Extension of coronavirus lockdown without ensuring access to healthcare for non-COVID-19 patients may defeat efforts to avoid collateral damage
India has a whopping 54.6 million people with heart disease, 83 people per lakh population have cancer.
When Julius Caesar attacked the Gallic countries in 58-52 BC, Gallic leader Vercingetorix gathered the Gauls and led a fightback. By 52 BC he locked down himself at a fort in Alessia expecting Caesar’s forces to recede or help from outside to arrive, none of which materialised fruitfully, and Vercingetorix had to surrender finally to stop the collateral damage.
The strategic lockdown proved a trap and the battle was lost and the Gallic lands of France and Denmark came under the Romans. A lockdown is a tactical weapon to buy time, and it is not a measure to win a battle. To fight a virus we initiated a lockdown, intended at curbing its spread, not at defeating it. It has its collateral damages.
We are already more than a month into lockdown, and it is only getting stiffer, with places like Delhi-Noida border not even allowing non-COVID duty doctors and nurses to pass through. From a healthcare point of view, the price of a month-long lockdown was not cheap, and any extension with strict measures would be particularly difficult on a certain patient population, so much that they may end up as collateral damage of this war effort on the virus.
The patient population in focus is the one that falls in the grey zone between emergency and elective or by choice. This is the patient population that is not needing emergency life-saving care but are not actually elective, given that they have a disease condition in which delay can diminish the chance of survival considerably. Diseases like cancer, heart disease, dialysis requirements, liver failure etc. can’t keep waiting for the lockdown to end.
The Institute of Health Metrics and Evaluation, a global health research centre, finds that the top causes of death in India are disorders of a newborn child and heart diseases. Chronic respiratory diseases and stroke also figure prominently in the list. According to our own ICMR cancer registry India has about 1,300 deaths every day from cancer, and about 200 people per lakh population die of heart disease daily.
India has a whopping 54.6 million people with heart disease, 83 people per lakh population have cancer. These are numbers for just two conditions for which comprehensive care is not possible in a district hospital and patients need to travel to a specialised centre. With time-sensitive treatment requirements in these diseases, a delay is a likely cause of the poor outcome. There are more health conditions, many with multiple organ system involvements, that need continuous high-quality care through tertiary care centres.
Telemedicine is not an alternative to actual patient care in a health institution. The lockdown has definitely put this patient population at disadvantage by restricting their travel to hospitals, availability of drugs and medical and surgical care, etc. The premise for the lockdown that a very large number of patients with COVID-19 may overwhelm healthcare facilities leading to an unacceptable number of deaths may be true, but it is still a probability and not a real event, while the existing non-COVID patient population is real, at-risk and sizeable, and need immediate attention.
The COVID-19 and the lockdown is a peculiar situation in that in the abundance of doctors, hospitals are finding themselves with a reduced workload. This is an actual wastage of precious resource that a country like India cannot afford. For example, in India there are about 1,30,000 patients needing dialysis, about 60,000 heart surgeries are done every year, lakhs of cancer patient get surgery, chemotherapy or radiotherapy every month.
Some of these patients would die and others would have their treatment delayed. In addition, lakhs of prostate and gall bladder and uterus are operated on, knees and hips are replaced, and the list of this kind of elective cases would cause a backlog that would need months or maybe a year, to clear. Any further extension of the lockdown without considering the fate of this patient population would lead to an inexcusable number of lives being lost, and the irony is that these would not even count as death as a consequence of the pandemic!
The other important healthcare-related aspect of the lockdown is community health. With the weakening of the financial structure of the country and the increase in the incidence of poverty due to loss of job and income, malnutrition and related problems are bound to increase. India dropped to 102nd position in global hunger index in 2019, and 20.8 percent of Indian children are already undernourished. The Centre for Monitoring Indian Economy states that the country’s unemployment rate is at 8.4 percent in March 2020. These are not healthy figures, and any extension of the lockdown is likely to aggravate these numbers.
As the summer approach, India is also at the cusp of the yearly escalation of diseases like Dengue, Japanese encephalitis, meningococcal meningitis, malaria, infective hepatitis and diarrheal diseases in the endemic areas. There is a possibility that public health authorities are too engaged with COVID-19 and the appropriate measures like mosquito control etc., fogging are taking a back seat. This can be a dangerous situation, with access to healthcare facilities already becoming difficult for the non-COVID patients due to the lockdown the recognition of another epidemic that we normally control well may be delayed and cause many causalities.
There is a continued need to maintain vigil and preventive measures against the COVID-19 , and there is little possibility that the threat from COVID-19 is likely to abate in the short run. As such, we need to formulate measures to continue with life in a sustainable way in the presence of the virus in the society. Till an effective vaccine is available we are unlikely to have a decisive victory against this virus.
One solution can be opening up the minimally affected regions like the northeastern states or the states that have effectively controlled the virus spread while maintaining restrictions on free movement and non-essential activities, dividing localities to zones and increasing testing facilities so that testing can be done in a goal-directed way targeting the red zones.
There should be a provision of pass for patients in need of medical care so that they can travel. A blanket ban on travel and suspension of all means of mass transport is proving counterproductive and there has to be opening up of transport facilities in a limited, safe mode to allow for essential travel. Public health measures need to be boosted up to prevent other seasonal communicable diseases to avoid added burden on a health system already under stress.
There is the urgent need to have an exit plan from the lockdown due to end on 3 May, and any exit plan needs to consider how food is going to reach the hungry, money reaches the poor, and medical services reach the patient. The question is not only of maintaining essential services, but there is also a need to do more to ensure the strategic lockdown itself doesn't give suffering and deaths and be the cause of our defeat.
The author is a consultant in anesthesiology at a private hospital in Delhi-NCR.
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