Non-Covid patients a casualty of the pandemic

Jagat Ram

Director, PGI

Rakesh Kochhar
Prof, Gastro Department

It has been over 10 months since the pandemic began and there are no signs of it abating soon. There have been encouraging news about more than one vaccine, but it’s still some time before we get it.

Even as we are burdened by the logistics of caring for active cases, doctors are concerned about what the New England Journal of Medicine has called ‘the untold toll’ of the pandemic: the neglect of non-Covid patients.

No one had visualised that the pandemic would disrupt healthcare systems for so long. The lockdown prevented patients from seeking non-emergency care for months. The problem was compounded by most hospitals being converted into Covid-related facilities and a sizeable chunk of doctors and nurses diverted to the latter (in Delhi, more than three-fourths of the ICU beds are reserved for Covid patients).

To decrease the risk of the transmission of the virus, hospitals have deferred scheduled follow-up visits, elective surgeries and annual screening tests. Most in-person visits have been converted into tele-consultations. A majority of the patients, too, have avoided hospital visits, fearing exposure. Around 9,000-10,000 patients used to visit the PGI OPDs. Their number came down to 25-30 per cent of that.

This has affected patients suffering from other acute illnesses and chronic diseases like diabetes, hypertension, renal failure and cancer. A report by National Cancer Registry of the ICMR has estimated that there would have been close to 14 lakh cancer patients in India in 2020.

With 70 per cent of our population being in villages and 90 per cent of cancer facilities being in tier-1 and tier-2 cities, the mismatch is glaring. There are disruptions in chemotherapy and radiotherapy and delays in surgery.

The PGI did continue with its radiation and oncology services through the last nine months, but there is no denying that many patients have failed to get optimum treatment. Even the Tata Memorial Centre, Mumbai, was forced to scale down its operations.

There have been major disruptions in the vaccination programmes across the world. Around eight crore children under the age of one are thought to be at greater risk of preventable diseases like measles, polio, mumps and hepatitis-B. A recent Lancet report compared the health benefits of routine childhood vaccination in Africa with the risk of acquiring severe Covid-19 infection from visiting vaccination centres. It was noted that for every one additional Covid-19 death, 84 deaths in children could be prevented by continuing the vaccination schedule.

Another infectious disease whose patients may have suffered during the Covid crisis is tuberculosis. India accounts for one-fourth of the TB cases in the world. As per a WHO Global TB report, weekly TB notifications in India, which had reached over 50,000 in February, this year, had dipped to about 15,000 one week after the lockdown, before reaching to about 35,000 cases by mid-May. Distribution and availability of the drugs, given free of cost to the patients, has also suffered a setback.

It is estimated that disruptions due to Covid-19 will result in two-four lakh additional deaths worldwide.

All patients with chronic diseases have suffered during the pandemic. Patients with cardiovascular diseases, liver cirrhosis, chronic renal failure, inflammatory bowel disease or epilepsy, to name a few, have failed to get optimum treatment. Most chronic diseases require periodic monitoring and drug dose modifications. While tele-consultations have been made available, they cannot replace actual visits to the physician.

More importantly, the complications or worsening of the basic disease cannot be always identified or predicted in a tele-consultation. Some conditions like liver failure or cardiac failure may become irreversible if not treated at the right time. The same holds true for any elective, planned intervention, be it surgery, coronary stenting or joint replacement. Many of the eye conditions like diabetic retinopathy or glaucoma can take a course for the worse. Diseases like diabetes require close monitoring to prevent complications, and for adjusting dosage of drugs.

While most hospitals were handling emergencies like heart attack or stroke, in many cases, there was a delay in seeking treatment. Public health doctors say that people are more than twice as likely to die from a heart attack during the pandemic because of the delay in seeking help or being provided the right intervention.

The burden of infections like dengue, malaria, typhoid, diarrhoeal diseases and pneumonia is huge in India. Any delay in providing the appropriate treatment can be fatal. We know how much the ‘golden hour’ counts in heart attack or head injury.

Organ transplantation has been another major casualty of the pandemic. The lack of availability of surgeons, problems in arranging donors, difficulties in accessing healthcare facilities and diversion of ICU care for Covid patients, have all contributed to a decline in organ transplantation.

There are two other aspects of healthcare during the pandemic. One is the increasing recognition of ‘long Covid’, that is the persistence or recurrence of symptoms after recovery from Covid. Persistent fatigue, aches and depression are common, but many patients have lung fibrosis or worsening of the cardiac function.

The other is the conundrum of mental health issues related to Covid. They range from anxiety, stress, depression, anger, fear and insomnia. Prolonged hospitalisation or staying at home in isolation and fear of death are responsible for a variety of symptoms. There has been an increase in suicides, too. A compounding factor has been the disruption in critical mental health services, including counselling, psychotherapy and treatment of substance abuse.

One often neglected aspect of the pandemic is the increasing dependence on private healthcare services since government facilities have been predominantly converted into Covid treatment ones. This has affected the not-so well-offs as they depend on it.

Another worrisome thing is Covid reinfection. Though it is believed that after an episode, the individual will have immunity for six-nine months, stray cases of reinfection have occurred.

We are enduring Covid-19 at a huge cost to non-Covid patients. While it had made sense to divert resources to handle the surge, as the pandemic lingers on, healthcare systems must find better ways to manage all patients. An article in the Harvard Business Review has suggested a multi-pronged strategy, with emphasis on proactively managing non-Covid patients who have high-risk conditions.

Thus, till the time a vaccine is widely available and the pandemic controlled, we must continue in earnest with Covid-appropriate behaviour (mask, social distancing and hand hygiene) and redouble our efforts to treat Covid-19 and non-Covid patients.

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