We’ve got just what the doctor ordered.
By Aiden Jewelle Gonzales
The current COVID-19 pandemic has been responsible for a wealth of misinformation, our vicissitudes of fortune, and even the avalanche of doomsday memes, but there is a silver lining, as with any storm cloud.
Proving that generosity of human spirit still exists, many essential workers have continued work so that the rest of us may be safe while living a hermit’s dream. Medical professionals in particular have been working at the front lines of the pandemic, treating cases, adapting their hospitals to better take on the load, and researching vaccines and antivirals.
Masala met with three Thai-Indian medical professionals who’ve seen the ravages of COVID-19, and asked for their take on this once unheard-of virus that has taken over our lifestyles, our livelihoods and the public consciousness.
DR. DAVIN NARULA, SENIOR INTERNIST AND FORMER DIRECTOR, SUKUMVIT HOSPITAL
Davin Narula, a veteran of the medical field for almost 50 years, came to medicine through a desire to keep his hands clean and an avid interest in medical detail, despite coming from a family of engineers. Born and raised in Bangkok, he studied medicine in Chulalongkorn University, did his speciality in Ramathibodi Hospital, and then moved to Sukumvit Hospital, where he’s worked for 41 years, 20 of those as the Hospital Director.
Although he’s semi-retired as of June 2020, his passion for medicine still shines through: “I’m 72, and I still love being a physician. It’s scientifically challenging and is far less stress than administration,” he says with a laugh. “As doctors, we have a responsibility to help out, wherever that leads, especially in times like these.”
Tell us about your hospital’s experience with COVID-19 over the last few months. What measures did you take to ensure everyone’s safety?
Firstly, we appointed a director to specifically handle the pandemic, an experienced doctor who was in Singapore when SARS hit and had relevant experience, and he chose a team to help him.
Secondly, we separated our outpatients department, and we had separate rooms, machines, and personnel with PPE. If any patient had symptoms related to the virus, they’re taken to the Acute Respiratory Infection (ARI) clinic where paramedics fully-equipped in PPE will do the swab test, and the Patient Under Investigation (PUI) is put in a negative-pressure emergency room to wait for the results. Every floor has medicine distribution so other patients don’t have to meet the PUIs.
We had to get laboratory accreditation from the government hospitals, but after that, we were free to test any PUI, with no cost to the patient. All our staff had to undergo new training to get this accreditation, and we had to bring new machines for the tests. Afterwards, patients who tested positive – of whom we’ve had a few – were sent to the infectious disease centres in government hospitals, who had the knowledge and equipment to deal with the virus.
Did you have easy access to the tests, and do you believe there was adequate testing in the beginning?
Yes, I believe so. The tests came from government hospitals, and that’s why they had to come down and give us laboratory accreditation but once we had that, we could test any PUI. The question always is, have we detected so few patients because we had fewer tests? But no, I do think we’ve tested an adequate amount. Secondly, active assessments were done in places where there was a risk of a spike in cases. Many places in the South, for example, did door-to-door checks and tests.
In your professional opinion, can we believe the numbers now?
Yes, in the last 5-6 weeks, we’ve been checking every day for this virus, but the results have all come out negative. There have been no local transmissions that we’ve seen. As for the people who’ve come in from abroad, they’re all in state quarantine and we’re not exposed to them.
How did you, in a position of leadership, have to adapt to this crisis?
What’s important in any crisis is to delegate to someone who has experience. We had a natural choice come up, and we made sure that all of us in leadership positions reassured the doctors and paramedics about how we would protect ourselves and others, and what equipment we have to protect them. Safety comes first. We are very lucky that our doctors and paramedics support all the systems we have in place.
Why do you think this part of the world has been better prepared for this crisis?
SARS and MERS made us alert. We got the experience at that time and we were lucky that we didn’t get many of those cases. Here in Thailand, we get a lot of Chinese tourists, so the moment we heard about the virus, we were immediately alert. And I think the government here has done a good job of making people understand the severity of the situation, so more people easily followed the rules and regulations in place.
How should we be preparing for the post-pandemic future?
