Article

Lessons for medical profession during management of covid-19 pandemic: Is there a silver lining?

Dr Sahul Bharti

Covid 19 pandemic caused by corona virus has become a sort of global ‘showstopper’ with apparently huge negative impact on human life as well as economy worldwide. It has, undeniably, emerged as a daunting challenge for medical profession in 21st century. Despite its glorious victories over the past pandemics of plague, cholera, polio and smallpox, medical profession is bracing itself to take on Covid 19 juggernaut. Currently, every person, layman or medical, is dismayed by ferocity of its spread and rapidity of its killing, particularly among high-risk persons. In various hotspots of this pandemic, healthcare systems are severely overwhelmed by clinical load of patients requiring hospitalization as well as intensive care. This is first time that medical professionals have a dual responsibility- to treat the patient as well as to prevent themselves from succumbing to same illness. While healthcare professionals all over the world are showing exemplary fortitude and gusto in dealing with this uphill task, it is time to decipher few lessons which can be usher in new era of healthcare following covid pandemic.
Advantages of recent rationing of routine specialized medical services

Undeniably the patient load at various hospitals (both public as well as private) over last few weeks has hit the rock bottom due to people’s reluctance and doctor’s hesitance in engaging with medical care. Even suggesting going to hospital is sending shivers down the spine of a person with simple fever or cough. This sudden aversion to hospital visits clearly echoes the scenario 150 years back when hospitals were first established in western world. The hospitals in early America were primarily used as alms-houses for homeless poor and getting hospitalized was a stigma for the society (Health, Illness, and Society: An Introduction to Medical Sociology By Steven E. Barkan). Same stigma has resurfaced now during covid 19 pandemic, though in a different social and medical context.

Elective procedures are almost at standstill for following two reasons: First, as an austerity measure to preserve potential resources for covid patients and second, to protect the vulnerable from exposure to virus. Even, emergency facilities are also witnessing load shedding with recent reports of 40-70% decrease in STEMI (ST Elevated Myocardial Infarction) patients all over the world (https: //www. tctmd. com/ news/ mystery-missing-stemis-during-covid-19-pandemic). In a study published in Spain (by Rodríguez-Leor O et al), interventional cardiology is almost in a state of lockdown and surprisingly corresponding increase in medical management of heart disease patients is still slight. Published reports of activation of cardiac catheterization labs for STEMI patients also showed a decline of 38% (Garcia S, et al. J Am Coll Cardiol. 2020; Accepted Date: 7 April 2020). This should not be alone attributed to serious patients failing to reach hospitals due to fear of corona virus. Literature search easily reveals that false activation rate of catheterization labs ranges from 12.5-40% (by Degheim G et al JRSM Cardiovascular Disease 2019, Vol 8;1-5). Therefore, recent decline of 38% during Covid pandemic is concordance with previously reported false activation rate and thereby reflects avoidable or unnecessary therapeutic demand.

One potential upside of this recent drop in healthcare utilization is the reduction in “too much medicine”- a term gaining prominence in recent medical lexicon. This is wide ranging concept which encompasses processes like over-detection (diagnosing harmless, static or incidental conditions which will either resolve spontaneously or do not progress), over-definition (where thresholds for diagnosing illnesses are gradually lowered leading to quasi-indications for treatment) and over-selling (by alarming patients with insidious symptoms mirroring serious pathology, carpet testing for some vague symptoms till patient is medically labelled)(BMJ Evidence-Based Medicine February 2018 | volume 23 | number 1). These terms assume importance when we look at the previously published data for out-of-pocket medical expenditure by patients with medical care. A recent study revealed that healthcare spending pushes 3.5 to 6.2% of Indian population below poverty line every year (BMC Public Health19, 1020; 2019). In another study using National Sample Survey Organization (NSSO) data, odds of falling below poverty line were 38% higher for persons hospitalized with cardiovascular disease as compared to communicable disease (Engelgau MM, Karan A, Mahal A. The Economic impact of Noncommunicable Diseases on households in India. Global Health 2012; 8: 9). Importantly, spread of covid 19 is already forcing every hospital or healthcare institute for rationing of medical care and many hospital-based practices including tests and procedures routinely performed before covid 19 catastrophe have suddenly become redundant and avoidable( by Wang X & Bhatt DL in J of Invasive Cardiology 2020; 32 (4): E81-E84).

