Jessy Skaria

In 2021, when the world was focused on the COVID pandemic, Indians were caught in the glare of an additional nemesis — the dreaded “Black Fungus”. The condition struck a chill in our hearts. Images in the media of suffering patients with their stories of utter despair sent waves of panic through the country. The infection killed many of its victims, while even the “lucky” survivors faced physical disfiguration, debilitating surgeries and long periods of recovery, made worse by the crippling financial costs of treatment. Black Fungus made even COVID appear benign in comparison. As the country searched frantically for answers, What is Black Fungus? became the most recorded Google query among Indians in 2021.

What is Black Fungus? Why is it so dreaded? Why does it seem such a particularly “Indian affliction’’?

As most Indians know by now, Black Fungus or mucormycosis (as it is correctly called) is an opportunistic fungal infection, caused by a group of fungi called Mucorales. These fungi are ubiquitous, meaning they are present all over the world. And yet, mucormycosis is a relatively lesser-known disease globally, even among doctors. This is because humans are typically resistant to fungal pathogens; this immunity keeps most of us safe, even if we come in contact with these microbes on a regular basis. The word “opportunistic” indicates that the fungus causes illness (i.e., mucormycosis) in humans only when the human host is weak or prone to infections, as with any kind of immunocompromise or conditions like diabetes. And hence the rarity in our acquaintance with this villainous microbe.

Mucormycosis and Black Fungus became household names in India when the condition wreaked unimaginable havoc across the country during the second wave of the COVID pandemic. The world watched with dread as well — wondering if the condition would spread globally from India along with the Delta variant of the Coronavirus — and then breathed a sigh of relief when it did not. Except for a few scattered cases worldwide — only Iran had a sharp increase with more than hundreds of cases recorded — Black Fungus remained staunchly Indian. Official statistics put the number of Indian cases recorded in the period of six months between May 20, 2021 and November 29, 2021 as 51,775.

51,775 cases is a huge, unacceptably huge number, by any means. But, if we took a step back and studied the available medical literature closely, we would realise that the truth is more nuanced, that this sudden “surge” during the pandemic is just the tip of a particularly dangerous Indian iceberg.

In a peer-reviewed article from February 2019 — months before the onset of the COVID pandemic — leading Indian mycologist, Professor Arunaloke Chakrabarti quotes a stunning statistic from the Leading International Fungal Education (LIFE) portal: that India’s estimated annual (pre-COVID) prevalence of mucormycosis is 900,000 cases! Which translates to 450,000 cases in 6 months, and a virtually unthinkable 2500 cases per day!

And here we are, quaking with dread, googling frantically, when a 6-month officially recorded figure of 51,775 cases bursts in the open during the COVID pandemic- almost 8 times less than what was estimated in pre-COVID 2019!

Of course, the reported figure of 900,000 was only an estimate. But remember, this estimate was offered by a leading global fungal infections monitoring portal, and quoted by the foremost mycologist in India, in a peer-reviewed paper.

Time for a reality check.

India, with her teeming billion plus population, has always had a cavalier, almost laid-back attitude to deaths and diseases in general, and a casual unconcern for routine health statistics. A certain iconic line, although uttered — and immortalized — in a different context, voices this attitude aptly: ‘Bade bade deshon mein aaisi choti choti baatein hoti rehti hain’. We simply take thousands of deaths daily in our stride. For example, how many of us know or care that more than 2.6 million Indians contract tuberculosis (TB) every year and over 400,000 succumb to it annually? Which means that, on average, more than 1095 Indians die of TB every day. Routine. Not worth our notice. But we do sit up and take notice when there is an unusual surge. Especially if the surges take place in the affluent urban or suburban areas. If 100 TB patients were to be admitted to a single tertiary hospital in Mumbai at the same time, and 25 of them succumbed to the condition in one day, it would certainly make national headlines. And if this ‘unusual pattern’ trended for a period of time, instead of black fungus, Indians would be online frantically searching answers to “What is TB?” and “How to avoid getting TB?”

The fact is, for India to tackle the menace of “black fungus” or mucormycosis appropriately, we need to first accept that India has always had a disproportionately huge and long-standing problem with this rare opportunistic fungal infection.

We’ve always had an invisible epidemic! That’s the truth.

The reasons for this lack of visibility could be many. Maybe the condition goes largely undiagnosed. Fungal infections are notoriously underdiagnosed and underestimated, even in developed countries. And India’s lack of such diagnostic facilities has been a matter of concern for mycologists all along. It is also likely to be more prevalent among the poorer and rural populations, such as the farming communities, with infections going untreated and unreported. And again, since the affected individuals are most likely to be in the vulnerable, immunocompromised, diabetic or elderly categories, infections and deaths among such patients may not attract much scrutiny.

