How Can India Combat COVID-19's Collateral Damage?

The pandemic has completely disrupted essential health services, it will take more than proactive states to regain the lost ground.

COVID-19 has broken Indian essential health services like never before.

Panic is sweeping across homes with patients in advanced stages of chronic ailments – from cancer, diabetes, renal failure, heart disease, tuberculosis to even those with new born babies not administered with basic immunisation shots.

The just released National Health Mission data on this collateral damage, that has been splashed across various news publications, talks of a 64% fall in child immunisation, 50% drop in BCG vaccination in April as against the numbers in pre-COVID-19 January. Though they recovered slightly by June, still, they are over 700,000 short from the January numbers.

Similarly, polio drops administered were down 39% in April as compared to January numbers and slipped even further by June. Institutional deliveries (in a healthcare or hospital setting) fell by a third in April.

It is a concern experts have been raising for months now. In the Lancet issue dated May 30 itself, Richard Cash and Vikram Patel from the Harvard T. H. Chan school of public health in the US, quote data from India’s National Health Mission, and say, “There was a 69% reduction in measles, mumps, and rubella vaccination in children, a 21% reduction in institutional deliveries, a 50% reduction in clinic attendance for acute cardiac events and, surprisingly, a 32% fall in inpatient care for pulmonary conditions in March, 2020, compared with March, 2019.’’

Also read | Rajasthan: TB Services Hit as Staff, Diagnosis Machines Diverted to COVID-19

That sinking feeling

To a 36-year-old lady from Karimnagar in Telangana, this is a question between life and death. On March 31, she noticed a small lump in the breast. A Fine Needle Aspiration Cytology or an FNAC test in quick-speak doctor lingo, raised the suspicion of cancer and since she hailed from the commuter belt of the state capital, she was referred to a hospital in Hyderabad.

But with the lockdown in force an endless wait began and with the lump not painful, she learned to live with it. Finally, on August 28, she underwent a PET scan in Hyderabad only to find herself diagnosed with a secondary lung cancer involving even the skin.

Medics screen people for COVID-19 diagnosis, at a government hospital in Hyderabad, Friday, July 10, 2020. Photo: PTI

“At a young age, a tumour spreads very rapidly and from what was easily treatable, it is now a stage four cancer that may not be curable,’’ said Dr C.H. Mohana Vamsy, a surgical oncologist and founder of Omega Hospitals, who is now treating her.

In the neighbouring state of Tamil Nadu, Dr V. Mohan, a reputed diabetologist, was crestfallen. A 50-year-old’s leg had to be amputed because the patient, from a district near Chennai, held back by lockdown and the subsequent fears around COVID-19, could not make it in time to the hospital and his foot infection had turned severe with cellulitis, a serious bacterial infection leading to gangrene, death of tissues.

Dr Mohan, the co-founder of the Dr Mohan’s diabetes centres across the country, says, footfall is down to half from the pre-COVID-19 times and have yet to recover. Up north in Delhi, Dr Naresh Trehan, cardiac surgeon and chairman and managing director of Medanta, says, initially, when the COVID-19 caseload was rising in Delhi, the patient footfall fell sharply and in some areas of Delhi down by over 70% in some areas. “With numbers declining in Delhi and Haryana, we have over the past two to three weeks seen patient footfalls returning and now back to a reasonable 60%.’’

Hospitals across the country have similar stories with dialysis services disrupted, either completely shut in some hospitals because of low patient footfalls or on account of disruption in imports from China of some of the consumables used. Lower footfall of patients with renal issues that need clinical intervention, kidney transplants hardly happening, dental and ophthalmic care taking a back seat and rising mental health cases with some even seeing a break in treatment and now coping with the deleterious consequences became commonplace.

Also read: How the Coronavirus Outbreak Has Disrupted the Lives of Cancer Patients

Doctors in some of the major Indian cities talk of nearly 50% fall in patient footfall for cancer care and diabetes from the numbers they saw earlier.

Pain, deep and wide

Delivering a talk from Geneva on August 26, at an online conference organised by the Centre for Public Policy of the Indian Institute of Management Bangalore, World Health Organisation’s chief scientist Dr Soumya Swaminathan says:

“The pandemic has impacted the health system in many ways. The lockdowns that were imposed resulted in complete disruption of essential health services.”

The WHO, she says, “Did a survey in about 120 countries (including India) and found that 80% of the countries that responded told us that essential health services were disrupted in more that one domain starting with child immunisation service, antenatal care, essential surgeries, tuberculosis to even  malaria prevention programmes. All of these saw impact of anywhere between 30 and 80% (depending on the country and the ailment in question).’’

Healthcare experts, including Swaminathan, therefore warn that, “We will see the impact of these especially in areas like cancer in coming months both in terms of mortality and in health status.”

A way out

Former Indian health secretary Keshav Desiraju, who has been tracking the unfolding of the pandemic and its various ramifications, sees the need for a four-pronged response cover the lost ground in health services.

Also read: As South India Welcomes COVID-19 Praise, Many Doctors Remain Unhappy

First, he says, “We need to take stock on where we stand on each of these chronic ailments – what is the rough approximation in each state of how many people have fallen out of the net in the past few months, at the block and district level.

“Second, quickly put in place options available now for those that have missed out on the essential treatment or immunisation or have had a break in treatment, say in case of tuberculosis.’’

Third, he says, “Begin the tracking and tracing of the people that are so impacted using the available set up of community health workers – the ASHA (Accredited Social Health Activist) and the ANMs (Auxiliary Nurse Midwife).”

ASHA workers in Karnataka protest demanding a fixed honorarium of Rs 12,000 per month. Photo: By arrangement

“And, finally, get into an accelerated outreach programme to connect with those that did not rely on the government system and instead relied on private doctors (any healthcare provider and not necessarily big hospitals).’’

For this perhaps the chief medical officer in every district could put out an appeal to public through newspapers or television. All of this, of course, backed by fully-functional district hospitals and an operational private doctor set up that the patients can turn to.

Model health care

Dr Swaminathan however, talks in terms of putting in place systems that will ensure long-term abilities at better surveillance and the prevention and care that comes with it.

For this, she sees the need to invest in building a model public health care, increased investment in universal health coverage, as laid out in the National Health Policy of 2017. Then, the immediate need now after the vaccine is developed, putting in place an adult immunisation programme plan.

Apart from this, invest in better capture of data relating to medical cause of deaths in India and finally invest in research and development focussed on evolving affordable solutions.

Building the stockpile

As is apparent, in a country where 26 million babies are born every year (70,000 per day), shortfall in basic immunisation is a serious issue with potentially serious consequences in months to come.

Some experts have, in fact, felt that it may help if this can trigger plans to build a stockpile of MMR (Measles, Mumps and Rubella), DPT (Diphtheria, Pertussis or whooping cough and Tetanus), polio drops and hepatitis B. This can help us be better equipped for a spurt in demand. As any paediatrician will tell, all these are basic immunisation, needed within the first 18 months for a newborn. These cannot be avoided and those that have missed on these need to be administered as early as possible.