In COVID battle, doctors are down but not out

The Confederation of Medical Associations of Asia and Oceania met on 6 June 2020 to discuss the pandemic. One of the topics was the safety of doctors treating COVID patients. Malaysia and Hong Kong reported that not a single medical doctor was infected with the coronavirus.  If healthcare system is well managed, healthcare workers can be fully protected.

‘DailyRounds’, a network for academic doctors on 5 June had a different and disturbing picture for India.  Too many healthcare workers in India have been infected. Often, resident doctors have to manage the wards without help from nurses and ward attenders. Too many nurses from Kerala were infected with the coronavirus and many have returned home.  Do resident doctors have a choice except to carry on stoically?

Often, resident doctors have to manage the wards without help from nurses and ward attenders. Do they have a choice except to carry on stoically?

Prime Minister Narendra Modi had been appreciating the stoic doctors and supporting staff of the healthcare system – by asking citizens to clap for them and by showering rose petals from Air force helicopters. The other day he declared that the enemy was invisible – but the ‘soldiers’ fighting it, the doctors, are ‘invincible’ – too powerful to be defeated or overcome.  That is probably his genuine belief – just like most of the lay public.  There is mystery and magic about doctors who figure out internal diseases and correct them with medicines or surgeries.  The lay public should be forgiven for not understanding the scientific principles of diagnosis and treatment.  Doctors do not have x-ray eyes to see the invisible or secret potions to build immunity against any disease.

The message is clear.  It is now up to the doctors to treat and defeat the pandemic. Soldiers will have casualties. ‘DailyRounds’ quotes the Indian Medical Association – at least 500 doctors were infected with the coronavirus in Maharashtra alone.  In AIIMS New Delhi, 480 healthcare workers including 19 doctors and 38 nurses were infected.  In Ahmedabad, over 100 doctors were infected in the last two months. The story is the same in Hyderabad – 47 doctors and 10 supporting staff are already positive and results of 70 more are awaited.  The cardiology Department of Nizam’s Institute of Medical Sciences, Hyderabad had to be shut as nine doctors there were infected.  In JIPMER Puducherry, six healthcare workers were found infected in the last three days.

Hospital-acquired infection is evidence enough that PPE is substandard.

The Ministry of Health has supreme confidence in doctors, stating to the Supreme Court that “the final responsibility lies with the healthcare workers…their responsibility to train themselves and take all measures in preventing infection.” 

I have talked to a number of doctors – none wanted names mentioned, for fear of vindictive action.  The simile as soldiers for doctors is apt.  They have a code of conduct and sense of job satisfaction when they have fulfilled their duty to those who have come for disease-care.  They have pride in their profession.  When posted for COVID care, they do just that – even when PPE is inadequate. Hospital-acquired infection is evidence enough that PPE is substandard.   

Everyone knows that COVID was never taught in medical college.  “So where did you get information and training?”  All from social media.  In some States like Kerala and Tamil Nadu, government doctors were given basic information and some mentoring by seniors who learned by reading medical journals.  In private practice or in small private hospitals, they talk to friends and colleagues from medical college days and clarify doubts.  The mental stress is extremely severe. 

In some States, it is two weeks work and two weeks quarantine.

The Government had all of February and March to create a platform for disseminating authentic information to doctors.  However, the responsibility to control the epidemic was assigned to the National Disaster Management Agency which has no rapport with the medical profession or professional associations. The ICMR maintains that COVID is ILI, an influenza-like illness. COVID has specific clinical features.

‘DailyRounds’ of 22 May highlighted the ordeal of healthcare professionals. In Kerala, after one week in a COVID ward, the doctor gets two weeks off.  But that time is not for going home, but to stay in a hotel in quarantine.  Then back to work.  In some States, it is two weeks work and two weeks quarantine.  Lately, the government of India has said there is no need for the two-week quarantine unless there was a breach in personal protective protocol.  Everyone knows there is acute shortage of doctors.  “The calm surface appearance is the only armour we are left with. Underneath it, many healthcare workers are barely keeping it together” – said Dr K Anvar, pulmonary medicine professor in Palakkad Medical College.

In big cities, many hospitals are under-staffed but beds are full; nurses are overworked; ward attenders are far too few to assist patients – family members are disallowed, naturally. Doctors, however capable or motivated, are mere humans with too much stress – they have to forget about their own homes and families.  In many places, we get the image of the frontline of the stoic battle on the verge of collapse – where life-and-death decisions are made.

Has the Government built a mechanism to audit the quality and the cost paid out of pocket, in all private hospitals? Why has the government allowed profit-making by private hospitals for providing service for a human right?

Even before the coronavirus crisis, the healthcare system was in silent crisis – well-known, but ill-addressed for decades. Does a citizen have the right to a hospital bed when sick enough for hospitalisation? After all, health, hence healthcare, is a human right and we are a democracy in which the State has a duty to provide for healthcare.  Has the Government built a mechanism to audit the quality and the cost paid out of pocket, in all private hospitals? Why has the government allowed profit-making by private hospitals for providing service for a human right?

In all countries that India gets compared with for epidemic outcomes, it is their Public Health Service that is primarily in charge of prevention of disease and promotion of health.  Its absence was felt by the Government, for which reason the next best alternative, disaster management agency, was used.  Public Health (not to be conflated with public sector healthcare) uses epidemiology as its foundation science; an epidemic is not a disaster like earthquake or tsunami, but a slow-motion string of individual and family calamities.

We need all hands on the deck, a unified command, and all the resources that the governments can pump in if this battle is not to be lost.

When the brunt of the battle is assigned to healthcare workers and if they are demoralised and over-worked-stressed-stretched, we know we have a disaster, not by the epidemic, but by the fragmented, fragile and under-prepared healthcare infrastructure even for normal times.  

There are no easy solutions. When the soldiers fall short or are felled, how do you guard the frontline against the enemy? The only answer is to call every available resource to action – public or private. We need all hands on the deck, a unified command, and all the resources that the governments can pump in if this battle is not to be lost.

(Dr T Jacob John is retired Professor of Clinical Virology, CMC Vellore, and past President of the Indian Academy of Pediatrics)