The COVID-19 pandemic has been raging for over seven months now. It has directly killed over 800,000 people and, indirectly, caused massive losses to people who are mostly unseen. While I do not have the figures for this ‘collateral damage’, I have no doubt that it is many times more than the 800,000 deaths. Vulnerable people in need of care for other diseases are suffering because the pandemic is devouring resources that could have helped them.
…[A]round 80 pc of the programmes intended for the treatment of tuberculosis, malaria and HIV have reported disruptions worldwide, giving rise to the possibility of increased deaths and development of drug resistance in patients. Tuberculosis claims around 1.5m lives every year across the world (more than any other infectious disease) but the three-month lockdown and gradual return to normalcy over subsequent months will result in 1.4m additional deaths worldwide. Similarly, experts have also predicted that the death toll from malaria could double while 500,000 additional deaths would be caused by HIV/AIDS due to interruptions in treatment cycles.
The list of treatments indirectly affected by COVID-19 is not limited to tuberculosis, malaria and HIV. People who are suffering include those who need to visit the hospital regularly because they have a chronic disease. Diabetes, hypertension and cardiovascular diseases are receiving less than due attention because hospitals are dedicated to COVID-19. This is especially true for government hospitals, which in many parts of the world offer affordable services to the poor. Even ambulance services are unavailable in many parts of the world because drivers fear being infected by the coronavirus.
Cancer patients are also relegated to the background because hospitals are not welcoming those who suffer from it as the disease does not cause much pain. In fact, patients, especially in rural areas, do not know the urgency of the problem and are staying away at this time. Earlier this month, I saw a patient with carcinoma of the penis. He came to see me only after it had become a big mushroom shaped growth. He was afraid to come to the hospital three months ago, when it was still small and could have been treated better.
Rural patients like him face bigger challenges than their urban counterparts because of the lockdown and travel restrictions. Plus, loss of jobs, an extremely serious problem in itself, has left huge sections of the population in developing countries unable to access health services.
Another serious issue is that institutional deliveries have stopped. Children are not being immunised and sick children are being taken to traditional healers instead of being brought to the hospital. Disabled people are not seen anywhere in the vicinity of a hospital, again due to the fear of COVID-19.
It is difficult to estimate the death toll caused by all these ‘associated problems’. In developing countries this number may be very big. But now that we have acknowledged the problem, let us consider some solutions.
Move away from being doctor-centred
Because of the COVID-19 pandemic, we are realising yet again that we have an unbridgeable gap between the numbers of doctors and the numbers of people with chronic diseases. At the best of times, this ratio was scandalously skewed. Now it is a complete disaster. I think this is true not only in India which has 500 medical schools – the largest in the world – but in every developing country.
Train chronic disease technicians and get several of them to work under the supervision of a nurse/doctor. They can work in neighbourhood clinics or do home visits. Train chronic disease nurse educators who will not only support the chronic disease technicians but also provide education to patients so as to demystify chronic disease care. Teach patients all about the red flags – infection of the foot in a diabetic, very elevated or low blood sugars, albuminuria testing, giddiness or a blackout in a hypertensive, side effects of common drugs etc. Patients need to be empowered to manage as much of their health/disease as possible. Most importantly, chronic disease technicians will keep encouraging patients in their homes to change their lifestyle – manage their diet, do some exercise and quit smoking and alcohol.
Deliver proactive care using tele-consultation and virtual care visits. Symptoms can be evaluated and medication regimens can be changed – all virtually. Deliver prescriptions by e-mail marking a copy to the pharmacist.
Bring in vaccine educators or vaccinators
The hope is that a vaccine will tame the COVID-19 pandemic. But this will not happen until a majority of the population is immunised. Hence, now is the time for us to train vaccine educators/vaccinators. There is another important way that this move will be helpful. We know that the current politics of vaccination will prevent the poor and the marginalised from getting the vaccine for coronavirus. Moreover, since they form the bulk of the population, the threat of COVID-19 will not be dented for anyone. Our vaccine educators can lobby and become activists to make sure that the poor can and do access vaccination.
But all these steps will need investments of time and technology. So, will they be possible? Creativity and enterprise would be needed – not just to do them but also for the measures to pay for themselves. This can be a reality also through funding from philanthropic sources.
It is tragic that there is more to the casualty of the COVID-19 pandemic than is seen or properly recorded. The poor are struggling to get care not just for their diabetes, hypertension and cancer, but also for the epidemics that affect them the most – tuberculosis, malaria and HIV. This list is topped by the COVID-19 pandemic which threatens us all, but them even more.
Let us not take our eyes off the truly vulnerable.
Dr Vinod Shah is the former CEO of ICMDA.