Need to reboot health care system to also focus on non-Covid patients
Many hospitals that had shut down non-essential care services and postponed elective surgeries to lower crowding and free up health staff to treat coronavirus disease (Covid-19) patients will begin working to capacity once the lockdown lifts, but operations are unlikely to return to what they were before.
“Hospitals have and must adapt and evolve to treat patients with and without Covid-19, to ensure no one dies because of lack of treatment. Elective procedures can be postponed for a while, but they cannot be postponed indefinitely. We’re already seeing complications of gall bladder stones getting septic and people getting heart attacks, which could have been averted. Separated Covid-19 hospitals and wards, and strong infection-control and crowd management protocols will ensure patients and health staff will stay protected,” said Dr Naresh Trehan, who heads Medanta-The Medicity, Gurugram.
Non-communicable diseases (NCDs) such as heart disease, cancers, diabetes and chronic kidney disease account for around 61.8% in 2016, as compared to 37.9% in 1990, of all deaths in India, according to Indian Council of Medical Research (ICMR) report: India - Health of the Nation’s States 2018.
With social distancing being the new normal, reduced movement associated with social distancing and unhealthy snacking is threatening to aggravate risk factors for NCDs, such as obesity, high blood pressure, high blood sugar, and high cholesterol.
“A month of being cooped up indoors would not have caused irreversible health damage, but it will if it continues. Outdoor physical activity must be consciously re-initiated once movement restrictions are slowly lifted. More effort must be made to commence outdoor activity with basic precautions, such as wearing masks and not moving in groups,” said Dr Nikhil Tandon, professor and head of the department of endocrinology and metabolism, All India Institute of Medical Sciences.
What needs as much attention is the absence of routine, and anxiety about an uncertain future that will lead to undiagnosed mental health issues in millions of people. “A lack of structure can really damage health because regularity of when you eat, how much your exercise, when you sleep is critical to manage NCDs, such as diabetes, obesity and depression,” said Dr Tandon.
Many states in India have halted immunisation and reproductive health outreach services as community health workers help with Covid-19 surveillance and contact tracing.
Missed immunisation may lead to a resurgence of potentially fatal vaccine-preventable diseases, such as childhood pneumonias, diphtheria, pertussis, hepatitis B and diarrhoea. This threatens to reverse the gains India has made by immunising children against vaccine-preventing illnesses to bring down infant mortality rate to 33 per 1,000 live births in 2017 from 34 the year before.
States must begin drives to catch up on missed services. “Given travel restrictions and the very fear of contracting the disease, we have evidence showing that fewer women and children are visiting health facilities now... We see a gradual attention turning to safe motherhood, family planning services, emergency obstetric care, including safe abortion, but in India we are dealing with vast numbers, unlike any other country. Women of reproductive age here are close to 350 million. So the need is huge, but the Indian economy is the 5th in the world and if anyone can afford it, India is right at the top,” said Argentina Matavel Piccin, UNFPA Representative, India.
The national programmes to eliminate malaria, and treat tuberculosis and HIV have also taken a hit and will need a push to ensure they don’t derail. “Overall case notification (in India) has significantly declined due to reduced testing and though the lab services are open, people cannot come due to the lockdown. Once the lockdown is relaxed or completely removed, we think there will be a surge in people seeking services,” said Jamie Tonsing, Regional Director of The South-East Asia Office of the International Union Against Tuberculosis and Lung Diseases ( The Union).
Government officials are now realising the need to integrate health programmes, data systems and cross-departmental planning so that multiple agencies can work together. “What Covid-19 has taught us well is the need for coordination, not just inter-departmental, but also inter-ministerial. The central and state governments should not go back to bureaucratic normal after the worst of the Covid-19 pandemic is over but share resources to reach the common goal of keeping people healthy,” said a senior health ministry official, who did not want to be named.
“We don’t want a situation like in Congo where after Ebola, more people die of TB, malaria and measles than from Ebola,” he said.
“The biggest issue with public health delivery post-Covid is the recognition that universal health coverage is critical for any country to face a pandemic. Many countries are learning that you cannot build health care capacity during a crisis. It takes time and investment to build a good public health system. India has failed to invest in health for decades and this must change post-Covid19. Health spend must at least increase to 2.5% of GDP, at a minimum,” said Prof Madhukar Pai, Canada Research Chair in Translational Epidemiology & Global Health, and director, McGill Global Health Programs, McGill University, Montreal.