What changed in the second wave was that COVID, with its equal-opportunity affliction of all — the condition did not discriminate between rich or poor, urban or rural — along with its accompanying problems: especially the use of steroids in its treatment further lowering the immunity of the infected patients and worsening the blood sugar levels of diabetics, in conjunction with the very unique Indian ways practiced widely to fend off the virus, caused a surge of mucormycosis among Indians, particularly and very dramatically among the urban, affluent population, and brought this as yet unnoticed problem starkly to our attention.

It is thus not a new problem, but a chronic, hitherto casually under-recognized one.

From an Indian perspective, only a holistic, open-minded approach to its management will help us solve this problem.

The first step in this approach would be to seek answers to the question “Why India specifically?”

Of all the answers put forward in response, so far, by the experts, let us consider the two most important ones:

1. Host susceptibility: with India’s high numbers of diabetic patients — many of them undiagnosed or poorly controlled — we do provide the fungi with a large cohort of hosts vulnerable to an opportunistic infection.

2. High environmental fungal loads: Although only a few studies have been conducted to measure the environmental load of Mucorales spores, it has been shown that many parts of India have abnormally high levels of these spores in the outside air.

Ideally, we should have thoroughly explored both the host and environmental factors that could be held responsible for our high prevalence of mucormycosis cases. Instead, what we saw during the Covid-associated mucormycosis (CAM) epidemic was an abnormally skewed exploration of only the host factors. All through our “Black fungus Epidemic”, experts have been concentrating almost solely on the clinical profile of patients likely to contract mucormycosis- those with COVID/ treated with STEROIDS/ and those with DIABETES MELLITUS. They have repeatedly and aggressively hammered this information into the Indian minds so much so that many Indians now consider themselves lucky if they contracted COVID or are diabetics, and yet escaped the dreaded ‘black fungus’. With our innate subservient attitude to authority, not many patients or their families have asked the question: “Even given my clinical problems (COVID/steroids and/or diabetes), what are the chances that I would have contracted mucormycosis had I lived outside of India? When so many diabetics around the world are getting COVID and are being treated with steroids, why are Indians so particularly vulnerable to contracting the black fungus?”

It’s time to ask these unasked questions, which would invariably bring us to another: Why do many parts of India have exceptionally high Mucorales spore loads? What does India do different from the rest of the world that could contribute to this high environmental fungal load?

At the beginning of the CAM epidemic in April-May 2021, many Indian doctors pointed out a probable cause for our mucormycosis crisis: Indian traditions involving the excessive use of cow dung and urine. It made perfect sense. Cow dung — in fact all herbivore dung — is known to harbour Mucorales fungi (which are called coprophilous or dung-loving). And India has always had a special and close relationship with the cow and with bovine products, including dung and urine. Many of these doctors called for restricting the personal use of cow excreta in order to avoid getting infected with mucormycosis. But most of these sensible voices faded by mid- May, possibly from lack of adequate media coverage. Following this, only isolated opinions on this issue were heard, mainly on social media and infrequently on online media portals, my article published in the Countercurrents in June being an example of the latter.

A few of us interested physicians and public health professionals continued our queries along these lines. We followed the mucormycosis epidemic closely, as we attempted to see how it intersected with both the host and environmental factors.

Soon, it became obvious that there is a pattern. Areas where community havans with burning cow dung were held to ward off Corona subsequently showed major clusters of cases of mucormycosis, whereas regions within India which did not indulge in such activities were relatively spared. Here, then, was the potential basis of understanding the high environmental load of Mucorales in India! The fungal spores present in dung are potentially dispersed widely through smoke, thus exposing everyone who breathes in such air to infection with the Mucorales spores. However, mucormycosis being an opportunistic infection, only the vulnerable, including the diabetics, the immunocompromised, or the COVID infected, actually contracted the condition. Medical literature supports such spread of fungal spores in fumes and wind, and experts in the field of pyroaerobiology agree that this is plausible.

Armed with this corroborating information, we have embarked on the long and arduous process of proving a potential causative association between fumes from burning biomass — including herbivore dung and crop stubble — and invasive fungal diseases, including mucormycosis and aspergillosis, in vulnerable populations exposed to such smoke, anywhere in the world. Evidence-based medicine being a necessarily rigorous process, we know that the frustrating wait for academic validation and conclusive proof must be endured patiently. We only wished that in the meantime, there was a way to warn potential patients about avoiding this possibly dangerous exposure. In an attempt at achieving this objective, we have issued multiple and continuous warnings through social media posts, trying to engage with as many influential people as possible, to disseminate the message. Even while cognisant of the limitations of our reach, we never stopped trying.