Since most hospitals are not currently teaming up with non covid patients, the burden of pervasive hospital acquired antibiotic resistance pathogens is also likely to ebb. Past data had shown that 7% of patients from developed countries and 10% from developing countries suffer from hospital acquired nosocomial infections at any given time totaling hundreds of millions worldwide every year (https://www.who.int/gpsc/country_ work/gpsc_ccisc_fact_sheet_en.pdf). This unintended break in continuum of hospital care is a valuable opportunity to sanitize all those hospitals which are not involved in active patient care of covid patients. In addition, medical research (mostly repetitive or redundant) in tertiary institutes has also come to standstill which will save patients from avoidable investigations and additional visits just for the sake of data collection. Finally, it is a rare medical touch point where patients are not being reprimanded by medical healthcare providers for delayed health care seeking and mutually participative healthcare actively guided by doctors on phones has become a new buzzword.

Advantages of emerging public health practices

With widespread practice of hand washing which has now emerged as a globally cherished pastime of human race, it can play a protective role against surge of bacterial infections during ongoing summer season. Also, if this forced ritual becomes a habit (very likely due to so many weeks of rigorous daily practice), the trend for community acquired bacterial infections is likely to be further blunted for longer duration. Food borne illnesses like typhoid, shigellosis and bacterial infections like staphylococcus are going to see notable fall in coming peak season. Worm infestations of children where dirty hands are the key culprit are also likely to recess as well. Recent emphasis on use of warm/hot water for repeated drinking as a guard against covid 19 will certainly play key role in stonewalling common waterborne illness like cholera and hepatitis A or E. Stringent guidelines for not coughing or sneezing in public with widespread use of masks will further stymie the spread of viral infections like measles, mumps, rubella as well as other flu viruses including H1N1.

Advantages of accompanying lockdown

Orthopaedic, neurosurgery and trauma wards are no more brimming with injured patients. It is quite apparent that trauma due to road traffic accidents and criminal acts is almost negligible during the lockdown.

With the rapidly accumulating evidence of fall in pollution levels of air, most medical professionals are going to see far a smaller number of acute exacerbations of asthma in children as well as adults. The impact of improving air quality on the incidence of other respiratory illnesses, cardiovascular disorders as well as lung cancer will be very interesting to monitor in near future.

Earlier most of the urban population was spending time indoors in the air-conditioned offices, cabs, metros or even homes. This lifestyle had morphed almost whole human race into vitamin D endemic species. Fortunately, with strictly imposed lockdown, people are forced to spend good amount of their daytime in the lawns, rooftops, balconies or corridors. Though there may be many who still are not fortunate to have enough sunlight exposure, yet overall lockdown has come as a blessing in disguise for the health of urban population. Availability of ample opportunities for exposure to sun will replenish the chronically depleted vitamin D stores, again a known immune booster which may be crucial during this time of crisis. Most mothers, wives as well as daughters are rediscovering the time tested and traditional recipes with rich repertoire of macro as well as micro nutrients which will further uplift and fortify the nutritional milieu of families. The typical middle-class penchant for enjoying fried, oily and refined sugar laced foods is also likely to be subdued due to limited availability of raw materials at homes during ongoing lockdown. This will further safeguard their health from risk of obesity and its subsequent health consequences. Renewed interest in intake of seasonal and local fruits available easily is another take-away of lockdown.

Party culture with access to unhealthy food as well as substances of abuse is certainly a nonstarter now. College students compelled to be at home are enjoying freshly prepared healthy home food. Most hostel messes providing nutritionally sub optimal meals are closed.

