The impact of covid on health

YOGESH JAIN

THE Covid pandemic has been the largest health crisis that we have seen in our lifetimes. What started at the end of 2019, is still raging in several parts of India and the world a year and a half later, and no one knows how long it will last.

Globally, in terms of the direct impact on people’s lives and health, it has already resulted in about 3.2% people being infected with this disease and about 5 million deaths. Of course, these numbers would need to be multiplied by a factor of at least 10 to get to the true numbers. We should not be surprised if the impact on illness and survival is greater than what the world faced in the 1918 influenza pandemic.

But numbers fail to convey the true impact on human life and in fact cold numbers do not capture the misery that the disease has caused. What the tribals of the Amazon River basin in Brazil and the African Americans in US faced during this pandemic are only matched by the misery Indians went through when the health care infrastructure fell woefully short in terms of oxygen for the treatment of the disease or for a hospital bed for the sick or a pyre or a piece of earth to be cremated or buried after death. These images of inhumanity will remain with us long after the last word has been said about this pandemic.

It would be unfair to say that the impact was equal for all people in the country. In the first year, 2020, as well as in the first months of the second surge earlier this year, saw people in bigger cities being infected or dying due to Covid. But soon after the onset of this second surge, the disease moved into rural areas with reports of massive numbers dying in the remotest villages in many states including Maharashtra, Telangana, Odisha, Chhattisgarh, M.P. and Jharkhand. While the number of people being reported with Covid has been steadily dropping in most cities, the numbers in rural areas continue to rise, and are likely to remain high over the next few months.

Tragically, the rural surge is likely to remain under-documented due to the paucity of testing facilities and lack of trust people have for our flailing health system. Social media that was agog with cries for help to access care for city folks a few months ago is a non-starter in rural areas. In fact, the rural Covid mayhem may be the defining crisis of  2021.

The impact of Covid in rural areas is likely to be worse because of the pervasive poverty of health systems. It may not be an exaggeration to say that most rural areas are ‘clinical deserts’ with space, stuff, staff, skills and systems in a dismal state. Further, due to the distrust with the health system, rural communities are even reluctant to approach them for testing, fearing that in the event of the report being positive for  Covid, they would be taken away to a city hospital or a Covid care centre, where impersonal care cannot replace the comfort of a home. In fact, the guidelines for handling the dead are so strict that even the family is not allowed to perform the last rights. To add to this litany of woes is the increasing levels of vaccine hesitancy due to poor messaging strategies that we have employed. We have also shown an inability to counter rumours and misinformation that goes viral more easily than correct information.

 

 

In any case, people have limited resources to access private health care and those public facilities where out of pocket expenditure is high. Ambulance services need to improve for people to access health care quickly. Even today, people requiring secondary or higher-level care that includes high flow oxygen, careful monitoring, and emergency drugs, can only access them in a district hospital or private clinics. Even at most community health centres at the block level, which are supposed to cater to a population of 1,50,000 to 200,000, the tendency is to refer almost everyone who looks sick to a ‘higher’ centre. Diagnostic services including a good quality chest X-ray or specific blood tests or other imaging services such as a CT scan, are only available in district headquarter towns.

We are already reporting one to two per cent of our infected people dying due to Covid. Almost everyone believes that the numbers are grossly unrecorded by a factor of 5 to 20. Everyone has seen images of large numbers of the dead flowing down major rivers or being buried or cremated in shallow graves on riverbanks.

 We also know the problem with attributing deaths due to Covid even if the symptoms before death were compatible with Covid. People who are not tested before death or whose reports are negative, do not get a certificate of death due to Covid.

How do we get to know the truth regarding the deaths due to Covid? This is a difficult but highly desirable objective. One way is to document all the deaths that happen in a community over a period of time, and record the age, sex, place of death and the cause of death in the words of the nearest family member. Such numbers could be compared to the numbers of the past year/period, and this would allow us to study the excess number of deaths which could be safely attributed to Covid. Such information would be useful for future planning and pandemic preparedness.

 

 

One of the striking observations during this pandemic has been that the otherwise discredited public system ended up providing the most care. The bulk of testing, admission facilities, and also care centres for people with other ailments was provided by the public system. In fact, in the first year of the pandemic in 2020, many private health facilities shut down, and it was only later that they opened up after sensing an opportunity to profiteer through Covid care. This started with excessively charging for laboratory tests, as well as prescriptions for further investigations and unnecessary treatment. The community-level prevention and health education were also provided by the public health systems. 

