key: cord-0912238-vhue3l7n authors: Prasad Das, Sri Aurobindo; Nundy, Samiran title: Rationing Medical Resources fairly during the Covid -19 Crisis: Is this possible in India(or America)? date: 2020-05-07 journal: Curr Med Res Pract DOI: 10.1016/j.cmrp.2020.05.002 sha: 454af62073d6c44e2346b48a016f84bd271b6644 doc_id: 912238 cord_uid: vhue3l7n nan The novel Corona Covid-19 virus infection, which started as a disease endemic in the Wuhan province in China, has reached pandemic proportions in a short time. Apart from bringing the global economy to its knees it has also brought the whole world to a near standstill. The worst affected sector in this time of crisis is healthcare. Apart from exposing a lack of safeguards like manpower shortage and infrastructure, the disease has also put a strain on the availability and allocation of scarce medical resources. At a time like this where the major focus of medical research has been on rapid testing and diagnosis, developing newer antiviral drugs and optimising patient outcome, the venerable and influential New England Journal of Medicine(NEJM) in their latest issue have published an article by Emanuel et al 1 (from the Departments of Medical Ethics and Health Policy in Pennsylvania, Denver, and Washington in the USA, Toronto and London, Ontario in Canada, Sao Paulo in Brazil, and Oxford, England)who have addressed an important sphere of patient care(which has always been relevant in poor countries and is now affecting the rich ones) that is the fair allocation of insufficient medical resources. The authors have highlighted the projected overwhelming of the healthcare infrastructure in the United States of America. They estimate that 81% of the population will be infected over the course of the epidemic. In a moderate Covid-19 scenario 80% of these will be asymptomatic or have mild symptoms, 20% will require healthcare services, 8% overall will need hospital care, 6% will need intensive care and 0.5% will die. In a severe scenario 3.0% will die. The American Hospital Association data show a total of 85 000 adult ICU beds in the US. In the case of only the moderate Covid-19 infection scenario at least 15 million beds would become necessary i.e. 176 times the number now available. This problem will be compounded by the shortage of ventilators, trained respiratory therapists and critical care staff. In addition the lack of widespread diagnostic test kits, effective drugs or vaccines and unavailability of adequate personal protective equipment (PPE) also has exacerbated the problems of the US health care system. Against this rather frightening background the authors have rightly pointed out that ethical rationing of medical resources should be considered urgently using a system which is transparent, fair and 'scientific'. Their recommendations for allocation are based on four fundamental ethical values which they obtained from previous pandemic models. These are 1. Maximizing the benefits produced by scarce resources 2. Treating people equally 3. Promoting and rewarding instrumental value 4. Giving priority to the worst off Based on these principles the authors have suggested 6 recommendations for health resource allotment for the Covid-19 pandemic: These are discussed in further detail in our commentary and include the following headings The authors suggest an open discussion on how to implement the rationing of healthcare resources which will soon become inevitable to ensure their fair and consistent allocation. We all urgently need to balance multiple ethical values for various interventions and circumstances and develop prioritization guidelines and standard operating protocols At a time when the world is facing one of the worst pandemic outbreaks in history, this article brings to the notice of more affluent nations a problem with which we in India have dealt with all our working lives i.e. the rationing of healthcare. But are its suggestions practicable and can they be implemented in an unequal society like India or even in the US? The bare facts. India has a population of nearly 1.3 billion people and one of the most inefficient health systems in the world. More than 70% of the population pay out of pocket for their healthcare expenses choosing to go to private doctors(even at the risk of bankruptcy 2 ) rather than an underfunded, overcrowded and inefficient public system, there is a doctor:population ratio of 1 in a 1000 concentrated mainly in urban areas 3 , the government spends only 1.5% of its GDP on healthcare(the US spends 17%) and our scarce resources are usually monopolised by the rich and powerful. However we feel it would be an interesting exercise to see if and how the recommendations of Emmanuel et al can be implemented here, or for that matter in the USA. They recommend allocation of limited resources be aimed at both saving the greatest number of lives and at maximizing improvements in the individuals' post-treatment length of life. They also state that a balance between lives saved and life-years should be maintained. Comment. This is already being done in many ICUs of public hospitals which have a shortage of say ventilators. We ourselves have occasionally chosen to ventilate young mothers in preference to patients with terminal disease. However it would be naïve to suggest that if an important politician or business magnate needed treatment at the expense of two or three poor labourers it would be denied to him. We have little doubt that the same situation would prevail in the US. Would the President or his cabinet colleagues be denied optimal intensive care in a time of crisis? 2 Prioritize health workers They suggest that critical Covid-19 interventions like testing, PPEs, ICU beds, ventilators, therapeutics, and vaccines should go first to front-line health care workers and others who care for ill patients and who keep the critical infrastructure operating. Comment. This is going to be highly unlikely in this country where the rich and powerful already monopolise high end expensive treatments like transplants or cardiac procedures. Although frontline health workers are deserving it is unlikely that they would be given treatment on a priority basis and it also send out an unpopular and politically incorrect message to the general public. 3 Not allocate on a first-come, first-served basis They recommend random allocation of resources using a process like a lottery and not on a first-come, first-served basis. The latter would give undue preference to people who have easy access to healthcare facilities and result in crowding and even violence especially during a period when social distancing is paramount. Comment. This has never been done here. Even in public hospitals we tend to choose to provide care to the sickest patient e.g. with a resectable cancer who is lower on the waiting list than someone who arrived earlier e.g. with an asymptomatic inguinal hernia. Our private system also depends heavily for its existence on prioritising care for the rich and powerful. Prioritization guidelines should be based on scientific evidence. For example Covid -19 vaccine should be given to high risk groups like health care workers and old people with comorbidities. Younger people are better benefited with exposure with mild symptomatic disease with lifelong immunity. Comment. Unlikely here as the vaccine will be first given not to health care workers or old people but to politicians, bureaucrats and rich and influential businessmen. They recommend people who participate, either as subjects or investigators, in research trials for the vaccine and drug development should receive priority for Covid-19 interventions. This will ensure better participation in trials as their efforts will be recognised and rewarded. Comment. Not relevant here as there will be little research output on this disease given the sad state of medical research in this country 4 . 6 Apply the same principles to all Covid-19 and non-Covid-19 patients Comment. With this recommendation we wholeheartedly agree. We cannot let a person die from intestinal obstruction by closing operation theatres and wards, as we are now doing, just because we have to prepare to treat a presumed influx of Covid-19 patients. In fact our main criticism of the countrywide 'lockdown' is that we may have more patients who need urgent medical care for other reasons and may be dying without it rather than the number who will be projected to die from a Covid infection. The huge mass migration of the hungry and unemployed poor has been the consequence of trying to prevent a major outbreak of a possible viral epidemic -which might never happen in our unhygienic environment that may have already provided us some herd immunity 5 . It needed a huge pandemic to make people in affluent countries aware that even their present abundant medical resources may not be sufficient to cope with its consequences and they should examine how what is available be used fairly, rationally and effectively. We in the developing world have to make such choices every day of our working lives. However although the article is of great interest it seems unlikely that the authors' suggestions can be implemented in India(leave alone the USA) Fair Allocation of Scarce Medical Resources in the Time of Covid-19 The private health sector in India India achieves WHO recommended doctor population ratio: A call for paradigm shift in public health discourse! J Family Med Prim Care The research output from medical institutions in South Asia between 2012 and 2017: An analysis of their quantity and quality Herd immunity and herd effect: new insights and definitions None