I do feel that the ‘new normal’ will actually be the ‘old normal’ of our beautiful culture that we’ve recently overlooked – we’ve always said sawasdee instead of shaking hands and touching, we’ve always been conscious of hygiene and the food we eat. And that’s the way it should be. In the last four months, we’ve even had fewer respiratory infections because of the precautions people are taking now.
For medical personnel, hospitals already have these type of basic precautions, but now it’s become more conscious. If we don’t sanitise, even the patients look at us. They’re all conscious about it. It’s beautiful.
DR. WINAI BOWEJA, HEAD OF HEALTHY LUNG CENTER, PULMONARY AND PULMONARY CRITICAL CARE, PHYATHAI 3 HOSPITAL; CO-OWNER, PNC MEDICARE
Winai Boweja became a doctor through a chance encounter in 6th grade when a classmate chose to teach him the biology lessons his father, who was a doctor, had taught him over summer break. Reading over kidney functions, he discovered an enduring love for the sciences.
Graduating as an MD from Mahidol University, Winai did his residency in Samutsakhon Hospital, where he encountered a patient who was on a ventilator for two years, a seemingly hopeless case. “Somehow, his destiny crossed with mine,” Winai recalls. “I was fascinated with his case and read up a lot on pulmonary illnesses. Within a month, I was able to take off his ventilator and he went home. It’s been 15 years, and he’s still doing well. That was the catalyst for me.”
Frustrated with the lines in public hospitals and the lack of connection with his patients, Winai started his own private practice, PNC Medicare, a private clinic which he co-owns with his dermatologist wife to be able to spend more time with his patients and better research cases. “I feel great when I can solve a case,” he reveals. “It’s just learning every day, you know?”
As a pulmonary health specialist, you must be on the front lines of the COVID-19 pandemic. What has your experience been?
When we first heard about COVID-19 in January, I had more of a political mindset in that I didn’t think it would be that big of a deal. However, when the outbreak happened at Lumpinee Boxing Stadium, and specifically celebrity Matthew Deane Chanthavanij was infected, that’s when I believe the turning point was for Thailand that made everyone take it seriously.
I treated a case from that sanam muay, and it was eye- opening. The initial seven days it seemed like nothing, I was even laughing with him, but once he entered the eighth day, he deteriorated seemingly overnight. That’s when I realised how serious it was. Thankfully, he’s all right now, and his blood is even being used in the vaccine development programme.
We had a lot of cases of cytokine storm – where your own immune system attacks your body – so I used steroids to treat our patients, one of the first doctors here who did so. I didn’t wait for the research because at that point we had nothing to lose.
Is there a common factor in the people who are more susceptible to the virus?
No doubt, the elderly, but I’ve seen younger cases too, and I’ve seen many elderly people who’ve been discharged. It’s something we’re studying till today, and we have to treat each patient on a case by case basis. There’s still conflicting data – hydroxychloroquine, for example, was proven not to work.
In your opinion, why is Thailand doing so well?
I’m trying to be neutral – I don’t trust everything we’re told either. But what I know is that firstly, we started taking precautions very early. A doctor friend of mine in Don Mueang Airport informed me that by 10th January they were already hiring more staff to screen incoming visitors, especially those from China.
We had the second highest number of cases aside from China and because of that, we took initial steps. There was a lot of pressure on social media as well as political pressure so by the end of January, we were already halfway into prevention.
Secondly, I believe that Thai culture is very accepting of new changes. You tell people to put on masks, and they’ll follow the trend really quickly. It’s really lucky that culturally, we’re happy to listen to authority – washing our hands, social distancing, etc.
In light of this crisis, many are questioning whether private hospitals are overcharging patients. As someone who’s worked in a public hospital and has a private practice, what is your response?
I think there are two reasons why the private sphere is more expensive. Partly, our culture drives up the cost of healthcare. We Asians, especially Thais, are a customer experience culture. People give credit to the things that give them a certain experience.
However, on the other side, you start comparing the price of the service with public hospitals, where the benchmark is THB 30 because the government absorbs the cost. Honestly, Thailand’s healthcare system is very cheap for the experience you get. But if you go to the public hospital, you can’t get more than three minutes with a doctor. So it’s finding that balance.
