COVID-19: are there lessons?
CEO and Chief Cardiac Surgeon,
National Heart Institute, New Delhi
COVID-19 has wreaked ghoulish devastation on not only health but also on economic, social and political fronts. Even though we are in the midst of the rampaging pan-demic, with no green shoots of control or regression, it behoves us all to take a peep into the past with a view to seeking lessons for the future. George Bernard Shaw once said, ‘History teaches us, that history teaches us nothing’. Genius as he was, Shaw was clouded in judgement on this issue and stands suitably chastised by Prof. J. Cunningham: ‘In order to understand, where we are now and where we are going, we must first understand, where we have been’. Though both the stalwarts spoke on different issues, their musings are probably nowhere better applicable than to the curse of COVID-19. Just as dreams of tomorrow must start with learning from the past, our future responses to the current pandemic and for that matter, to any, and many more to come, must be based on a perspective of the past and the lessons learnt thereof. The past in that sense should be a‘ Friend, Philosopher and Guide ‘to all of us. Alas, it’s easier said than done. The early lessons from Wuhan and Lombardy were ignored, and caution thrown to the wind, for history not only to repeat itself but repeat with a bigger fury in the USA and Brazil. Closer at home, the lessons that should have been learnt from the sudden and unplanned implementation of de-monetization were again given a go-by, when lockdown was imposed at a 4-h notice, totally oblivious to the socio-economic upheaval, that it was to subsequently cause and become one of the prime reasons for unbridled spread of corona virus in the country. No point bemoaning the bygone past, but it may still be worth ruminating on the lessons that we may draw for the future.
Chain of command
Health is a state subject, and there was a glaring lack of communication and camaraderie between the federal and state structures. Even fiscal-federalism was conspicuous in its absence or partisanship. The centre’s support to states was lacking or delayed. Contradictory orders were flying fast and furious, more inclined to the political ideologies of the incumbent administration, rather than a response to an apolitical disease. Morning orders were rescinded by the evening, there-by not only confusing, but demoralizing, the entire work force, who as such were dealing with the uncertainties of an, yet not well known, enemy. Lesson: Too many cooks spoil the broth. There should be well-defined line of leadership, and demarcation of domains of each stakeholder, to avoid chaos and confusion of response, as also for an optimum utilization of scarce resources.
‘No ‘knowledge better than‘some’knowledge
As much, if not more, damage from COVID-19 has come from fear psychosis, rather than the virus itself. The root cause of this was the lack of an authentic, transparent, and verifiable single source of information. Half-baked knowledge, and at times even gumption, was dished out in the electronic and print media by self-styled ‘Godmen of Medicine ‘as the ‘Gospel truth’. In fact, the entire official response to the pandemic was governed by all and sundry including paediatricians, gastroenterologists, dental surgeons and the likes, rather than the public health experts, who were nowhere to be seen, even in the horizon. It is with a view to addressing this gap in knowledge that the Indian Association of Thoracic and Cardiovascular Surgeons (IACTS) has tried to assimilate the scant, and at times confusing and contradictory, knowledge and has issued its guidelines (published later in this issue) to assist our cardiovascular and thoracic surgical fraternity in framing their responses to the challenges of practice in COVID times.
Lesson: Let the domain experts lead, take the centre stage and call shots. Rest, irrespective of their clout, must for once, take a back stage, sans a mumble.
Health infrastructure
It did not take long for our basic health structure, especially in the government sector, to be exposed and laid bare. Professionals have been bemoaning, ever since the independence that our spending on health sector is woefully short and that the intangible benefits of health should not be compared with the tangibles from the manufacturing industry, but should be monetised in terms of disability adjusted life years (DALY) saved. We are still lucky that even though the disease is ravaging in the urban areas, it has largely spared the rural hinterland, but I fear it may not be for long, and at which stage, the deficiencies of the primary healthcare infrastructure in terms of primary health centres, community health centres and district hospitals will be exposed further. Already, there are signs that the government is waking up to this realisation and the sooner it does, the better it shall be for the future of the country. Lesson: Government must increase its allocation to health sector to at least 5% of GDP and focus on strengthening the primary care.
Private public partnership (PPP)
As a corollary of the foregoing, the out of pocket spending on health in India is an overwhelming 60–70% and two-thirds to three-fourths of all healthcares is in the private sector. Instead of realising this fact and embracing the private sector with an all-encompassing hug, the government has always treated the latter with suspicion, disdain and ‘carrot-stick’ policy.Successive governments have tried to reign and subjugate it through oppressive legislations and archaic regulations. This attitude needs to be changed and profit, albeit reasonable, should be accepted as ethical, moral and in fact a necessity for a vibrant and effective private healthcare system, to meet the health needs of the society. Crushing private sector at the altar of the socio-political agenda of the incumbent political dispensation is going to be to the disadvantage of all stake-holders, and last but not the least the government itself.