It was a relief, then, as doctors in India announced a decline in mucormycosis by September, accompanying a fall in COVID cases — welcome news indeed. The relief was, however, short-lived, as another possible startling connection with mucormycosis came to the fore, with the potential for serious imminent danger.

Indian festivals are colorful, bright occasions, with many of them involving bonfires or ritual fires. And I was aware of the increasingly popular recent trend to use cow dung, in lieu of the traditional wood, as fuel in the festive fires. With the knowledge garnered about the potential spread of Mucorales spores through dung fumes, I realised the possible high risk involved for the Indians attending such festivities and inhaling the smoke from burning cow dung. October-November is the main festival season in India, with Diwali being the most popular of them. Media reports were celebrating the “green” Diwali oil lamps or diyas made of cow dung, with news about millions of them being prepared for sale prior to the festival! If the “cow dung hypothesis” was correct, if the Mucorales spores did indeed spread through smoke from smoldering cow dung, unsuspecting Indians were again in dire danger of getting the dreaded black fungus! With crop-stubble burning also in progress, I was seized with a sense of urgency to try and prevent more suffering, and shot off urgent emails early in October to all responsible leaders I could think of — including the Prime Minister, the Union Health Minister, the Principal Scientific Advisor, the Indian Council for Medical research (ICMR), the World Health Organisation (WHO) and even some well-known media personalities. I never received any responses. The few of us who believed in this hypothesis also made efforts to warn as many Indians as possible through social media platforms. I specifically contacted, tweeted at and tagged reporters and doctors, in an attempt to spread the word. Except for some scattered individual support, the warnings were largely ignored. Diwali was celebrated in many places with cow dung diyas. Our helplessness at not being able to avert the crisis was, however, replaced by scientific curiosity. Now, if the cases did go up post-Diwali, it would certainly be a validation of our hypothesis, and the academicians, doctors, leaders and journalists whom I had warned would have to acknowledge that. It might prompt honest research into our hypothesis, and ultimately help potential future patients. But what followed was a disturbing concerted silence on the topic, an almost deliberate avoidance in the mainstream media. However, by diligently gathering news from different online portals, especially regional media websites and social media, there is now enough evidence that there was an additional spike after Diwali ; that mucormycosis cases have gone up quite noticeably in many places where cow dung diyas were used extensively. Regional newspapers, such as this one from Lucknow, report them with alarming headlines like “Black Fungus Returns”.

Now here follows the crux of the matter I want to highlight, the reason why I would like this article to be read and understood, as soon as possible, by all Indians and interested mycologists:

Diwali, as we know, does not follow the Gregorian calendar — the date varies from year to year. This year, it fell on November 4th. Last year, in 2020, it happened to be on November 15th. In 2022, it will fall on October 24th. There is only limited data in the academic literature about the incubation period of mucormycosis: incubation period refers to the time between exposure to a disease-causing organism (bacterium, virus or fungus) to the manifestation of the illness (that is, when symptoms and signs of the illness become apparent). It is also important to understand that the same infection may have different presentations (or forms) and incubation periods, based on the manner of exposure to the pathogen. Percutaneous inoculation of the Mucorales fungus causing cutaneous mucormycosis, for example, is reported to have an incubation period of 1–2 weeks .This means that after being exposed to the Mucorales fungi through a cut or burn in the skin, a vulnerable patient would develop symptoms of mucormycosis in about 1–2 weeks. But there is virtually no data in the medical literature about the incubation period for the rhino-orbito-cerebral mucormycosis (ROCM), which is the most common presentation in India, and the form of mucormycosis most likely to result from inhalation of the fungal spores, such as through smoke. From our research of CAM and based on the assumption that our hypothesis is correct, I am of the impression that the incubation period of ROCM is 2–5 weeks (or roughly 10–40 days). I came to this conclusion mainly based on the time interval between reported cow dung smoke exposure (such as through community havans) and reports of clusters of mucormycosis cases within the same communities. And from the history of cow dung smoke exposure prior to diagnosis in the few patients I could contact directly. And this was why, through social media, I took the bold and risky step of predicting a rise in mucormycosis cases after mid-November this year, based on the hypothesis that increased infections would start manifesting by 2–5 weeks following the inhalation of spore-laden fumes from the cow dung diyas lit during Diwali on November 4th.

