That’s what Prakash Raj (name changed), an internal-medicine expert, told his close friend a few days ago. It was light banter, but his friend couldn’t have missed the poignant undertone. The doctor was named to lead the first-level response team set up to identify and treat Covid-19 infected patients at a large private hospital near New Delhi.
Sixty-four-year-old Raj knows how co-morbidities and his old age put him at a greater risk of contracting the viral infection and its higher mortality rate. Involved in examining patients from the time they walk into the fever OPD, he just prays that he and his family members don’t get infected. The lurking danger is that many Covid-19 carriers may not even display any symptoms and pass on the infection before getting tested.
In the three months that China has battled the epidemic, 3,300 healthcare workers have been infected despite strict triaging rules and carefully monitored flow of patients. In Italy, the virus has left 5,000 health workers infected.
The infection can significantly cripple healthcare delivery in a large hospital setting. According to the latest news reports, 108 staff members of Sir Ganga Ram Hospital in New Delhi, including doctors and nurses, have been quarantined after they came in contact with two patients, who tested positive. Of those, 85 have been sent to home quarantine and 23 are in the hospital.
Studies in China suggest healthcare workers (HCWs) are the ones at the highest risk of getting infected. Many of them were also overstressed and diagnosed for mental-health issues. Overworked and under-resourced HCWs, facing a possibility of infection and misleading information about a rapidly developing epidemic, may refuse or be unable to work, resulting in a critical shortage of healthcare workers.
In India, thousands of doctors, nurses, and paramedics have pitched in to play a front-line role in the country’s long and tough battle with the deadly Covid-19. But their sense of duty runs parallel to the risks of contracting a highly contagious virus. A growing list of doctors have been infected, and a few have died. To add to their woes, in some parts of the country, doctors and sample-collection staff are being castigated or even attacked because they are seen as carriers of the virus.
Doctors and healthcare workers hold out the only hope for the rising number of patients, it is critical that they get a regular supply of protective gear and are kept energised to meet the tough demands of their work. Above all, they have to be looked upon not merely as healthcare resource, but as humans.
Why protective equipment is top priority
In a March 22 piece published on the research-literature platform ScienceDirect, noted medical expert Anoop Misra, executive chairman of Fortis C-DOC (Centre for Diabetes and Obesity Care), says in India, private hospitals are not yet ready to manage such highly infectious, seriously sick patients and if government-run hospitals were to do it, they would have to upgrade their ICUs. Another matter of considerable concern is maintaining a continuous supply of PPE (personal protective equipment) in public-sector hospitals. PPE items are supposed to be discarded after a single use.
Even in the UK, Misra highlights, PPEs provided are inadequate, and some healthcare workers are left with just a surgical mask and plastic apron for protection. In China, he adds, despite the high priority and dedicated funding, many healthcare workers had bought protective gear on their own, at times with money or donations from friends in China and abroad.
Besides, there are other issues. While in complete PPE, as required in an ICU, doctors and support medical staff would not be able to drink, eat, or go to the toilet for about six hours, says Misra. Taking off the PPE after duty hours requires training and great care, so as not to infect the doctor himself. “When this doctor goes home, he does not talk to his wife or children, avoids touching any article there, and goes to disinfect in the bathroom first,” he adds.
Misra believes that dealing with the outbreak is a war-like situation, and akin to the army, doctors and healthcare workers working with Covid-19 patients should be given extra allowance and adequate rest/leaves to overcome physical and mental fatigue.
“The bigger risk is that many of the doctors may become exhausted and insist on taking leave to rest. That situation may add extreme pressure on a healthcare system like India. We will have to watch out in the next four to six weeks,” he says.
Some news reports indicated doctors and nurses from a hospital in Delhi tendered mass resignations citing poor work conditions and insufficient protective coveralls.
Withdrawal of medical staff from work could be a lurking danger that India can ill-afford at this crucial stage. Experts are of the view that even at the peak availability of PPEs, India may need a buffer stock. If doctors who have specialisation in ICUs start withdrawing, shortage of trained medical staff can lead to massive pile up of patients needing immediate care.
Risk at every step
The first level of risk of infection is to the general physician at the local-community level. A typical Covid-19 patient may manifest mild symptoms for the initial four to five days and visit a doctor, who in turn could recommend isolation, home quarantine, tests, and urgent hospitalisation. At this stage, the patient may expose the doctor to infection and it may get passed on, leading to a rapid spread of the disease.
