Black Fungus, Coronil and Cow Dung: A Serendipitous Turn of Events - Dr. Jessy Skaria

An account of the conversation between Dr. Jessy Skaria and MedBoundTimes
Dr. Jessy Skaria, MBBS, Independent Researcher
Dr. Jessy Skaria, MBBS, Independent Researcher

Welcome to another section of DocScopy. MedBound Times was fortunate enough to get an opportunity to have a candid conversation with Dr. Jessy Skaria on her life, professional journey, and research.

Dr. Jessy Skaria, MBBS, is a physician from Thiruvananthapuram, Kerala. She now lives in Texas, United States. Dr. Skaria is also an amateur gardener, avid reader, and an enthusiastic social media activist.

The conversation between Dr. Jessy Skaria and MedBound Times (Tanya Singh) from January 2023 gives us an insight into various aspects of Dr. Skaria's life. We dive deep into her professional journey, the experiences and challenges she faced while researching Mucormycosis/Black fungus.

A confluence of uniquely Indian environmental and host factors likely drove the CAM epidemic of India.
A confluence of uniquely Indian environmental and host factors likely drove the CAM epidemic of India.Dr. Jessy Skaria

Tanya Singh: Tell us about your life journey.

Dr. Jessy Skaria: I completed my MBBS from Medical College, Thiruvananthapuram, Kerala. I was training as a General Practitioner (GP) in the UK, when we moved to the USA, where I gave up my clinical practice due to multiple personal and practical reasons, including visa restrictions.

Tanya Singh: Why did you choose to become a healthcare professional?

Dr. Jessy Skaria: Growing up, I always wanted to be a doctor. I wished to see my patients as the sum of their genetic, physical, and environmental influences, and to view health and disease as intertwined entities, together, and not in isolation. That is the reason I chose to train as a general/family practitioner rather than specialize in any one area.

Tanya Singh: You have done intense research on MUCORMYCOSIS/BLACK FUNGUS over the past 1-2 years. What started/prompted you into your research on “Mucormycosis/Black fungus”?

Dr. Jessy Skaria: My research into mucormycosis/black fungus was an entirely serendipitous involvement. As the second wave of COVID-19 struck India in an unprecedented manner by April-May 2021, Kerala - my home State – particularly reeled under the mounting cases. As ex-pats, we were inordinately worried about our families back home. And close monitoring of the trends of the pandemic became a daily obsession. That is when we started hearing about the ‘black fungus’/mucormycosis striking patients with COVID. It brought a new kind of terror since this seemed to pile on the misery for Indian patients – while this was a pretty rare complication of COVID in the USA or really anywhere else. When excessive use of steroids in India was first blamed for the mucormycosis cases, it made sense, since we know that secondary fungal infections are common with immunosuppression. But the fact that the ‘black fungus’ infections seemed almost uniquely Indian was certainly strange since steroids were used first and widely in the West to combat the COVID cytokine storm. Isolated warnings from some Indian doctors about quack Covid therapies among Indian patients that could invite secondary infections like black fungus caught my attention. Foremost among these quack remedies highlighted were cow dung and urine (naturally microbe-rich substrates) and Coronil (which could have compounded the immunosuppression). As the black fungus cases exploded across the country, and the condition became even scarier than Covid, I started to search the scientific literature trying to look into how strong a link there could be between these unique therapies in India and mucormycosis. While Coronil, (with its largely unknown constituents) and 2-Deoxy D Glucose, (with its potential to cause hyperglycemia) could certainly have created metabolic derangements in patients rendering them conducive to secondary fungal infections, I was shocked to learn that the causative organisms of mucormycosis, the fungi, Mucorales, are actually called ‘coprophilous’, literally meaning ‘dung-loving’ since they are known to have an affinity for herbivore dung, like cow dung!