Here are some regional media reports (I used Google translate to read in English) that show that the prediction appears to have sadly come true, with multiple instances of patients admitted to different hospitals, and labs diagnosing higher numbers of mucormycosis in and around places where cow dung diyas were lit extensively:

· November 17, Moradabad, Uttar Pradesh (UP)

· November 19, Noida, UP

· November 23, Mehsana, Gujarat.

· November 24, Delhi

· November 28, Vadodara, Gujarat

· November 30, Jamnagar, Gujarat

· December 3, Rohtak, Haryana

· Dec 4, Hisar, Haryana

· Dec 4, Hisar, Haryana

· Dec 4, Indore, Madhya Pradesh

· Dec 5, Hisar, Haryana

· Dec 7, Hisar, Haryana

· Dec 8, Hisar, Haryana

· Dec 9, Vijayawada, Andhra Pradesh

· Dec 10, Rohtak, Haryana

· Dec 10, Vadodara, Gujarat

· Dec 13, Hisar, Haryana

· Dec 13, Lucknow, UP

· Dec 14, Hisar, Haryana.

· Dec 15, Patna, Bihar

· Dec 22, Vadodara, Gujarat

· Dec 26, Rohtak, Haryana

So, yes, as feared, there certainly was a surge 2–5 weeks post-Diwali this year.

Next, I decided to check for media reports of similar clusters 2–5 weeks after Diwali last year (2020), which was celebrated on Nov 15th. And there it was! Multiple reports of clusters during the first three weeks of December from places ranging from Delhi, Ahmedabad, Rajkot, Vadodara, Bengaluru — again, places where cow dung diyas were used during Diwali. .

· Dec15, Delhi

· Dec 16, Delhi, Bengaluru, Ahmedabad

· Dec 17, Ahmedabad, Gujarat:

· Dec 17, Hyderabad, Telangana

· Dec19, Tamil Nadu

· Dec19, Ahmedabad, Rajkot, Gujarat:

· Dec 21, Vadodara, Gujarat :

· Dec 27, Bengaluru, Karnataka

· This was a huge surprise: to see that a peer-reviewed academic paper about mucormycosis cases in India between September and December 2020 was actually headlined by a leading newspaper as “Mucormycosis recorded 46% mortality in “post-Diwali surge”! So, clearly, the journalists and doctors in India are aware of a post-Diwali surge! They simply didn’t want to look further into “why”. Interestingly, the same academic paper mentions this statistic: “We noted a 2.1-fold rise in mucormycosis during the study period compared with September–December 2019.” It is worth noting here that for the first time in India, a National Cow Commission (Rashtriya Kamdhenu Aayog) was established by the Government of India in February, 2019. And a major initiative of this Cow Commission was to make millions of ‘eco-friendly cow dung diyas for Diwali’ in 2020! This tradition was continued with increased vigor in 2021! And, of course, in both those years, our mucormycosis cases have exploded post-Diwali!

· Other articles also mention “the Diwali wave” of 2020.

Most 2020 reports show that the cases started rising in the first half of December, with clustering and worrisome media reports appearing in the second half of December. So much so that Rajasthan, on the15th of December, and Gujarat, on the 21st had issued advisories warning about the rising cases of mucormycosis.

In comparison, in 2021, the reported cases, seem to have started rising in the second half of November, with clustering mainly in the first half of December. In the absence of actual epidemiological studies with accurate daily counts of cases, these reports gave me a rough pointer: Diwali, which came 11 days earlier this year (Nov 4, 2021 as opposed to Nov 15 in 2020), has also given rise to clusters of mucormycosis about 11 days earlier in 2021 as compared to 2020! The 11-day difference in the festival dates is almost directly reflected in the pattern of rise of cases and clusters. Not an accurate science, but with the limited information available to me, I felt I was onto something here.

I returned to the Indian festival calendar, and realised that 2–5 weeks before all hell broke loose in India with the second COVID wave and the CAM epidemic in April-May 2021, we had another major festival celebrated with huge bonfires using cow dung: Holi, with Holika Dahan (burning of the Holika- an important purifying ritual held the night before Holi) on March 28th. In recent years, Holika Dahan had started using huge piles of cow dung for the bonfires. Interestingly, while COVID norms restricted public gatherings in many places in India during Holi this year, the ritual of Holika Dahan was mostly allowed to happen. And observed across India.

