To contain the spread of the novel coronavirus, countries across the world have gone into lockdown. But, how do you tell 1.3 billion people spread across urban and rural India to stay at home? Lockdown measures have worked in other countries, however, India comes with its own set of challenges including a high population density with a large part of its workforce that’s dependent on daily wages.
We spoke to physician and public health expert Dr. Sonali Vaid to understand India’s public healthcare capabilities and the efficacy of the measures being put in place to control the fast-spreading virus.
Editor’s note: the interview has been edited for length.
Q: What are the challenges that the Indian healthcare system faces and will it be able to take the strain of dealing with COVID-19?
Dr. Vaid: The healthcare system suffers from decades of neglect, we only spend 1.28% of the GDP on healthcare. India has some of the highest out of pocket expenditure, which means that the majority of health-related expenses are paid by the people themselves. During normal times, our system is like wearing broken shoes, then dealing with a pandemic like this is like running with broken shoes.
It is only with this situation that the middle class of this country has woken up and understood the dismal state of public healthcare infrastructure [because most of the COVID-19 screening and treatment centres are government hospitals].
Q: What are some of the strengths of the Indian public healthcare system?
We have seen some successes in the past where we have been able to eradicate smallpox and polio. There was a time [in 2007 when some hospitals] did not even have gloves, so things have gotten better. Our strength lies in having stronger administration at the district level. In some states like Himachal Pradesh, there have been door-to-door surveys, identifying travel history [to isolate and prevent the spread of COVID-19]. Look at the example of Bhilwara.
Editor’s note: In Bhilwara, a city in the state of Rajasthan, stringent lockdown measures, strategic containment, and robust healthcare measures have helped in reducing the number of coronavirus cases.
Q: Are there other healthcare issues that are being deprioritized to focus on COVID-19?
There were reports of some North Indian states where immunization campaigns are being suspended. This is concerning because a resurgence in preventable illnesses like measles will only [cause further issues]. The effect of the pandemic on non-COVID care is unmeasured, but it is a huge issue.
The lack of information on which hospitals are treating non-COVID illnesses is causing problems, the public has no clarity as to which hospitals they must go to for what problem. Previously, if someone were to meet with a road accident, they would be taken to a hospital like AIIMS, but today it operates as a COVID hospital. It is an easily solvable issue, the government needs to use TV media, social media to give directions to people as to where they can seek help. [Some places] have started telemedicine consultations, but again there needs to be information transparency, people need to know which number and which doctor to call for [the issue they face].
Q: How has the lockdown affected the millions of Indians who live with different illnesses?
The medicine supply chain has been affected, people are not getting the medicines they need to treat [illnesses like] cancer, tuberculosis and HIV.
One of the main problems that [have come up] are transport issues. The medicine supply chain has been affected, people are not getting the medicines they need to treat [illnesses like] cancer, tuberculosis, HIV and this is just the tip of the iceberg. If someone is traveling to get treated for HIV, they have to show the police their HIV-positive papers and there is a stigma attached to that. There have also been reports that hospitals are unable to repair ventilators because of transport and labour issues caused by the lockdown.
Even in cases where someone comes to the hospital with chest pain, an angioplasty is usually done and a stent is placed in 90 minutes, if required. Now they need to be screened for COVID, the process [of angioplasty] might not get done in time, but it is unavoidable.
Q: Almost a quarter of the Indian population live in places such as slums, and for them social distancing is a seemingly impossible concept, what measures then can the government take to resolve this?
In my opinion, it’s better to send people back home if they wish to return because district systems are better, like in the case of Bhilwara. In their villages, spaces are more open. Restart public transport on the migrant labourer routes, spread the [underprivileged] people around, let them return to their hometowns. Let them be quarantined for 14 days after which the community can be reassured that these people are absolutely fine now. Basically, decongest every place you can find.
Q: What are some of the concerns about the health of India’s healthcare workers and what changes can hospitals make to better protect them?
It is a question of whether people remember this or it fades from public memory. Does this become a call for strengthening public health systems?
PPE alone is not the only way to protect health workers, we also need to look at patient flow, buffer zones, restricting movement between different zones of the hospitals.
Staff should not be mixing between [suspected cases and confirmed cases], attendants and patients should also not be moving around. There also needs to be a single point of entry for potential COVID cases, where people are screened. We’ve seen some hospitals where one or two people test positive and almost a hundred healthcare workers are in quarantine. We need to restrict the number of workers that come into contact with a particular patient. There needs to be improved workflow, better ventilation. There is also concern about workers in the growing heat in their full PPE. There are more chances for them to be fatigued and overworked…especially since most of them are pulling 14-18 hour shifts, [and] the potential to make mistakes also goes up.
Q: How could this pandemic affect the healthcare system in the long-run?
One positive could be an improvement in hand hygiene, the other being a focus on the need for better PPE. We might have more ventilator capacity, in normal times [they] are rationed, so it’s not like we’ll have excess capacity. We will have the capacity that we normally need. It is a question of whether people remember this or it fades from public memory. Does this become a call for strengthening public health systems? Politicians will deliver on what the public opinion is…which remains to be seen. There needs to be better community engagement. With police going around pasting posters on people’s homes [about mandatory quarantine], it is only creating a stigma around it. A pivot is needed in terms of the projection of the disease, we need to change the language that we use like “super spreader” and stop alienating those who are ill.