With India mainly being an agricultural economy, with farmers using dung as a main source of manure, with the majority of Indians considering cow as a holy animal, even revering cow dung, and using it extensively and intimately, it was only natural to consider dung as the possible “additional” and unique source of Mucorales fungi infecting Indian patients.
With India mainly being an agricultural economy, with farmers using dung as a main source of manure, with the majority of Indians considering cow as a holy animal, even revering cow dung, and using it extensively and intimately, it was only natural to consider dung as the possible “additional” and unique source of Mucorales fungi infecting Indian patients. Dr. Jessy Skaria

Tanya Singh: Please give us a brief of your research, and the conclusions that you’ve derived from it so far.

Dr. Jessy Skaria: From that point on, I was focused on delving deep into the available medical literature on mucormycosis, Mucorales, Zygomycetes , and herbivore dung. The findings were truly mind-boggling to me. The fact that India was always known to have a disproportionately high caseload of mucormycosis (70-80% of the global burden) was a sure pointer that, apart from COVID, we have unique factors pushing up our risks of acquiring this infection. With India mainly being an agricultural economy, with farmers using dung as a main source of manure, with the majority of Indians considering cow as a holy animal, even revering cow dung, and using it extensively and intimately, it was only natural to consider dung as the possible “additional” and unique source of Mucorales fungi infecting Indian patients, even though the fungi themselves are considered ‘ubiquitous’. And I figured that the fact that no other country uses dung intimately to the degree that India does, could explain why India had such a disproportionately high burden of the disease in comparison to the rest of the world.

Further research only strengthened this association between cow dung use and mucormycosis in India. The very first glaring association was the noticeable rarity of ‘black fungus’ in my State of Kerala as compared to most other Indian States. This was especially significant since Kerala was struggling with the highest burden of COVID cases at the same time. But it only recorded a few cases of black fungus. Being well acquainted with our culture, I knew that what distinguished Kerala from the rest of Indian states was an almost universal lack of reverence for cow dung, which at best is only used as manure. The marked paucity of cases of Black Fungus in Kerala, therefore, was the primary epidemiological pointer to me that cow dung could have a definite role in India’s epidemic of mucormycosis.

With the help of a data scientist on Twitter, and media reports, I tracked daily cases of Black fungus in every region and state of India. It was also fortuitous that Mucormycosis was made a notifiable disease by the Health Ministry, which helped bring this data to the public domain. Very soon, I noticed a pattern - places that held community havans with smoldering cow dung cakes to ward off the Coronavirus, showed clusters of cases of Black fungus within weeks of the event. This was when I started researching the possibilities of the fungal spores spreading through the smoke. And came across a pioneering paper that showed viable fungal spores can travel hundreds of miles in the smoke of biomass fires! This was exciting knowledge.

Because, if I was right about this hypothesis of the spread of spores through smoke from dung fire, there was a clear explanation why India had the Mucormycosis peak in April-May: the huge bonfires of Holika Dahan in March with the burning of thousands of cow dung cakes must have spread so many spores into the Indian environment, to be inhaled by Indians, that as the second wave of the pandemic rolled into India and the patients’ immunity plummeted (both with Covid and its treatment with steroids), mucormycosis was almost the inevitable outcome among the vulnerable, especially the diabetics!

We are yet to arrive at the definite proof of the spread of fungal spores and toxins through dung fires. The one study done by PGI Chandigarh did not demonstrate a significant spread with the burning of cattle dung. Though, for the first time, they conclusively proved that cow dung- both fresh and dry samples- is a rich source of the specific types of Mucorales fungi causing Black Fungus in Indian patients.

We are yet to arrive at the definite proof of the spread of fungal spores and toxins through dung fires. The one study done by PGI Chandigarh did not demonstrate a significant spread with the burning of cattle dung.
We are yet to arrive at the definite proof of the spread of fungal spores and toxins through dung fires. The one study done by PGI Chandigarh did not demonstrate a significant spread with the burning of cattle dung.Dr. Jessy Skaria

Pyroaerobiology, an exciting new field of study in the USA, mainly evaluates the spread of microbial pathogens in wildfires- an emerging global threat, with the climate crisis. Initial studies have shown the likelihood of the spread of viable fungal spores in such wildfire smoke. We are awaiting results from more extensive studies for conclusive proof of the spread of microbes, spores, and toxins through the smoke of biomass fires.