Lesson: Create a policy environment for PPP to thrive and flourish
Regulation
Regulation is a necessity and that is given. However, it must address the aspirations of the society it serves. Therefore, it must factor the ground realities and the resources available, and incorporate the social, economic and cultural confounders to be effective. Unfortunately, we seem to be caught in a warp, where we are copying regulations from the developed world and issuing regulatory guidelines as ‘One size fits all ‘solution to the needs of the entire country—a country, as vast and diverse in all dimensions, as India. The recent urgency seen in regulatory bodies in clearing trials and fast tracking of approvals for new drugs is worth appreciating, but even in routine matters, regulatory jigsaw should be simplified and made User-friendly.
Lesson: We should focus more on standardisation with view to enabling deregulation.
Innovations
India has neither the ecosystem nor the finances, for basic, molecular level core research. It therefore needs to look at the low-hanging fruits of translational research. We already have enough lab knowledge; we just need to transform it into bed-side knowledge. India is lucky to have an amazing pool of young talent, just suited for this kind of research. This can even subsequently be commercialised and monetised and may help address the economic woes of the country. The information technology (IT) and biotechnology companies can team up for developing rapid testing kits for not only corona virus, but for other diseases rampant in the country, and concentrate on developing point-of-care tests. A start-up culture should be developed with the government providing the handhold by provisioning for the initial seed money, the physical infrastructure, patenting and subsequent commercialisation and marketing of technologies. ‘Aatam Nirbhar Bharat’ and‘ Vocal for Local’ are good initiatives, but need to be transformed from jargon to reality, something which has not happened in the past——‘Make in India’ and ‘India shining’ initiatives having flustered badly.
Lesson: ‘Bench to Bedside ‘innovation is the ‘Mantra ’but we need to ‘Walk the Talk’.
Leverage technology
Healthcare is heading to a new normal. Necessity is the mother of invention and a lot of bright minds, either by design or by default, developed new processes and technologies during theCOVID-19 outbreak. Sure enough some of them will fall by the wayside, but at least some and more meaningful ones will continue to survive even after the COVID-19 pandemic is over, either because of the value they have demonstrated, or maybe even because of necessity. Connectivity in India has improved following the Global System for Mobile communication (GSM) roll-out and Indian Space Research Organisation’s (ISRO) support through provisioning of free satellite time for public health initiatives. Technologies can now be leveraged, not only for diagnostics but also for healthcare delivery with successful models in South Indian states delivering intensive care through Tele intensive care units (ICUs) and ophthalmology services, especially for diabetic retinopathy, being delivered in rural areas through mobile care units. Thus, telemedicine and tele-consultations would, in all likelihood, become a norm in the future. Remote sensing and monitoring and point-of-care testing would decongest the bursting at the seams tertiary care hospitals. For a lot of diseases and illnesses, for which we always believed that patient care in a secondary or tertiary care hospital was mandatory, domiciliary care and conservative management have dawned as an effective alternative. The flattening of curve in Delhi, and available infrastructure not stretching itself, was achieved entirely with the realisation that ‘Domiciliary quarantine ‘was as effective as ‘Institutional quarantine’. Even‘Analytics’to change ‘Big data ‘into action and value-driven partnership of industry with physicians is the need of the day.
Lesson: Leverage bio technologies and IT to deliver healthcare at the door step of the masses.
Behavioural change
COVID-19 has been a big epidemiological experiment, albeit carried by nature. The universal outcry on a sudden drop in non-COVID hospitalisations in all specialities, not only of elective cases but also emergencies, without a proportionate and countervailing increase in non-COVID mortalities should sensitise us all—the medical fraternity, public and the government, to the overarching benefits of holistic living and good lifestyle. Whether these realisations will stay or be as ephemeral as the virus, only time shall tell.
Lesson: A stitch in time saves nine.
Last post
Just as we concentrate on our COVID-19 responses, we must not forget that the main health burden of India lies in non-COVID illnesses. A recent modelling study in Lancet Global Health showed that the mortality from Malaria was expected to increase by 36% over 5 years as against the pre-COVID levels, of tuberculosis by 20% and HIV by 10% [1]. All the routine vaccination programmes have taken a back seat. Schools are closed and the midday meal programmes are suspended. This, along with the attendant economic woes of the COVID-19, compounded further by the natural disasters of floods and typhoons like ‘Amphan’ will have a snowball effect on additional problems of nutritional deficiencies in children and infectious illnesses, besides psychological and mental disorders creeping in. A thought should also be spared both for the physical and mental health of the Health Taskforce and the Corona warriors in general. Let this calamity not go waste and let us treat this as an opportunity, a new dawn in the healthcare landscape of our country.
Reference
1. Hogan AB, Jewell BL, Sherrard-Smith E, et al. Potential impact of theCOVID-19 pandemic on HIV, tuberculosis, and malaria in low-incomeand middle-income countries: a modelling study. Lancet Glob Health.2020.https://doi.org/10.1016/s2214-109X(20)30288-6.
https://nhihospitals.blogspot.com/2020/08/covid-19-are-there-lessons.html
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