coordinate care for the sick cardiac unit patients he had been caring for prior to falling ill. A gastroenterologist friend tells me he called him up the day prior to his admission to the hospital, to discuss management for one of his patients with acute liver injury due to COVID-19. Ten days into the illness, he remained very ill and requires admission. Twenty days into the illness, he sustained a stroke and a few days later passed away in the same ICU where he cared for his patients. A life which promised so much and touched so many lives, is tragically cut short. He left behind 3 young kids.

This is just one story. Over the course of the past week, we have lost at least half a dozen senior faculty members to this raging pandemic. So many pioneers, giants in their respective fields lost to this virus

How do you cope with being so far away?

Social media remains the main source of communication between colleagues in medicine and family members who are living through the ground reality. Every morning as I wake up, with much trepidation I check my social media platforms for updates on those sick with COVID-19.

The international Indian community in the U.S. has come together by various avenues to provide relief to those desperately in need back home for basic medical supplies and oxygen. My medical school alumni in the U.S. have come together to develop an emergent funding channel to set up an oxygen generator plant in order to supplement the unprecedented oxygen demand. Many of us are shipping out oxygen concentrators to India from vendors in the States, with the fear that our own family members may fall ill and if needed, will likely not have a hospital bed and facilities/care available.

As we mourn the loss of friends and family members every day, we cannot seem to find any hope that the days ahead will be better for India. Experts say the worst is yet to come. It’s a feeling of watching your home burning to the ground……a deep, painful feeling of helplessness.

What should people in the U.S. know or take away from what’s happening there?

Early intervention at the community level with mandated social distancing protocols and masks. Get vaccinated!


While we talked I could sense the sorrow in Dr. Khan’s voice forged from helplessness. But at the same time, I also sensed an awkward dichotomy playing out: that she was really thankful to be here in the U.S. and away from the ravages of the pandemic at home, yet frustrated with the national debate and ongoing reluctance around vaccination. To see many still doubting the reality of this pandemic and the desperate need for vaccination! Well, maybe that wasn’t all her; more than likely, it was also the way I felt.

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