Fungal toxins, called mycotoxins, are known to be heat-stable, and a recent study has also linked the pathogenesis of mucormycosis to a specific hyphal toxin called mucoricin- which could strengthen our hypothesis further.

Tanya Singh: After your first media publications on June 13th, 2021 in Countercurrents, what was the kind of response you received from your peers/healthcare researchers and professionals around the world?

Dr. Jessy Skaria: My first article in Countercurrents, brought mixed responses. From India, I received mostly condemnation. It was derided as a hypothesis aimed to bring disrepute to India, as racist, anti-Indian, and anti-Hindu. Valid questions were also asked as to why Mucormycosis affected even Indians who did not use cow dung, such as those in urban areas. These questions helped me research further into different possible modes of spread of the fungal spores into the environment. At the time of writing that article, I was only considering fresh and dried dung as the sources of spores. Since quite a lot of Indians use cow dung intimately, and since the friable dried dung can easily be aerosolized and be carried far by wind, I was mainly concentrating on such modes of spread. My hypothesis that the smoke of burning dung could also be a source of spore dispersal came later. The Countercurrents article, shared through social media and emails, did attract the attention of many reputed mycologists around the world, who mostly agreed that cow dung could contribute to India’s excessive caseload. Though there were naysayers, even among Western academics, who stubbornly hold on to the ‘ubiquitous’ nature of Mucorales and refuse to acknowledge the higher risk of mucormycosis with the extensive use of dung in India. (Ironically, these same researchers think that laundered hospital linen in Western healthcare institutions, which might be contaminated by - relatively fewer - Mucorales in their laundering facilities, poses a high risk of causing mucormycosis among the vulnerable patients in the hospital. Which I completely agree with, by the way. But, then why the double standard? At the same time, why not also accept that cow dung which potentially contains a significantly higher spore burden than washed hospital linen poses an equal or higher risk to those using it extensively? Talk about health inequities based on privilege!)

To attract serious medical research into the possible role of dung and other factors, I tried to publish my article as an academic hypothesis in Elsevier’s Medical Hypotheses. But when it was rejected by the journal after months of waiting, rather than wasting more time waiting on the academic publishing process, I self-published it on Medium. It was this Medium article that actually gained serious medical attention in the West, and enabled me to connect with eminent co-authors who helped publish it as a peer-reviewed hypothesis in the reputed American Journal of Microbiology, mBio.

Tanya Singh: What kind of help/support/evidence you’ve received so far that gives your research a strong, sturdy backbone support?

Dr. Jessy Skaria: Overall, I know that I am on the right path since not one respected mycologist I have directly communicated with has said, “You are wrong”. Indeed, many respected figures with expertise on Mucorales/Zygomycetes fungi have privately and publicly agreed that it is a very plausible hypothesis. Though some ‘clinical experts’ both in India and the West have ridiculed the hypothesis – asking me to prove it, knowing very well that proof for such an epidemiological association needs to be undertaken with multiple, large studies, which is beyond any one individual’s capability, especially a non-practicing physician settled in faraway USA!

For my part, I have done what little practical research I could do- by testing cow dung cakes exported into the USA from India (and purchased on Amazon) - at a reputed academic lab here. And they isolated different species of Mucorales and Aspergillus from these dung cakes, including the most commonly isolated species from Indian patients: Rhizopus arrhizus.