At the same time, it should be noted that it was actually citizens and other community-based formations, who provided support for transportation, food, admission facilities and oxygen facilities when the public systems got overwhelmed and failed to do triaging to ensure systemic support to the people. But for the yeoman service these groups provided, it would have been an unmitigated disaster without comparison in history.

Another systemic observation in the course of the last 18 months has been the widespread irrationality in our diagnostic and treatment prescriptions in both the public and private health systems. Investigations were often excessive and repeated frequently on those who did not require them. It was not unusual that people spent over Rs 25,000 per patient for mere investigations. Due to the poor recommendations made by the Indian Council of Medical Research and AIIMS Delhi, which did not change in spite of high-quality contrary evidence, the use of certain drugs was poorly regulated.

Useless drugs like hydroxychloroquine in 2020, ivermectin in 2021, universal prescription of antibiotics like azithromycin and doxycycline, minerals like zinc and vitamin C and medicines used for flu like favipravir, found their way into packaged prescriptions by both public and private providers. In fact, states like Goa started mass prescription of some of these medicines to all above 18 years of age. Antiviral drugs like remdesivir were irrationally prescribed to many who did not need it resulting in hoarding.

 

 

The icing on the cake was the irrational use of steroids. It is normally recommended to be used in a small dose for 5-7 days, only for those who are moderately and severely sick due to Covid-19. Due to the rapidly changing recommendations from the AIIMS, and unregulated prescription of this drug that has significant adverse events including the risk of superinfections, steroids were overprescribed for those even with mild severity Covid, and in large doses, often for weeks on end. This resulted in a national embarrassment that is likely to stay – we already have over 10,000 cases of a devastating fungal infection with a mortality risk of over 50% despite early treatment, compared to 1-2% of Covid.

Countries like the US, Brazil and Western Europe have not reported any mucormycosis in those who recovered from Covid, likely due to the more regulated use of steroids by their physicians. No wonder, most large hospitals in India are seeing scores of people who came out of Covid but are now down with this fungal superinfection.

Another worry is the worsening of an impending health crisis – that of increasing antimicrobial resistance to antibiotics. An overwhelming majority of people with Covid have got one, sometimes two or three antibiotics for what is a viral infection. Such strong antibiotic drug pressure is a sure recipe for amplification of drug resistance, whose consequences will show up in times to come.

 

 

When the Covid-19 epidemic hit India, and concerns about its rapid spread to rural areas emerged, health care systems for non-Covid illnesses were severly challenged. A shift of focus to Covid care was felt all over. A striking observation we made was the elimination of physical examination of patients seeking care. Arguably this was to minimize the risk to health workers and in line with the advice to observe physical distancing. 

Since the beginning of the pandemic, health care workers have maintained a distance of one to two metres from patients. Checking pulse or mere touching of hands or a handshake have been replaced, if at all, by an oximeter applied to the finger. Even critical examination was not done, for example, abdominal examination for uterine height or checking the chest with a stethoscope for someone with fever and cough was not performed.

Due to instructions handed down to the peripheral workers, compounded by the media blitz about the risk of contracting Covid, they have stopped doing a physical examination as part of their diagnostic evaluation. Trust in their clinical skills and personal rapport they had built with the community they served, are now seriously at risk. We need to provide appropriate personal protection equipment to all National Public Health Workers and allow them to continue with their important work in primary health care.

 

 

The proportionate role that physical examination plays in primary health care is larger than in secondary or tertiary care, simply because availability of laboratory investigations as the third pillar is poorer. An unnecessary reliance on investigations has made it harder for modern-day physicians to meet the day-to-day needs of patients seeking medical care, especially in resource-scarce settings. I fear this change in the way we practice clinical medicine will last beyond the pandemic.