Do you believe a second wave is possible, and what are the current public malpractices that we can avoid to help worsening that wave?
A second wave is definitely possible – we are a tourist country, and people will escape here once the borders open just to stay safe here.
We also have asymptomatic carriers among us in Thailand. Don’t take it lightly – this year you have to start living the new normal. Stay alert, sit far, wear your masks, be cautious when you’re living outside, wash your hands often. As for malpractices – people need to practice social distancing even in public transport. They’re still packed so tight in the trains!
DR. NALINI SCHADUANGRAT, COMPUTATIONAL BIOLOGIST, CENTER OF DATA MINING AND BIOMEDICAL INFORMATICS, FACULTY OF MEDICAL TECHNOLOGY, MAHIDOL UNIVERSITY
Born in Thailand but having gone to boarding school in India, Nalini Schaduangrat did her Bachelor’s degree in Biomedical Sciences in Mahidol University International College (MUIC) where she was selected for the Royal Golden Jubilee Scholarship given out by the Thailand Research Fund to pursue a PhD in Microbiology. Coincidentally, her focus was on virology and the influenza virus in particular, a cause of past pandemics.
Her affinity for the sciences started with her father, guide and encourager to this day, although her initial ambition was to be a dentist. That changed when she took her first microbiology course at MUIC, which catalysed her fascination with how infectious agents are able to evade immune systems so effectively.
“Prior to an opportunity to work at a computational laboratory in Seattle, Washington, I had no knowledge of computational biology so the biggest challenge I faced was to get over the learning curve that finally made me love protein modelling,” she reveals. “But I believe the ability to uncover a novel drug or discover something of value to humankind is the most exciting part of being a scientist.”
As a computational biologist, you must be busy researching the COVID-19 pandemic.
Yes, we are working on uncovering novel antiviral drugs that could potentially target hotspots on the viral proteins and thus, inhibit its replication and spread. However, this is not easy as the virus uses many mechanisms to avoid detection and to overwhelm our body with what is called a cytokine storm.
There hasn’t been a pandemic of this scale in recent history – what would you say makes this virus unique from others?
Indeed, it will make a great story to tell our future grandkids. Pandemics are a big part of the world we live in but modern medicine and technology has only slowed down their occurrences. All the deadly pandemics of the past were caused by the influenza virus…in short, COVID-19 is a smarter cousin of SARS and MERS, but it’s learned that if you kill the host too fast, it will be difficult to spread far. Hence, COVID-19 has a higher transmission rate and lower mortality.
In addition, a unique feature of the virus is that, upon infection, the virus hijacks your immune cells and downplays certain responses while increasing others. This phenomenon causes your body to overreact and those whose immunity is already compromised (i.e. those who have an underlying disease, metabolic syndromes or through old age), are the most affected.
Do you believe it likely that COVID-19 will mutate into different strains even after a vaccine has been created?
It’s not only likely but inevitable. The only question is – will the vaccine still be effective? Viruses naturally replicate very rapidly which sometimes causes their DNA to accumulate errors. If a favourable mutation arises that renders the vaccine ineffective, it could overtake the entire viral population and result in severe disease.
Approximately what timeline would you give for the creation of a vaccine? Why is it taking so long?
If creating a vaccine was easy, HIV would no longer exist. Producing a safe and effective vaccine is time-consuming and labour- intensive. In order for a vaccine to be considered safe, it has to undergo various stages of testing from the laboratory, to animals, and then no less than four stages of human testing.
The fastest that a vaccine can be produced is four years, but that being said, funding is usually a major reason for the slow pace of vaccine production. In the current situation, that is not the case. If there ever was a time to fast track a vaccine, it would be now.
What is the most important advice you would like to give people regarding COVID-19?
We need to educate people regarding the consequences of their actions. For example, I have seen many elderly people in our community who did not take this seriously in the beginning and were out and about without masks. Similarly, many young people don’t understand the concept of social distancing as they are “bored” at home and want to meet their friends.