The recent isolation by researchers (including India’s most known mycologist, Prof. Arunaloke Chakrabarti) from PGI Chandigarh of Rhizopus arrhizus and Lichtheimia corymbifera (the common pathogenic Mucorales isolated among Indian patients of mucormycosis) - from 75% of fresh cow dung and 50% of dried cow dung samples - proves beyond any doubt that cow dung is a rich source of Mucorales, particularly the specific species of the pathogen that most commonly causes Black fungus in India. When Indians are known to use cow dung disproportionately extensively and intimately, this study alone should be enough to prompt the Health Ministry and ICMR to issue public advisories to Indians on the high risk we face with our traditional and agricultural practices involving so much dung.

In this context, it is worthwhile to look at how the West deals with another fungal illness – Histoplasmosis. The disease, which is more prevalent in the West, is thought to be a high risk to people exposed to fungal spores in bat and bird droppings, and they are warned through public advisories about the risk of Histoplasmosis and educated on ways of reducing the risk. And this is despite the fact that it’s more an epidemiological association of the increased risk than substantial lab isolation of Histoplasmosis spores in bird or bat droppings that have prompted such clear and extensive public advisories! So why not follow that same example in the case of another dung which has actually been conclusively shown to carry large amounts of the spores of a fungus that causes a terrible illness in India? This hypocrisy, as I said earlier, is just another example of health inequity based on privilege. What is risky for the privileged Western population is simply ‘ubiquitous’ and hence ‘normal’ for the poor in developing countries!

I also researched the use of dung in other countries and identified a few other countries at risk – particularly Iran. Through social media, I had repeatedly warned as cases of mucormycosis started rising in Iran- since Iranians use and revere female donkey dung (called Anbarnesa) the same way as Indians do cow dung. It is heartening to see that researchers in Iran are now connecting Anbarnesa to mucormycosis patients.

Pyroaerobiology experts have already obtained evidence of the spread of microbial pathogens including fungal spores in wild forest fire smoke. Larger studies are underway, and we are confident they will prove beyond doubt the spread of viable fungal spores and toxins in biomass smoke, and by extension, such spread through dung smoke.

Tanya Singh: What difficulties or obstacles did you face in your research?

Dr. Jessy Skaria: What I have realized in these months researching the potential role of herbivore dung in the causation of mucormycosis is frankly petrifying:

A) Even in this 21st century, science takes a back seat to religion and traditions. We are willing to sacrifice the health and welfare of our people on the altar of long-standing and entrenched beliefs and habits, rather than raise public awareness on such dangerous practices.

B) The appalling inequity in healthcare between the rich and the poor, the privileged and the underprivileged, developed and developing countries- is a systematic crime against humanity, for which global medical organizations including the WHO and India’s own ICMR, and eminent academicians, researchers, and physicians need to be held accountable. Why is the presence of dangerous microbes and mycotoxins in the dung of dairy animals not studied, while extensive research is done to prevent the spread of diseases through milk and meat? The answer is very simple. Milk and meat are used by all the privileged and the underprivileged. Exposure of humans to dung pathogens, on the other hand, is a problem almost exclusive to the poor and the developing world.  

The majority of the victims of such terrible ‘dung’ diseases are agricultural and dairy workers and rural/nomadic populations in poorer economies, who use/are in contact with dung excessively, with no personal protective gear.

In a way, one should be thankful to COVID for exposing this inequity so vividly in different ways, the CAM (Covid Associated Mucormycosis) epidemic in India being a prime example.

Why did the CAM epidemic in India garner so much attention?

Three points come to mind:

a) Unlike non-COVID-related mucormycosis which is usually confined to the rural poor, CAM affected even urban and affluent Indians. Because COVID was non-discriminatory and compromised the immunity of all (especially the ones treated with steroids) and played havoc with blood sugar levels in diabetics and others prone to hyperglycemia, too many urban, wealthy Indians fell prey to the effects of the increased environmental Mucorales spores in India at that time. These spores in urban India, I postulate, were likely released by the cow dung bonfires of Holika Dahan, and the community havans held even in urban localities to ward off the Coronavirus. Once super-specialty hospitals in metropolitan cities started seeing these clusters of affluent urban CAM patients, it became grave news.

b) So, is mucormycosis a rare condition in India? Is that why we got rattled by the sudden burst in ‘black fungus’ cases during the COVID second wave? To answer this question, we need to understand the gravity of some startling statistics, before and during the CAM “epidemic”.

