key: cord-315801-hurpcc4e
authors: Yadava, Om Prakash
title: COVID-19: are there lessons?
date: 2020-07-31
journal: Indian J Thorac Cardiovasc Surg
DOI: 10.1007/s12055-020-01024-w
sha: 
doc_id: 315801
cord_uid: hurpcc4e

nan

Health is a state subject, and there was a glaring lack of communication and camaraderie between the federal and state structures. Even fiscal-federalism was conspicuous in its absence or partisanship. The centre's support to states was lacking or delayed. Contradictory orders were flying fast and furious, more inclined to the political ideologies of the incumbent administration, rather than a response to an apolitical disease. Morning orders were rescinded by the evening, thereby not only confusing, but demoralizing, the entire workforce, who as such were dealing with the uncertainties of an, yet not well-known, enemy.

Lesson: Too many cooks spoil the broth. There should be well-defined line of leadership, and demarcation of domains of each stakeholder, to avoid chaos and confusion of response, as also for an optimum utilization of scarce resources.

'No' knowledge better than 'some' knowledge As much, if not more, damage from COVID-19 has come from fear psychosis, rather than the virus itself. The root cause of this was the lack of an authentic, transparent, and verifiable single source of information. Half-baked knowledge, and at times even gumption, was dished out in the electronic and print media by self-styled 'Godmen of Medicine' as the 'Gospel truth'. In fact, the entire official response to the pandemic was governed by all and sundry including paediatricians, gastroenterologists, dental surgeons and the likes, rather than the public health experts, who were nowhere to be seen, even in the horizon.

It is with a view to addressing this gap in knowledge that the Indian Association of Thoracic and Cardiovascular Surgeons (IACTS) has tried to assimilate the scant, and at times confusing and contradictory, knowledge and has issued its guidelines (published later in this issue) to assist our cardiovascular and thoracic surgical fraternity in framing their responses to the challenges of practice in COVID times.

Lesson: Let the domain experts lead, take the centre stage and call shots. Rest, irrespective of their clout, must for once, take a back stage, sans a mumble.

It did not take long for our basic health structure, specially in the government sector, to be exposed and laid bare. Professionals have been bemoaning, ever since the independence that our spending on health sector is woefully short and that the intangible benefits of health should not be compared with the tangibles from the manufacturing industry, but should be monetised in terms of disability adjusted life years (DALY) saved. We are still lucky that even though the disease is ravaging in the urban areas, it has largely spared the rural hinterland, but I fear it may not be for long, and at which stage, the deficiencies of the primary healthcare infrastructure in terms of primary health centres, community health centres and district hospitals will be exposed further. Already, there are signs that the government is waking up to this realisation and the sooner it does, the better it shall be for the future of the country.

Lesson: Government must increase its allocation to health sector to at least 5% of GDP and focus on strengthening the primary care.

As a corollary of the foregoing, the out of pocket spending on health in India is an overwhelming 60-70% and two-thirds to three-fourths of all healthcare is in the private sector. Instead of realising this fact and embracing the private sector with an all-encompassing hug, the government has always treated the latter with suspicion, disdain and a 'carrot-stick' policy. Successive governments have tried to reign and subjugate it through oppressive legislations and archaic regulations. This attitude needs to be changed and profit, albeit reasonable, should be accepted as ethical, moral and in fact a necessity for a vibrant and effective private healthcare system, to meet the health needs of the society. Crushing private sector at the altar of the socio-political agenda of the incumbent political dispensation is going to be to the disadvantage of all stakeholders, and last but not the least the government itself.

Lesson: Create a policy environment for PPP to thrive and flourish

Regulation is a necessity and that is given. However, it must address the aspirations of the society it serves. Therefore, it must factor the ground realities and the resources available, and incorporate the social, economic and cultural confounders to be effective. Unfortunately, we seem to be caught in a warp, where we are copying regulations from the developed world and issuing regulatory guidelines as 'One size fits all' solution to the needs of the entire country-a country, as vast and diverse in all dimensions, as India. The recent urgency seen in regulatory bodies in clearing trials and fast tracking of approvals for new drugs is worth appreciating, but even in routine matters, regulatory jigsaw should be simplified and made user-friendly.