Another disturbing trend has been the excessive use of tele-consultation. Telemedicine is being offered as a solution to improve access to clinical diagnosis and treatment especially in the peripheral health facilities, and is being encouraged in these pandemic times. Such remote and virtual consultations suffer from the larger emphasis on personal history, on tests and hardly any physical examination. This poses limitations to its effectiveness in reaching a clinical diagnosis. The much-touted success of being able to manage clinical consultations from afar could justify not having skilled doctors in rural or other disadvantaged places. Having a paramedic in a peripheral site, who could link to this remote physician, may be considered as a new standard of care. This is a worrisome trend.

One specific learning from this pandemic for health systems has been the need for building surge capacity. It seems obvious that to be prepared for pandemics, just having a well-functioning and efficient health system is not sufficient. We require a margin for sudden increase in numbers of patients using the system. This lesson came so starkly in Delhi and some other cities when oxygen availability and supplies were clearly inadequate to manage the sudden spike in demand resulting in large numbers of avoidable deaths and mental misery for all. But building surge capacity requires extra resources and would also lead to many hospital services lying unused during normal times. Can we afford this? Can we afford not to build surge capacity?

 

 

Like epidemics do, Covid-19 managed to draw all the resources of the health system towards itself and away from other illnesses such as maternal and child health issues, non-communicable diseases like diabetes, heart disease, cancer, and mental illness, along with other communicable diseases like tuberculosis and vector borne diseases. For several months, most routine outpatient and specialty clinics stopped functioning, worsened by a lack of public transportation facilities to the clinics. Elective surgeries had to be postponed for over a year now. As a result, maternal health care has suffered a great deal with women having major problems in accessing hospitals. Child immunization rates have drastically fallen. Nutrition programmes such as the ICDS services have stopped and only take-home rations are being allowed and reopening of angan-wadis delayed much after cinema theatres and malls were allowed to open, leading to a perceptible decline in nutrition levels of children in the age group of 0 to 5 years.

Similarly, services for non-communicable disease care have been severely affected, increasing the risk of disease severity and death in Covid. These illnesses require regular intake of medicines for years and decades; breaks in monitoring and treatment can compromise quality of care affecting longevity of patients and predispose them to complications. It seems the urgency to manage the pandemic led to destruction of all non-urgent but equally important disease specific problems. Care for cancers was observed to have been disrupted with people unable to get chemotherapy, surgery or radiotherapy in time. Similarly, care for mental health problems has received a setback.

 

 

The programme for managing tuberculosis, arguably our most important disease suffered badly. Case detection rates dropped sharply as most people could not access clinics and hospitals. The laboratory machines like the CBNAAT and TrueNat were redirected to be used for Covid diagnosis making it unavailable for detecting tuberculosis. Holding people on treatment for over six months also suffered with sharply increasing defaults. It seems we undid the successes of the last two decades in controlling tuberculosis. Similarly, HIV disease requires a strict daily intake of anti-retroviral drugs and periodic tests to monitor improvement, suffered a break in care of the illness all over the country. We did not see the system measure up and go to people’s homes to deliver a refill of medicines, which could have prevented avoidable decline in continuity of care.

Covid illness, even if one comes out of the acute episode in 14 days, has now been associated with post-Covid effects such as pervasive fatigue, breathlessness, mental health issues like depression, anxiety and cognitive problems in thinking and memory, clotting problems resulting in strokes and myocardial infarctions in almost 30% people. Mental health issues have been observed in almost one-third of the people. There is incomplete knowledge of the impact of these post-Covid symptoms on the longevity, productivity and return to work and future health of the people. We need to handle this. It is abundantly clear that Covid is not merely an acute illness like a bacterial pneumonia or typhoid or dengue fever but one with long-term consequences.  We will have to quickly develop management services to handle post-Covid after-effects in our public health systems.

 

 

How do we move on in the coming year, hopefully to a post-pandemic era? The rude shock of this pandemic has made us realize that only with resilient public health systems with a primary health care focus, can we manage a third wave and other disease epidemics in the future. We need to urgently invest in developing more durable health systems across the wide expanse of the country.

At the same time, communities, especially in the rural areas, need to build on their collective strength as well as be more knowledgeable and skilled in managing common health problems on their own. Civil society formations have a new task cut out for them.

In a system where universal health care remains a far cry, and most people incur expenses to access health care, the crippling impact of loss of livelihoods due to the economic shutdown on health of the people will also pan out in the days to come. Can this pandemic teach us that in the unequal society we are, we desperately need to put in place a system of universal health care?