Covid-19 has humbled the world over the past month. An unimaginable chain of events has put the healthcare industry at the forefront in the fight against the virus.
Each country is trying to evolve a unique strategy to reduce their disease burden and mortality rate. The virus too is testing the ability of different healthcare systems to deliver safe outcomes in an unprecedented situation.
Keeping in mind the inability of healthcare systems in developed countries to prevent mortalities, India is pinning its hope on stringent lockdown measures to restrict the virus’s spread. This is a tacit acceptance of the limitations of our healthcare system. Although concerns remain over testing, the quality of travel screening and the timing of the lockdown, the acceptance of restrictive measures by the public reflects an understanding of the consequences of the outbreak.
In the social media buzz associated with travel bans, the number of people infected and unprecedented mass migration of unorganized workers, the focus on frontline healthcare workers seems to be getting lost.
The current healthcare situation and dwindling lines of defence
The number of infected and seriously ill Covid-19 patients has increased exponentially over the past week. This is alarming, since cases aren’t only confined to designated government hospitals in large metro cities, like Mumbai and Delhi. The virus is rapidly spreading to smaller towns with limited healthcare infrastructure.
First Line of Defence — Family Physicians
In a ‘war’, general physicians (GPs) can be compared to foot soldiers, who defend the healthcare system from getting overwhelmed by patients with minor ailments.
Over the past few weeks, there have been cases of family physicians contracting the infection from asymptomatic Covid patients. These GPs in turn have spread the disease to many patients, particularly in Bhilwara, Mumbai and Agra. This vulnerability to Covid-19 has led to many GPs closing their practice or operating on limited working hours.
It would be a catastrophe if patients with minor illnesses are forced to visit overstretched hospitals handling Covid cases or start self-medicating.
Second Line of Defence — Nursing Homes –
With a limited 1.15% of GDP spend on healthcare, India has developed a unique healthcare delivery system where nursing homes provide secondary care to each strata of society. The Covid pandemic has led to many nursing homes shutting down because of official guidelines to stop elective work to conserve resources and to limit the risk of Covid infection spreading to patients. Although these establishments are allowed to continue emergency work, the fear of the disease and limited/non availability of protective equipment has led to ward staff, nurses and medical officers preferring to sit out the epidemic.
These nursing homes act as watch towers for the health care system by reducing the hospitalization load of tertiary care hospitals. Curtailment of nursing home operations is likely to force patients to visit government hospitals or expensive and remote private hospitals.
Third Line of Defence — Large Government Hospitals
Centrally-funded government hospitals are the primary care providers for the war against Covid-19 in India. They are relatively well-equipped being major beneficiaries of government’s limited investment in public healthcare.
Unfortunately, many affluent citizens and healthcare professionals do not trust these institutions because of concerns over hygiene, bureaucratic functioning, procurement delays, accountability, lack of standard operating protocols and dubious quality of care.
During a pandemic of this scale, the lack of protective gear for frontline health workers is a major concern. Doctors, nurses and even cleaning staff are at high risk of catching the infection, if they remain unprotected even briefly. These hospitals are likely to get overwhelmed with Covid patients or will be forced to limit operations due to healthcare workers being quarantined as the epidemic unfolds.
Fourth Line of Defence — Corporate Hospitals
With the aim of increasing capacity, authorities have requisitioned 10%-25% beds in major private hospitals for Covid-19 patients. Though logically sound, this strategy is fraught with the risk of crippling an essential pillar of the healthcare delivery system. There is a risk of infections spreading to non-Covid patients and healthcare workers in common areas like radiology, pathology and intensive care.
In the last 15 days, many staff members in private hospitals have been infected by asymptomatic patients visiting for other procedures like CT scan, heart angioplasty etc. This is similar to China’s experience where many health care workers were initially infected due to a lack of hand hygiene, social distancing and barrier nursing at hospitals.
The overzealous lockdown of many private hospitals by local medical officers is compounding the problem. As I write this piece, 8 major hospitals and 3 nursing homes in Mumbai are already in lockdown for 2 weeks along with over 100 healthcare workers in different hospitals.
As the focus shifts to saving the lives of Covid-19 patients, the care of thousands of regular patients remains unanswered. These patients have become increasingly vulnerable to delayed or denied treatment which increases their morbidity. Just yesterday, a young boy with pneumonia died after a Covid hospital and a municipal hospital refused to admit him due to the non-availability of beds. The medical fraternity is increasingly concerned that in the fight against the pandemic, many non-Covid patients will be adversely affected.
The need for cohesive policy action to protect healthcare workers
The closure of neighborhood clinics has prompted a few government functionaries to suggest the invoking of Essential Services Maintenance Act (ESMA) and other punitive measures to force doctors to see patients. This knee jerk response to a systemic failure is likely to prove counter-productive. It could not only result in more physicians getting infected, but also puts future patients at risk. As more doctors become symptomatic, punitive measures will become infructuous with doctors needing to be quarantined or hospitalized.
Instead, it is imperative that a cohesive and comprehensive policy is formulated to protect healthcare workers. These civil soldiers are required to fight Covid-19 immediately and for an extended period of time as this pandemic is not expected to go away in the coming months.
Desirable Policy Actions
A. Testing — A freely accessible testing policy through both private and public sector health clinics, that is available on demand and with assured privacy of results should be the first national priority to identify and quarantine asymptomatic patients. This is likely to increase the numbers of Covid patients, but is essential to determine the extent of the spread in order to contain it.
B. Screening of healthcare workers
– Immediate screening of all healthcare workers to identify and isolate high-risk individuals to protect them from Covid — over 60 years old, those on chemotherapy / steroids etc
– Regular testing and quarantine of Covid-positive healthcare workers to prevent them from spreading the virus to patients.
– Policy reversal and widespread publicity to keep all suspected and confirmed Covid cases away from GP clinics.
– Establishing definitive guidelines on the use of PPEs and streamlining their uninterrupted supplies.
– Government support to Covid-19 healthcare workers through free Covid treatment.
C. Nursing Homes must be permitted to resume routine hospital functioning with clear guidelines on the universal use of PPEs.
D. Augmenting dedicated government Covid hospitals through the takeover of stadiums, convention centers and hotels. The implementation of quality control measures with streamlined un-interrupted PPE supply.
E. Corporate hospitals should be mandated to use universal barrier nursing for all patients and usage of PPEs for all aerosol generating procedures. This will help avoid the spread of infections to staff and future patients. A rescue plan to isolate infected workers and the sanitization of premises should be formulated to reopen these institutions within 24–48 hours instead of a prolonged shutdown of 14 days or more.
Additionally, all private hospitals should be required to provide treatment through government welfare schemes like Ayushman Bharat. The payout to hospitals under these schemes can be enhanced by 20%-50% for atleast 1 year. This is likely to continue the uninterrupted healthcare of non-Covid patients.
Though the central and state governments are taking proactive steps to limit the fallout, non-utilization of the frontline workforce in an emergency situation of this magnitude is perplexing. Countries like the UK have already asked their armed forces to streamline healthcare supply logistics. In addition to immediate policy action, the Indian army too can be asked to step in for the protection of healthcare facilities. Without our soldiers — both literal and proverbial — India’s ability to reduce the fatalities of this war could be severely crippled.
Dr Ramen Goel, MS, FRCS(Edin)
President, Indian Association of Gastro-intestinal Endo-Surgeons(IAGES)