In the next stage, the need for PPEs becomes significantly higher. In a typical case, if a severely infected patient is to be put on a ventilator, the median duration they have to stay in the ICU is two weeks.
“So, we may have a situation where an ICU bed fitted with a ventilator and other equipment may be occupied by just two patients for the entire month. Even if we talk about adequate capacity at this stage, that may fall short if cases climb beyond a particular point,” says a doctor, asking not to be identified.
Besides, special skills are required for handling ventilators and respirators, says another doctor from a Noida-based hospital. “Many a time, the lack of training on intubations may lead to the deterioration in the patient’s vital stats. The training that AIIMS provides to doctors on handling ventilators is helpful. The need is to have on-site training for two-three days.”
All this would need a lot of PPEs, as they are meant for single use. For anaesthesiologists, who are key staff in critical care or ICU, the PPE is an imperative. “In the intubation process, the doctor gets very close to the patient and the chances of a viral load transmission is significantly higher,” the doctor adds. “There are many who don’t even go close to the patients. Some are seriously thinking of leaving their jobs.”
A work in progress
Top government officials have sent comforting signals so far. At a press briefing on March 2, Lav Agrawal, joint secretary in the health ministry, assured that the demand for PPEs would be met.
Since January, the government has been mobilising efforts to ease any future shortage of PPEs and sufficient supplies from Indian and global companies were already on their way, he said, adding that 150 million items of PPE were in various stages of procurement.
A ministry statement of March 30 stated that some PPE items are not manufactured in India, but given the critical situation, efforts are made to promote local manufacturing. The ministry said 334,000 items of such equipment were available in hospitals across the country.
However, Ravi Wankhedkar, former president of the Indian Medical Association, says a provision of roughly 7.5 million items of PPE should be made immediately. The count of Covid-19 patients has increased to over 2,500, doubling in less than 10 days. In such a situation, if doctors and hospital staff are not equipped and assured of their personal safety, it could trigger a bigger crisis.
Wankhedkar’s worry is justified. India has never had sufficient trained doctors to cater to the needs of the growing population, leave alone ramping up in times of a public-health emergency. According to the National Health Profile of 2019, India had a little over 1.15 million allopathic doctors. That is short of the World Health Organization’s (WHO) recommendation of a minimum threshold of 22 skilled healthcare professionals per 10,000 population. Recently, WHO revised that number to 44.5 doctors, based on latest data.
But counting India’s doctors, nurses, and midwives, that is still 20.7 healthcare professionals per 10,000 population, according to the National Sample Survey data. The Global Health Workforce Alliance and WHO have categorised India among the 57 most severe crisis-facing countries in terms of availability of human resource for health.
Hoping the contagion doesn’t aggravate
However, Rohidas Borse, a medical professor at Pune’s Sassoon Hospital, does not find the yawning deficit in the number of caregivers daunting.
Borse, who spoke to Prime Minister Narendra Modi on his radio chat Mann Ki Baat recently, exudes hope, saying the situation is under control. Borse tells ET Prime that this outbreak is not about developed nations or undeveloped nations. “We are at the same level of preparedness and taking on the challenge. Ventilators are in shortage in the US, China, and Italy as well. We are not seeing that situation here,” he says.
Naveen Malhotra, secretary at the Indian Society of Anaesthesiologists, echoes Borse, saying the body has 32,000 active members and another 22,000 in various capacities. “We do not anticipate a big crisis that will overwhelm the available ICU beds. Although a lot of emergency additions are planned, the situation should be in control.”
However, in a position statement of the body, Malhotra has cautioned its members that there could be a sudden surge of patients and healthcare demands. Hospital resources may get exhausted quickly and medical personnel can come under tremendous work stress, both clinical and psychological. Hence, existing resources have to be preserved and additions made immediately.
In the coming days, a large number of patients may suddenly require oxygen therapy, tracheal intubation, and ventilator support. The facilities, devices, and equipment for the same should be updated with repairs, services, replacements, and fresh purchases.
As renowned pulmonologist Zarir F Udwadia pointed in an editorial in the medical journal The Lancet, healthcare workers are not machines, unlike ventilators or wards, and cannot be urgently manufactured or run at 100% occupancy for long periods. It is vital that governments look at them not merely as resources to be deployed, but as humans.
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