June 28, 2020 01:07:00 | Dr. Sarosh Ahmed Khan
COVID-19 has exposed the shortcomings in the healthcare infrastructure, in not only the developing countries but the developed ones too
The burden on the healthcare has been overwhelming so far. Many countries have failed to tackle the onslaught of infection and suffered huge mortality. The disease has infected and killed thousands of healthcare workers (HCWs) worldwide. Suddenly there seems to be a shortage of HCWs including doctors. Countries like Italy have asked doctors to come out of retirement and nursing students have been fast tracked to graduation. In a press release on 16th March 2020, Médecins Sans Frontières (MSF) appealed to the European Union countries to share essential equipment, including masks and gloves, between countries and implement solidarity measures and protect medical staff from COVID-19.
On 27th March 2020, the Health Ministry of the Government of India issued a guideline encouraging the final year students doing MBBS to work as front runners in the fight against COVID-19. Even the retired doctors were called in to work. They were told to hold administrative posts and handle mild cases only. This was to ramp up the medical capacity to tackle any major rise in the cases of COVID-19 across India. The suggestions included allowing doctors in vital disciplines like anesthesiology, pulmonology, cardiology and radiology who were waiting to appear for the final exam with a “Board Eligible” degree. They could get “Board Certified” degree later after passing the exam, it was suggested.
The health ministry and the Board of Governors in Supersession of Medical Council of India (BoG-MCI) looked at senior medical students being given provisional permit to practise and manage Covid-19 cases. The proposal did not stop there but also included relaxing norms and giving temporary licence to those who have pursued medical education from Russia and China without them having cleared the MCI’s eligibility test. Note that more than 75% of these doctors are not able to clear the test multiple times. Isn’t this a risk for the seriously ill COVID-19 patients and the doctors themselves?
As if this was not unethical enough, the over 1.5 lakh Ayush doctors have been called to join the Covid-19 medical team in Maharashtra to provide additional hands during the pandemic. Ayush is an acronym for medical systems locally practised in India such as Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy. The Ayush doctors were asked to attend a week long online course and then take an online examination and start working. The government of UK and USA even allowed the medical students as well as the nursing students to work against COVID-19.
To complicate matters further, availability of PPEs was and continues to be an issue needing proper redressal. PPEs were not available in most of the government as well as the private hospitals in Australia, US, UK, as well as other parts of Europe and the World Health Organisation (WHO) had to warn countries of the danger. In India, not only PPEs were not available freely leading to complaints and protests by medical staff in many places, including the prestigious All India Institute of Medical Sciences, New Delhi, the standard of PPEs provided was poor too.
In California, nurses were suspended for refusing to work without N95 masks. Even in the UK, the NHS nurses were told they could refuse to treat Coronavirus patients if they did not have adequate PPE. Guidance issued by the Royal College of Nursing (RCN) reportedly stated that nurses should only refuse to provide care as a “last resort”. It happened in early April in UK amid a nationwide shortage of PPE which meant doctors and nurses had to risk their lives to treat patients. The British Medical Association (BMA) was critical of the advice. Nurses are taught not to refuse a patient on any ground, and here they were in a dilemma what to do. Advising them to “refuse care as a last resort” was testing their ethics and in fact coercing them to work without PPE.
But is all that justified? Probably no, considering that the disease is a novel one and still doctors and nurses do not know much about the disease. Anyone working in a hospital is at risk, more so the elderly post-retirement doctors. In the hospital-based case-cohort study from Wuhan, China, the mortality rate was 4.08% in COVID-19 patients younger than 40 years old, 15.1% in patients between 50 and 59 years old, 11.9% in patients between 60 and 69 years old, and 43.6% in patients over 70 years old. HCWs constitute around 8% of the total cases of COVID-19. It is a risky job as we do not know how this virus spreads so much in HCWs even though in many cases they apparently have been well covered. Is it the cumulative dose of the virus load an HCW gets over a period of time, which is important, or are there other factors, hitherto unknown, which are responsible?
Imagine a young MBBS student, an intern or a house surgeon, bubbling with confidence and pride, ready to take on the disease head on. In his newfound enthusiasm he fails to understand that he is about to deal with a virus known for its stealth and notorious for its killing prowess. Moreover, SARS-CoV2 being very virulent, affects the overworked and the tired. Lack of sleep is common among these COVID warriors, as they are called, which definitely hampers their immunity, making it easier for COVID-19 to strike more seriously. Now imagine their plight when they are not provided PPEs, are made to sleep in crowded hostel rooms and worked overtime.
The mental strain on the patients having COVID-19 is well known, but reports show that HCWs are one of the worst sufferers. The sense of responsibility on the prematurely graduated doctors and nurses is compounded by fear too. Even the seniors feel the heat. Recently a doctor in NYC committed suicide by inflicting upon herself multiple stabs. She had seen death from very close quarters as she was the medical director of the emergency department at NewYork-Presbyterian Allen Hospital and had become “withdrawn” for days before she ended her life. Similarly a young house surgeon in Tamil Nadu ended her life after feeling exhausted and informing her parents that “she was under tremendous stress”. She was attending COVID-19 patients for some time.
Who will take the responsibility of the deaths of thousands of HCWs including doctors? It takes decades to produce a doctor of caliber and experience and we are losing them on a daily basis to a killer disease, just because we want to fill in the posts. What compensation has been given to the families of the HCWs dying during their service? Pretty nothing, except being called heroes.
COVID-19 has exposed the shortcomings in the healthcare infrastructure, in not only the developing countries but the developed ones too. The governments of the day should realize that it is not the hoarding of weapons for war and the count of nuclear warheads which is the savior of mankind, but the investment in and advancement of healthcare. We have to start working on it and attain the goals set by the WHO and other world health bodies, not post-COVID but right from today. The billions of dollars spent on the rat race to reach the Moon and Mars is of no consequence when we do not have top class healthcare on this planet.
Being a pandemic, the fight against COVID-19 should be on a global level. Sharing essential equipment between countries and implementation of solidarity measures and protection of medical staff is the need of the hour.
(Dr. Sarosh Ahmed Khan, MD; FACP, FRCP (Edin) is Senior Consultant Internal Medicine and director Naseem Medical Center, Srinagar, Kashmir, JK)