This paper published in 2019 (before the CAM epidemic) and authored by Professor Arunaloke Chakrabarti -considered the foremost mycologist in India – quotes these staggering numbers from a reputed fungal disease monitoring portal, LIFE: “The true incidence/prevalence may be more in mucormycosis, as many of the cases remain undiagnosed due to difficulty in collecting the sample from deep tissue and low sensitivity of diagnostic tests. The Leading International Fungal Education (LIFE) portal has estimated the burden of serious fungal infections globally. According to their estimate, the annual prevalence of mucormycosis might be around 10,000 cases in the world barring India. After the inclusion of Indian data, the estimate of mucormycosis rose to 910,000 cases globally.”

So, here is the scary truth. Even before our dreaded “black fungus epidemic” in 2021, mycologists were aware of the terrible mucormycosis disease burden in India. From their estimate, India has an annual prevalence of 900,000 cases!! Which translates to 450,000 cases in 6 months.

Be prepared to be shocked when one compares this with the numbers released by the Indian government during the peak of the “black fungus epidemic” in the six months from May to November 2021: 51,775 new cases! Almost 10 times less than what was estimated in a “normal” pre-CAM year by experts!!

What does this say? In ‘normal times’, Indians still suffer disproportionately and horribly from mucormycosis - but it is the wrong kind of Indians, who don’t grab/deserve news headlines. The poor, the farmers, who rarely reach the multispecialty hospitals in the metros. The many who die in their homes, never getting any form of treatment for the suspected “infected insect bite” on the face. The fact that Invasive Fungal Diseases like mucormycosis are known as ‘opportunistic infections’ affecting mainly the vulnerable and the immunocompromised, has also probably not helped in getting this disease much scrutiny.

c) The third reason CAM got so much attention was that the West, already spooked by COVID, got further rattled by this terrible disease complicating COVID in Indian patients. The worry was - What if it spread to the West along with the Delta variant? Over Twitter, I had many debates where I confidently said it was unlikely since India had its own unique reasons for the ‘epidemic’. While never fully agreeing with my reasoning, the relief was palpable, when Delta did spread to the West, but ‘black fungus’ did not. And once the privileged felt safe in their clean, dung-free environments, there were no more debates on how strong a role is played by increased environmental spore loads in causing mucormycosis- it was conveniently back to ‘ubiquitous’. Because it affects the ‘ubiquitous’- the disposable, nameless masses that no one cares for- neither the prestigious global health organizations, the well-funded researchers, nor their own selfish governments….

Yes. We should be ashamed of the unacceptable health inequity in this world even in the 21st century.

And that brings me to my vision for the future of healthcare. Where wealth and privilege, and research grants from the wealthy and the privileged do not dictate what gets research priority, and who gets the benefits of research.

Tanya Singh: What are your future goals with respect to your research and what change do you want to bring about in the society with it?

Dr. Jessy Skaria: A future where science exists for truth and progress and health for all, and not as business ventures to help only the privileged or to garner wealth for big pharma, labs, hospitals, organizations, and governments. Where science will not be cowed by age-old dangerous traditions that are still propagated for selfish political and religious gains at the cost of precious lives.

A science for all. For the one life, we all have.

MedBoundTimes is extremely grateful to Dr. Jessy Skaria for sparing her time and sharing her research journey with us.

Editor’s note: Since this conversation in January 2023, Dr. Skaria has informed us that a new study by international authors published in the Journal Mycoses shows that the environmental fungal spore-load in the Delhi NCR region peaked in the 3-4 weeks (from March 29- April 26, 2021), preceding the surge of CAM cases in their hospital. Incidentally, Dr. Skaria adds, March 29 was the day after Holika Dahan on March 28, 2021- a fact that she feels further validates her hypothesis.

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