Lesson: We should focus more on standardisation with a view to enabling deregulation.

India has neither the ecosystem nor the finances, for basic, molecular level core research. It therefore needs to look at the low-hanging fruits of translational research. We already have enough lab knowledge; we just need to transform it into bed-side knowledge. India is lucky to have an amazing pool of young talent, just suited for this kind of research. This can even subsequently be commercialised and monetised and may help address the economic woes of the country. The information technology (IT) and biotechnology companies can team up for developing rapid testing kits for not only coronavirus, but for other diseases rampant in the country, and concentrate on developing point-of-care tests.

A start-up culture should be developed with the government providing the handhold by provisioning for the initial seed money, the physical infrastructure, patenting and subsequent commercialisation and marketing of technologies. 'Aatam Nirbhar Bharat' and 'Vocal for Local' are good initiatives, but need to be transformed from jargon to reality, something which has not happened in the past--'Make in India' and 'India shining' initiatives having flustered badly.

Lesson: 'Bench to Bedside' innovation is the 'Mantra' but we need to 'Walk the Talk'.

Healthcare is heading to a new normal. Necessity is the mother of invention and a lot of bright minds, either by design or by default, developed new processes and technologies during the COVID-19 outbreak. Sure enough some of them will fall by the wayside, but at least some and more meaningful ones will continue to survive even after the COVID-19 pandemic is over, either because of the value they have demonstrated, or maybe even because of necessity. Connectivity in India has improved following the Global System for Mobile communication (GSM) roll-out and Indian Space Research Organisation's (ISRO) support through provisioning of free satellite time for public health initiatives. Technologies can now be leveraged, not only for diagnostics but also for healthcare delivery with successful models in South Indian states delivering intensive care through Tele intensive care units (ICUs) and ophthalmology services, specially for diabetic retinopathy, being delivered in rural areas through mobile care units. Thus, tele-medicine and tele-consultations would, in all likelihood, become a norm in the future. Remote sensing and monitoring and point-of-care testing would decongest the bursting at the seams tertiary care hospitals. For a lot of diseases and illnesses, for which we always believed that patient care in a secondary or tertiary care hospital was mandatory, domiciliary care and conservative management have dawned as an effective alternative. The flattening of curve in Delhi, and available infrastructure not stretching itself, was achieved entirely with the realisation that 'Domiciliary quarantine' was as effective as 'Institutional quarantine'. Even 'Analytics' to change 'Big data' into action and value-driven partnership of industry with physicians is the need of the day.

Lesson: Leverage bio technologies and IT to deliver healthcare at the door step of the masses.

COVID-19 has been a big epidemiological experiment, albeit carried by nature. The universal outcry on a sudden drop in non-COVID hospitalisations in all specialities, not only of elective cases but also emergencies, without a proportionate and countervailing increase in non-COVID mortalities should sensitise us all-the medical fraternity, public and the government, to the overarching benefits of holistic living and good lifestyle. Whether these realisations will stay or be as ephemeral as the virus, only time shall tell.

Lesson: A stitch in time saves nine.

Just as we concentrate on our COVID-19 responses, we must not forget that the main health burden of India lies in non-COVID illnesses. A recent modelling study in Lancet Global Health showed that the mortality from Malaria was expected to increase by 36% over 5 years as against the pre-COVID levels, of tuberculosis by 20% and HIV by 10% [1] . All the routine vaccination programmes have taken a back seat. Schools are closed and the midday meal programmes are suspended. This, along with the attendant economic woes of the COVID-19, compounded further by the natural disasters of floods and typhoons like 'Amphan', will have a snowball effect on additional problems of nutritional deficiencies in children and infectious illnesses, besides psychological and mental disorders creeping in. A thought should also be spared both for the physical and mental health of the Health Task Force and the Corona warriors in general.

Let this calamity not go waste and let us treat this as an opportunity, a new dawn in the healthcare landscape of our country.

Potential impact of the COVID-19 pandemic on HIV, tuberculosis, and malaria in low-income and middle-income countries: a modelling study

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