Medics wearing protective suits are seen at a hospital during the nationwide lockdown imposed in wake of the coronavirus pandemic, in Bengaluru, Friday, May 1, 2020. Photo: PTI/Shailendra Bhojak
As the emaciated Indian healthcare system attempts to break the tide of the novel coronavirus pandemic, perhaps the highest cost for this fight is borne by the non-COVID-19 patients. For close to a month now, OPD and non-emergency services have been stopped in several hospitals so that all resources are diverted for combatting COVID-19 and emergency medical care.
However, as the coronavirus containment enters its second month, the ‘temporary’ pause could be detrimental for many non-COVID-19 patients. Thousands of patients from less developed states visited tertiary care hospitals in metropolitan cities, before the lockdown, to seek healthcare. Their fate hangs by a fine thread now.
As confirmed by several media reports, reduced access to both out-patient and hospitalisation services is proving to be fatal for several non-coronavirus patients; both communicable and non-communicable. With Kerala being an outlier, Indian public health system, which is weakened to its core due to chronic underfunding and overarching neglect, finds itself incapacitated to fight a global pandemic and not abdicate other responsibilities in the process.
While we fight the novel coronavirus, we must ensure that the price to be paid is not with the lives of non-COVID patients – that fight would be immoral and not worth waging. Although systemised reporting of data is hindered by the lockdown, individual news reports show that patients suffering from non-COVID-19 diseases, patients with scheduled surgical procedures and follow-up visits are undergoing an unimaginable crisis – the impact of which is compounded for patients needing hospitalised care. In a country with 5.5 government beds for 10,000 population, even a marginal increase in hospitalisation will increases the pressure on the system exponentially.
The neglected ‘many’
An analysis by Vikas Rawal and others points to the growing number of ‘Distress Deaths’ as the lives and livelihood of people are endangered by the nationwide lockdown. A BBC report highlighted the perilous state in which cancer patients are forced to live outside AIIMS Delhi after the sudden lockdown was announced. Given that more than 2,000 cancer patients die every day in India according to data from the WHO, the wait outside the country’s apex hospital would prove to be fatal for many.
More than two lakh new patients of end stage renal disease are added every year, which incrementally adds to more than three crore dialysis episodes per year. A recent study by Anna J Dare and others pointed out that a dialysis centre was at least 50 kilometres away for almost 60% of Indians. As most kidney patients in India depend on haemodialysis that might require as many as five sessions per week, their travails during the lockdown are apparent.
Consider the case of diarrhoea, which appears to be a common, non-lethal health condition but severe cases are responsible for the deaths of one in four neonatal children in India. Timely hospitalised care is the only safety net for an undernourished infant
A Lancet study reported that more than 7,000 people died every day in India because of cardio vascular diseases in 2016. As routine check-ups, doctor consultation and access to medicines become restricted both due to the lack of availability of healthcare workers and the difficulties in transportation due to the nationwide lockdown, the deaths are increasing every day and also remain largely unaccounted.
India has the largest number of TB deaths in the world with more than 1200 people dying every day. As more TB patients find it difficult to get tested or access medicine this figure is almost certainly increasing every day. Aarefa Johari’s report highlights the misery of patients whose health needs, with TB or HIV co-infection, are more complex and their health condition is more capricious and lethal and therefore needs frequent care.
What is happening to thousands of such patients is a dreadful but inevitable question that the Indian health system has to answer. Malaria and HIV/AIDS patients could arguably be the worst affected as reports about Hydroxychloroquine and Anti-retroviral drugs being used to treat COVID-19 patients has led to their acute shortage in drug stores. We have to keep in mind that India reported 3.3 lakh malaria cases in 2019 (estimates by WHO suggest we only report less than 10% of actual cases) whereas 21 lakh people were living with HIV/AIDS in 2017.
