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C.S. Enwemeka, et al. Journal of Photochemistry & Photobiology, B: Biology 207 (2020) 111891 25 years before the 1918 pandemic, a Danish physician, Niels Ryberg Finsen, had developed a light source that was successful in curing pa- tients with skin tuberculosis (lupus vulgaris) and other ailments [20,21]. Between 1896 and 1901, he treated as many as 804 patients with skin tuberculosis and similar microbial infections at his Medical Light Institute, achieving 83% cure rate [20,21,22]. The Finsen lamp became widely popular and was adopted in most of Europe and North America, earning Finsen the Nobel Prize in 1903. Finsen himself ac- knowledged the healing power of sunlight but erroneously assumed that his lamp took advantage of the UV spectrum of radiation. It is quite conceivable that his pioneering work spurred many in the healthcare industry to use sunlight to treat victims of the 1918 influenza pandemic and beyond. To date, studies continue to extol the susceptibility of viruses to rays emanating from the sun [11,16]. 3. From Heliotherapy to Photobiomodulation While it is obvious that Finsen pioneered the scientific doc- umentation of the bactericidal effect of light, the use of light to treat a variety of diseases predates him. Perhaps the earliest record of sunlight as medical treatment dates back to the time of Egyptian Pharaohs—more than 5000 BCE—as evidenced by images, arche- ological findings and artifacts [23–26]. A popular ancient Egyptian image clearly shows a family exposing themselves to the healing rays of the sun (Fig. 1). Veneration of the sun and acknowledgement of its healing power remains a cultural practice in most of Africa, and early records indicate that the Egyptians treated chronic ulcers successfully by exposing them to sunlight [23,24]. Furthermore, sunbathing was a common practice, not just in ancient Egypt, Babylonia and Mesopo- tamia, but ancient Greece and Rome [23–26]. The Greeks and the Romans clearly recognized the healing power of the sun. They built solariums and sunbaths, and the Greeks even used them to enhance the strength of athletes preparing for the Olympic Games by exposing them to several months of sunlight treatment. The word, heliotherapy, actually derives from the Greek name for their sun god, “Helios”; heliotherapy meaning sunlight therapy [23–26]. Fur- thermore, Ayurvedic medical records show that as far back and 1400 BCE; Hindus used the combination of sunlight and photosensitive herbs, such as furocoumarins, to treat vitiligo and other conditions—a combined treatment, which many refer to today as photodynamic therapy [27]. Moreover, records indicate that heliotherapy was a Fig. 1. An image showing Akhenaten, Nefertiti and three children exposing themselves and a house plant to the healing rays of sunlight. The religious symbols in the image suggest that the Ancient Egyptians venerated and wor- shipped the sun. Adapted from: https://www.sciencephoto.com/media/1005027/view/ egyptian-pharaoh-akhenaten-and-nefertiti. 19, serves as a vivid reminder that nature is unpredictable; no one knows what disease epidemic might emerge and defy available clinical armamentaria. With over 2.97 million confirmed cases and more than 260,000 deaths worldwide within a mere four months (as of Sunday, April 26, 2020), the world has—once again—become gripped with untold fear and panic as the number of those sick or dying continues to climb by the minute [6]. Further raising the level of fear are the por- tentous economic consequences, which has risen to hitherto unim- aginable heights and continues to worsen. That some of the world's largest economies—the US, China, Germany, France, Britain, Italy, Spain South Korea and Switzerland—rank among the worst hit coun- tries, cast a dark shadow on the future of the world as we know it. These developments call for immediate mobilization of every available tool to fight the disease. A frantic search for effective treatments is underway to stem the pandemic and give hope to billions quarantined—willingly or unwillingly—worldwide. However, the world continues to race against time given the rate of spread and the long period usually re- quired to develop effective vaccines. Whereas some of the important lessons learned from past pan- demics, such as social distancing, the use of facemasks and the search for new vaccines, have been marshalled to mitigate the pandemic, re- cords indicate that, phototherapy, one of the most effective tools used to minimize the impact of the 1918 pandemic and other disease epi- demics [7–9] has been overlooked. This paper suggests that photo- therapy, a seemingly forgotten treatment for bacterial and viral infec- tions, has immense potential to reduce the impact of COVID-19 pandemic and similar coronavirus infections, particularly in view of recent developments in the field. Further, it reviews contemporary evidence for this assertion, and offers suggested ways that modern healthcare may integrate readily available inexpensive light technolo- gies in its stash of clinical tools for patients with COVID-19 and other infections. 2. Disease Epidemics, Pandemics and Phototherapy In 1918, governments and the medical establishment frantically sought every means to fight the H1N1 flu pandemic, but the results were mixed. Available reports clearly show that sunlight was effective in reducing flu-related mortality and morbidity, and person-to-person infection [7–9]. Patients with severe infections exposed to sunlight therapy outdoors recovered better than those treated indoors, and the treatment prevented death among patients and infections among the healthcare workers [8–10]. Like the 1918 pandemic, most of those succumbing to COVID-19 pandemic today die from disease-related complications, such as pul- monary inflammation/edema, pneumonia and acute respiratory dis- order syndrome (ARDS). In the case of the 1918 flu, overcrowding in poorly lit and poorly ventilated enclosures raised associated risks of infection, a major reason that the City of Boston was badly hit by the flu until exposure to sunlight was introduced [7–10]. By one anonymous editorial account [9], the Massachusetts State Health Department found sunlight therapy to be “the most valuable factor in reducing mortality,” decreasing fatality of hospitalized patients from 40% to 13%, boosting flu immunity among physicians and nurses, and overall, besting the outcome of vaccines, which, then, were in their early stages of devel- opment [6–9]. The benefit of exposure to the healing rays of the sun was so obvious that it became a common form of treatment against tuberculosis—another respiratory disorder, as well as wound infections, psoriasis, acne vulgaris, rickettsia, depression, jaundice, and a host of other diseases [10–19]. Indeed, records indicate that across North America, many healthcare facilities built sunrooms to which patients were wheeled for sun therapy, then known as heliotherapy [11]. Written accounts of the successes of heliotherapy abound, and as the treatment became popular, it was adapted to include treatment with various lamps [15–19]. None of the foregoing should come as a surprise, because less than 2PDF Image | Light as a potential treatment for pandemic coronavirus infections
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