India’s flawed response to the second wave of COVID was not only due to the deficient healthcare infrastructure, but also equally due to lack of application of mind and total regulatory mismanagement. As much, if not more, devastation was carried out by fear, misinformation and panic.
By Dr O P Yadava
Enormous human suffering and travails, and the macabre dance of death unfolded on the planet for the last one year. Just when the political masters in the country were turning ‘Vishwa Gurus’ and extolling the Indian success story in the control of COVID-19, the reality was brought home with telling effect.
What went wrong?
The newly created infrastructure for control of the first wave of the pandemic was dismantled and all caution thrown to the wind in organising mass events like Kumbh Mela, Thus, failure of adequate response to the second wave of COVID was not only due to the deficient healthcare infrastructure, but also equally, due to lack of application of mind and total regulatory mismanagement. As much, if not more, devastation was carried out by fear, misinformation and panic. There was lack of cohesion between various regulatory bodies and between the Centre and the states leading to problems related to provisioning of beds, oxygen and vital drugs. There were no standard protocols for treatment and there was no-holds barred misuse of drugs, specially antivirals, steroids and antibiotics. Vaccine policy, pricing, sourcing and dispensing were contentious, leading to hesitancy in rolling out the programme on the government’s part and participating actively on the part of general public. All put together – a sure-shot potpourri of disaster.
There was lack of cohesion between various regulatory bodies and between the Centre and the states leading to problems related to provisioning of beds, oxygen and vital drugs.
No point in crying over spilt milk, and arguing about it, splitting hairs. Its time now to move forwards and a few suggested measures are:
1. Government should have reliable, authentic, transparent and single window release of information and statistics, which are currently being obfuscated and even manipulated, besides being confusing. You cannot fix a thing, unless you accept it is broken. Even if the reality is gory, let us reveal it, accept it, own it up and look at means to mitigate the consequences. COVID Task Force must be led and steered by Public Health Experts. COVID response should be based on recommendations of professionals and science, rather than political expediency (e.g. conduct of elections, Kumbh mela etc).
2. There is a major crisis of manpower. A lot of healthcare personnel, some out of disease and disability and others out of fear, are absenting from work. A sizeable number of young nurses, who came from South and North-East states, have been recalled by their families and, therefore, there is an acute shortage of healthcare work-force all round.
Human resources, therefore, need to be augmented and one would have to rethink on not just having highly qualified doctors, but even a basic intermediary work force, which can be flexible and versatile to serve as a paramedic-cum-medic – something akin to what the Britishers did in the Army, wherein an intermediary cadre of Junior Commissioned Officers (JCOs) was created to act as a buffer between the British officers and the Indian soldiers. This multi-purpose intermediary force can be used during normal times in vaccination drives, delivery of maternal and child health services or even carrying out surveys and such other sundry jobs, but they can double-up during major calamities and provide basic medical services. On short term basis, ruling should be issued to empower the interns to work as doctors and final-year nursing students as nurses during this period of the pandemic. So an official formal policy of healthcare human resource mobilisation and utilisation will have to be drawn and is the need of the hour.
3. The dichotomy of ‘haves’ and ‘have nots’, and the spectrum of contrasting healthcare infrastructure landscape, is nowhere better exemplified than in India. On one end are the sparklingly opulent and gilded tertiary care facilities in metropolitan cities, and on the other side are dilapidated and ramshackle primary care facilities in the rural areas – former an offshoot of privatisation and capitalism, and latter a grim reminder of the grossly corrupt, inefficient and indifferent governance of the political masters and policy makers.
A lot of ink has been spilt on the three ‘As’ of healthcare viz. availability, accessibility and affordability. Though some success has been achieved under the National Rural Health Mission to improve on these parameters, yet it leaves much to be desired.
Arguably, India has one of the most exhaustive and extensive physical basic healthcare infrastructure for delivery of primary healthcare in the world (Fig.1), but it is dysfunctional in terms of human (Fig.2) and fiscal resources. Ideally, a sub centre (SC) should be serving 5,000 population, a Primary Health Centre (PHC) 30,000 and a Community Health Centre (CHC) 1, 20,000 in ‘general areas’ of the country.
Even though a recent Rural Health Survey showed that the rural SC serves 5,729, PHC 35,730 and CHC 1, 71,779 population, which is worse than the planned norms, still this may be acceptable, only if these centres were working in sync with their projected norms and ideals.
Health is a ‘state’ subject and the budgets allocated for the primary healthcare barely meets the salary bill of even these depleted and deficient medical and paramedical personnel. There is gross, and in fact, I may like to call it criminal, misuse and disuse of even the available resources. For example, in Base Hospital, Almora in Uttarakhand, 2D Echocardiography machine, ventilators, etc were procured, but never used even on an anecdotal patient. Amazing amount of funding is received from international sources and from central government towards bulk purchase of some of these resources for primary healthcare, but staff posted there have neither the technical know-how, nor the willingness and drive to use these facilities. They are either busy doing illegal and unethical private practice or simply exemplify nonchalance, inertia and apathy, typically attendant to a fixed income government job.
Another bugbear of primary healthcare is absent civic infrastructure in rural areas. The staff posted in these peripheral areas must have adequate facilities for their welfare in terms of educational facilities for their children and overall a basic standard of quality of life with sanitation and recreational facilities. In that sense, it becomes a chicken and egg situation, as better healthcare would lead to improved social determinants, which will, in turn, further improve the healthcare delivery, and the vicious positive feedback loop.