What will be the fate of NCDs-noncommunicable diseases due to lockdown following covid 19 pandemic? The patients with poor control of diabetes and hypertension are at risk of higher covid 19 morbidity as well as mortality. On the positive side, the fear of contagion itself may provide these high-risk patients further incentive to optimize their compliance with the treatment as well as other lifestyle measures like diet and exercise. Lockdown restrictions will certainly block the easy access of diabetic and hypertensive patients to less healthy outdoor food served at popular restaurants or eating joints- usually a rite of passage for urban population. Moreover, limited accessibility to cold drinks, snacks like chips, burgers, pizzas either directly in the market or through online food delivery services will further play a protective role in controlling the needless intake of sugar and salt in such patients. Additional risk factor increasing the human vulnerability to NCDs is trans fats (mainly embedded in food items available from market). Trans fats are the major offender for worsening metabolic as well as vascular health and during lockdown, they are likely to be replaced by healthy polyunsaturated fats and oils routinely available in the kitchens of most homes.

Substance abuse is one more niche area which is likely to see substantial change in coming weeks. Accessibility to regular supply of substances of abuse especially recreational drugs as well as alcohol are in serious jeopardy due to lockdown. Reports of addicts reporting major withdrawal symptoms are already getting media attention. High risk sexual behaviours as well as free access to red light areas have been restrained to large extent, hence expecting fall in STIs as well as HIV incidence.

Hospital driven care for various psycho social needs have also plummeted considerably. Except for major psychiatric illnesses, patients with common mental or psycho social health issues are clearly opting for either self-management or various alternative modes of care to safeguard their mental or psycho social health. Occupational injuries including those due to noise and light pollution have declined due to industrial shutdown and on long term, hazards of occupational exposure to toxins or poisonous substances will show beneficial trend. In addition, palpable decline in crime rate all over the world will have indirect impacts on the health of people in those high-risk localities, especially the children and women.

Emergence of cost-effective models of healthcare with participatory patient doctor relationship

Role of mobile or e-healthcare has skyrocketed in last few weeks as a surrogate for actual care at hospitals or clinics. The need for digitized medical care cannot be overemphasized in the backdrop of the fact that hospitals and their medical staff are emerging as hotspots of covid infection and are likely to act as super-spreaders. Hence, hospitals or medical care centres are no longer the safest niche for persons with routine sickness and people are, instead, voluntarily opting for tele care through their mobile phones. Also, family doctors as well as local health volunteers are efficiently filling the recent void in medical care. Frankly speaking, the covid pandemic lockdown has catalysed the redux of long-forgotten art of medical practice through either family doctors or local health volunteers in the present heavily institutionalized medical ecosystem. The current phase of covid turmoil is, indeed, a salvageable touch point for public health. Covid 19 has clearly proven that more than 80% of our population just needs a sound public health advice (hand washing, cough hygiene and social distancing), another 10-15% of population needs minimal medical support (like paracetamol) while remaining 5-10% population is salvageable with basic medical support (with oxygen, IV fluids and antibiotics/antimalarials). Importantly, none of them require massive public or private health institutes and well-trained health workers or volunteers are competent enough to deal with it. It is only 1% extreme outlier or even lower percentage of population who will be eligible for intensive healthcare with significant chunk of them unlikely to be salvageable. This model of pyramidal approach where only top 1% will require technically advanced medical care is uniformly applicable to rest of the diseases as well. Given the hierarchical needs of healthcare, a highly cost-effective framework of ‘public health’ needs to be urgently prioritized over overbearingly technocratic medical science, both among lay public as well as policy makers.

The covid 19 pandemic is probably first instance where doctors are clearly finding themselves as or even more susceptible than their patients whom they treat. Reflecting thoughtfully, covid 19 is showing medical fraternity a mirror to judge their much-vaunted prowess as demigods. Never ever a situation has arrived in modern medicine where doctors find themselves at receiving end in treating patients as currently happening with covid pandemic. There is almost a role reversal where instead of patients fearing their doctor, doctors are fearing their patients. Honestly, this is the greatest humbling moment in the history of modern medicine. Have you ever seen doctors repeatedly and pleadingly begging each and every person for such mundane household chores of washing their hands and keeping social distancing? In the era of robotic surgeries, organ transplantations, stem cell therapies and genomic medicine, isn’t it an antithesis to the currently hyped medical armamentarium capable of potentially decimating any disease present in the world? On the other hand, almost every grandmother or nanny has been offering this time-tested household wisdom of regular hand washing (the current front line strategy to prevent covid spread) to the kids since time immemorial.