Now, here is a piece of information that I think might have made things worse for the urban Indians: Because of the restriction for gatherings in open public places like parks, many housing societies across India had conducted Holika dahan in their own premises, very close to the living quarters of people. Watching videos of the flames leaping up the many levels of apartments, it’s understandable why urban India suffered so much from “black fungus” during this COVID pandemic.

Though Holi is a very popular festival in most of India, the fact that parts of India — for example, cities like Jaipur, in Rajasthan — which aggressively promoted cow dung Holika dahans, were subsequently particularly afflicted by black fungus cases needs mention here. Also that states like Kerala, where Holi is not a popular festival did not have a significant caseload of mucormycosis cases.

We are currently in the process of researching and testing out these potential correlations. But by now, we are aware of the difficulties involved in obtaining academic approval for unconventional ideas, especially when they might outrage religious or political sensitivities, and are not easily proven conclusively in a lab. Even as we continue the much needed efforts for academic validation, I feel what knowledge we have garnered so far needs to be out in the public domain, as visible as possible, to anyone who cares to know more about how to avoid contracting “black fungus”. That this hypothesis needs to be available to every Indian frantically trying to find answers to “What is Black Fungus?” online. Hence this article.

I know that medical professionals in India who have been acquainted with this hypothesis already would, in all probability, warn their own loved ones to stay away from cow dung/biomass fumes. But they would still shy away from publicly voicing these warnings and helping in the much-needed research and large-scale epidemiological studies to prove or refute our findings. The tragedy that plays out when science and logic bow to fear, sycophancy and regressive traditions.

And finally, a word about real, on the ground implications for the near future:

In mid-January 2022, India will celebrate LohriPongalSankrantiBhogi — in different parts of the country, all festivals involving fires that use dried cow dung or other Mucorales-rich biomass like vegetation as fuel. In line with my previous observations, this year, in February, 2021, 2–5 weeks after these festivals on January 13–16, 2021, there were reports of rising numbers of mucormycosis cases — from places as diverse and far-flung as Delhi, Mumbai, Hyderabad and Madurai.

In February 2022, I fervently hope to not see more of my fellow Indians unnecessarily suffering from this most dreaded of infections. For that, I firmly believe that they will have to stay away from breathing in fumes of burning cow dung. In the coming year, I would like our people to be aware of the hidden dangers — awareness that would lead them to avoid the use of cow/herbivore dung as fuel, and to take care to avoid exposure to such fumes — in domestic/ritual fires or festive bonfires. I am aware that this change might take time, but sincerely hope the delay is at least not due to lack of awareness and education about the risks. It was heartening to see the first instance in December, after months of our campaigning, where an Indian doctor was quoted in the media advising people to avoid smoke to prevent black fungus. Yes, it was still only in a regional paper. But a hopeful sign nevertheless — that the change will happen, slowly but surely.

Meanwhile, I would like to challenge our scientists to test out this hypothesis. Measuring environmental Mucorales spore loads before, during and after a cow dung festive fire should be done wherever such bonfires are lit. And those readings compared with samples taken at the same time from areas in India where the practice of such bonfires is not observed. Scientific bodies like ICMR, medical organisations like the Indian Medical Association (IMA) and expert mycologists in India are sure to have the resources to obtain these measurements without much difficulty.

Let honest science prove or disprove this hypothesis. Even as we wait patiently for conclusive results one way or the other, may our festivals and celebrations always bring joy, health, peace and prosperity, but never the hidden ‘black fungus’. Let us reduce our exposure to animal dung, especially the fumes of burning dung. We owe that much to ourselves and our loved ones.

Take care, India. Together, as we gingerly — yet hopefully — step into 2022, let us try and defeat this terrible scourge of “black fungus”.

P.S: What validates that pre-COVID estimate of 900000 prevalence annually by LIFE mentioned earlier?

  • Possibly the fact that 54% households in India use solid fuels (including wood and animal dung). Which could translate to millions of Indians breathing in aerosolized Mucorales spores every day. Elevating the common wisdom of “Mucor in every breath we take” to a very different level in India!
  • 2014 study from the eminent PGIMER, Chandigarh with these damning statistics: “Seven out of every 1,000 patients admitted in ICUs across India are affected with fungal infection.” “At 39.55 per 1,000 patients, Global Hospitals of Hyderabad recorded the highest rate of infection. Delhi’s Safdarjung Hospital was second worst with 32.75 people per every 1,000 affected with fungal infection.” “Nearly 10 per cent of farmers and agricultural workers going blind can be attributed to fungal infection.”
  • courtesy medium