4. The pandemic exposed the grossly inadequate and dysfunctional governmental health infrastructure. A major part of COVID pandemic burden has been borne by the private sector – either at the family physician clinics as first responders, or by the secondary and tertiary care hospitals all over country. The government would probably realise and appreciate this reality and should invest in a healthier relationship and engagement with the private sector under the PPP model. The government may even consider out-sourcing some of the PHCs to private players, allowing a nominal and ethical profit margin of around 10 per cent.
5. This pandemic should come as an eye-opener and calls for increased spending on healthcare, especially developing a functional and effective primary healthcare system in India. The current spending of 1.6% of GDP on health, needs to be increased serially to at least 5-7 per cent. This spending is usually not seen as productive by certain ill-informed policymakers, as most benefits of better healthcare are intangible. However, one can still monetize these benefits if one looks at lost DALYs (Disability adjusted life years) and factor in increased productivity of a happy, healthy and content mind. Further, currently the government plays all the 3 roles – of the ‘Provider’, ‘Payer’ and the ‘Regulator’ of healthcare. It must gradually withdraw from the former role, especially for delivery of tertiary care services, and must keep itself confined only to the primary healthcare delivery. However, it may continue its role as ‘Payer’ and ‘Regulator’, albeit with transparency, efficiency and effectiveness.
I foresee positive things going forwards. COVID-appropriate behaviour and sensitization of the population at large towards hygiene and sanitation may bring collateral benefits…
And to bring up the rear, no matter how great an infrastructure government may create, if sensible, and in fact, just commonsensical policies are not implemented, then all the infrastructure will come to naught. A glaring example is advent of a slew of new medical colleges, where an inadequate infrastructure and a poorly trained team of teachers, impart knowledge to an otherwise uninterested, financially backed group of students, who in turn use this very inadequate knowledge and poor clinical judgement to deliver poor quality and unethical heathcare, all at the cost of the patient! We must not compromise quality at the altar of quantity – former must reign supreme.
Even hospital designing and architecture need a relook. Hospitals need to be designed with flexibility and with collapsible walls so that they can be repurposed for meeting various natural calamities and sundry challenges. Hospitals need to have lateral integration, rather than working as vertical silos.
6. Corona pandemic has highlighted the lack of a formal supply chain for vital drugs, oxygen and equipment like oxygen concentrators, nebulizers, BIPAP machines etc. The borders have again become sacrosanct between nations and even within the country, from one region to the other. Centralisation of power and authority and relegation of responsibility to states under the garb of federalism is a flawed policy, bringing in its wake untold suffering to the humanity. Therefore, this derailed Centre-State relationships must be brought back on track in an organically functional manner, based ‘on needs and resources’ rather than ‘ideologies’ and ‘political dispensations’.
Even though India has been the pharmacy of the world, we lack adequate infrastructure to indigenously produce the basic active pharmaceutical ingredients (APIs), thus hampering our own manufacturing of life-saving drugs. Therefore, India will have to take the path to ‘Atmanirbhar Bharat’ in letter and spirit and there should be more focus on the development of local supply chains with more manufacturing of high-end products. This may need a systemic push by the government, besides the active participation of the private players.
7. Planners and policy-makers must also spare a thought for non-COVID diseases, which seem to have taken a back seat. There is a total neglect of other communicable diseases like malaria, tuberculosis, measles, HIV/AIDS etc. Their control programmes should not lose their focus. Even control of non-communicable diseases like malignancy and atherosclerosis needs due attention, because a lot of patients of early malignancy, and candidates for curative therapies, are not getting timely attention and their cancer is likely to spread and become incurable. Even inadequate control of diabetes, hypertension, weight, lack of exercise etc may add to the burden of non-communicable diseases. This, combined with the direct effects of COVID on the heart and the lungs, leading to heart failure and fibrosis of the lungs respectively, may add to the pool of people, who may need mechanical circulatory support devices or even heart and lung transplantation in times to come. One should cater for such futuristic needs also.
8. Miscellaneous issues, like the psychological impact of the pandemic on the healthcare work force, as well as on the general population, in form of increased anxiety, depression, suicidal tendencies and other associated psychological issues may need focused attention.
The government also needs to target socio-economic determinants of health, more so in a developing country like India. The animal-human interface in the periphery of jungles and villages is getting constricted as human activity, in the garb of development, is extending into the total animal territory in the jungles, with cutting down of trees for cultivation or fire-wood etc. In one estimate, almost 3,500 zoonotic viruses are capable of infecting human beings as there is more and more human-animal contact. Therefore pandemics are not going to be one-off affair, but unfortunately we are going to see more and more of these in times to come.
Lest you label me a misanthropic and cynical pessimist, let me change gears. On the flip side of all the foregoing, I foresee positive things going forwards. COVID-appropriate behaviour and sensitization of the population at large towards hygiene and sanitation may bring collateral benefits, in terms of behavioural changes, translating into less number of infective respiratory and gastrointestinal problems. There will be, in all probability, increased empowerment of patients, wider insurance coverage, sensitization of government towards creating a better healthcare infrastructure, more focus on preventive and health-appropriate behaviour, increased telephony based delivery of healthcare and integration of clinical decision support systems in day-to-day patient care.
All this may sound music to the ears, but ultimately the buck starts and stops at the society – ‘you’ and ‘me’. Unless we take ‘Our Health’ in ‘Our Hands’, we shall not succeed, either in meeting the Corona pandemic, or for that matter any other challenge in life. Total dependence on governments and ‘sil vois plait’ attitude of masses would be fatalistic.
God save the king, should such a day see light.
(The author is CEO & Chief Cardiac Surgeon National Heart Institute, New Delhi)