Surely once the crisis settles, there will be serious contemplation about the heavily distorted medical care pyramid which stands exposed by covid like threats looming over the whole humanity. The heavily institutionalized framework of healthcare has proven to be a limitation both for treating increasing burden of covid patients as well as preventing the further spread of infection. The weakened public health foundation of healthcare landscape is a serious caveat which needs urgent makeover. Importantly, people have this rare opportunity to reboot their demagogy of overarching importance of hospital driven medical realm. Most of our health issues are self-limiting, benign or non-threatening or stress precipitated. Let us reclaim the control of such problems from the hands of medical professionals and set up our own roadmap with active participation of public health institutions. Over-reliance on medicines and treatments is self-defeating and preventive measures need to take centre stage in our daily lives. Luckily, there is a golden opportunity for people to allow natural healing of their bodies as well as minds unconfounded by medical care. Analysis of such data will motivate people to rediscover their self confidence in natural healing of body as well as other alternative sciences of healthcare.

Nature’s Experiment with Covid Intervention

Looking from nature’s perspective, it seems that a prospective controlled trial has been implemented in the world? It is not a multi-centric or multi-country, but it is a multi-continental research trial. And the intervention being tested is “primum non nocere” a Hippocratic oath “first, do no harm”. The data are being sequentially collected from precovid world (baseline or control phase) and covid affected world (study intervention phase). The precovid world which had been heavily dependent upon modernized medical care for last many decades will provide data for control or baseline phase. For the intervention phase, fresh data are being generated from all major hospitals where non-covid medical care has almost completely halted (a constrained form of primum non nocere). The data of baseline phase are already widely available in literature. The results have shown that nearly one in every 10 patients in developed countries is harmed due to hospital care, 50% of which is preventable (www.who.int › features › fact files › patient_safety). The baseline scenario is more alarming in low- and middle-income countries (LMICs) where hazardous hospital care causes 134 million adverse events leading to 2.6 million deaths every year. Now with a global lockdown due to corona virus pandemic, routine hospital care has almost ceased. Only limited cases are being treated and all resources are diverted towards management of patients with Covid 19 illness. In this scenario, it would be quite revealing to know the magnitude of harm inflicted every year due to medical care. If such data are collated from all over the world throughout the covid pandemic, it would provide a unique and valuable comparative insight about the magnitude of harm posed simply by failure of Hippocratic principle of “first do no harm”.

Actionable Metrics for future roadmap

Few statistical indicators will certainly offer deep insight into the real need of medical care in our modern society. The sales of medicines, the hospital admission as well as readmission rates, number of diagnostic and therapeutic procedures as well as surgeries performed, healthcare spending, baseline rates of commonly reported hospital illness before and during covid 19 pandemic and final mortality data (both non covid as well as covid related deaths) stratified by age, gender, socioeconomic strata as well as severity of underlying illness will be immensely discerning metrics for policy makers and planners. Interestingly, experts with institutionalized mindset of health care model are attributing recent decline in healthcare demands for non covid illnesses as “lull before storm”. So far, the post covid Wuhan scenario seems to contradict the ‘lull before storm’ theory of missing non covid illnesses and there are no alarming media reports that non covid mortality has spiked due to shutdown of most hospitals or clinic based medical centres. However, if things do not show the expected resurgence as fore casted by many experts, then it is high time to reboot the mindset of policy makers as well as public for better, safer, cheaper and simpler healthcare paradigms as well as models of care.

Take home message

It is high time that our highly institutionalized medical profession must cross the Rubicon and commit to ‘Home Based Medical Care’ (HBMC) and ‘Self-Monitoring’ (SM) as new paradigms of healthcare. Hopefully, the post covid zeitgeist is going to be marked with patient centric as well as patient driven care aided actively by public health institutions over hospital driven management protocols.

(Disclaimer: The author is Dr Sahul Bharti, MD Pediatrics (PGI, Chandigarh), PDCC Pediatric Endocrinology (SGPGI, Lucknow), Dip Statistics (PU, Chandigarh). He is Sat Pal Mittal National Award winner & founder of research based NGO-Build Healthy India Movement (BHIM). Views expressed are a personal opinion.)

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