In both cases, the reduced availability or affordability of these medicines could be disastrous. More than one lakh dengue cases, 1.3 crore acute diarrhoeal cases, 2.2 lakh cases of Typhoid, 4.2 crore cases of ARI and 7.5 lakh cases of pneumonia were reported in the year 2017 alone in India. The list of diseases killing and disabling people is very long in India and every day that it ignores them, more and more are dying. The possibility of how the coronavirus phenomenon is killing more people than the infection itself is worth considering.
Impact on child mortality
India has the highest U5MR (Under-five mortality rate) in the world, which means that more than 3000 families lose their children under the age of five every day in this country, most from perinatal conditions. Close to 30,000 mothers die due to pregnancy-related issues in 2017 as per UNICEF data and Indian government estimates show that only 21% of expecting mothers receive complete antenatal care.
These mothers and children, as the ICDS and MCH services take a backseat, will suffer due to the lockdown. More children will die of starvation and lack of healthcare than from the coronavirus infection. Please remember that the first Comprehensive National Nutritional Survey (2016-18) in the country reported that less than 7% of the country’s children under the age of two receive the global minimum acceptable diet.
A survey of migrant workers undertaken by The Hindu reports that less than 10% received government rations during the lockdown. The loss of livelihood for parents and the reduced availability of food has not only made children acutely more vulnerable, but a prolonged lack of food and nutrition will also have an impact on their entire lives. These children are heading towards hunger and undernutrition and, possibly, starvation.
Possible increase in suicide mortality
Mental health is an inalienable aspect of a person’s health and wellbeing. According to WHO reports, India is one of the worst countries in terms of the burden of mental health conditions particularly depression, with the prevalence of depression being as high as 39.6% in some areas. Health experts are worried about the effect of the whole pandemic and the ensuing control measures on the mental health of people and news reports vindicate those fears.
Suicide is the leading cause of death in the 15-29 age group in India according to the GBD 2016 report and 631 people ended their own lives every day that year. As mental health care, counselling, medications etc. become less accessible, the result could be devastating for mental health patients.
Prioritising deaths: a result of decades of neglect of health systems
India health indicators continue to be some of the worst in the world and yet its investment in public health is one of the lowest. Excessive use of vertical health programs and unregulated reliance on market forces to provide healthcare has only further weakened its health system. The government’s expenditure on health has barely slithered ahead in the last three decades and according to the budget estimates 2019-20, India has allocated 1.02% of its GDP for health, our Primary Health Centers (PHCs) are one of the worst affected by the lack of investment.
In the yearly grading of PHC conducted by the MoHFW, nearly half were not even qualified to be graded and less than 3% received the highest grading. Human resources in healthcare is another victim of this delinquent neglect. We have one government allopathic doctor (including dentists and GDMOs) per 22,000 people according to government data and there is an 80% shortage of physicians, paediatricians, obstetricians and gynaecologists in Community Health Centers (CHCs) in rural areas.
As patients needing specialist care throng tertiary care hospitals, one can imagine how overwhelmed government doctors in these facilities, who are at the forefront of the fight against coronavirus, are in the current crisis. Well-functioning PHCs and CHCs reduce the burden on tertiary care hospitals. A PHC is also the first point of contact with a clinical doctor for a patient and a system of well-functioning PHCs is critical for communicable disease surveillance and tracing. Kerala has proved the same, both in case of the Nipah virus outbreak and also in the battle against the coronavirus pandemic.
As the number of new coronavirus cases increases in India, although at a slower rate than before, a comprehensive withdrawal of the lockdown does not seem viable right now. However, healthcare systems can no longer afford to focus exclusively on COVID-19, oblivious that their response to the pandemic is jeopardising the wellbeing and life of others.
While the health system is hunkered down to fight the new coronavirus, the threat of more people dying of other health conditions looms large. It’s time we realise that COVID-19 containment is critical but healthcare for others can no longer be ignored.
Pratyush Singh is a research scholar at the Center for Social Medicine and Community Health, JNU.