Dr Anu Grover, DGM-Medical Affairs, Ipca Laboratories, Mumbai and Meenu Grover Sharma, Principal Consultant, BusinessAssociar Consulting, New Delhi chart out the long term consequences that a global pandemic like COVID-19 will have on our healthcare system and our policy making infrastructure
Prevalence of infectious diseases has increased globally as humans have spread across the world. Outbreaks have been occurring frequently, but every outbreak does not reach a global pandemic level as the Novel Coronavirus (COVID-19) has. Pandemics are large-scale outbreaks of infectious disease with high burden of morbidity and mortality over a wide geographic area and cause significant economic, social, and political disruption. Globalization, with increased global integration and travel, urbanization, and greater exploitation of the natural environment, has led to pandemics spreading quickly, with COVID-19 being deadliest of all witnessed in our lifetimes thus far.
Pandemics have had significant social and economic cost to humanity over centuries
Pandemics have afflicted civilizations throughout human history, with the earliest recorded outbreak of Plague of Athens during the Peloponnesian War in 430 BC. There are many views about the exact causes of this pandemic. Some believe it was Typhus or Typhoid. The disease passed through Libya, Ethiopia and Egypt, and then it crossed the Athenian walls as the Spartans laid siege. As much as two-thirds of the population died. Some of the other major pandemics that changed human history include Antonine plague (165 A.D) that began with the Huns, in Athens, who infected the Germans, who passed it to the Romans and then returning troops spread it throughout the Roman Empire. This plague continued until about 180 A.D. Between 1347 and 1351, Black Death or bubonic plague spread throughout Europe, killing approximately 25 million people. It killed greater number in Asia, especially China, where it is thought to have originated. In 1665, the great plague of London, led to the deaths of 20 percent of London’s population. These pandemics had significant impacts on human society, from killing large percentages of the global population to causing humans to ponder larger questions about life. A brief history of impact of pandemics is summarized in Table 1.
In 2003, SARS (Severe Acute Respiratory Syndrome) is believed to have possibly started with bats, spread to cats and then to humans in China, followed by 26 other countries. SARS is characterisZed by respiratory problems, dry cough, fever and head and body aches and is spread through respiratory droplets from coughs and sneezes. Quarantine efforts proved effective to contain the virus. Global health professionals took SARS as a wake-up call to improve outbreak responses, and lessons from the pandemic were used to keep diseases like H1N1, Ebola and Zika under control.
Table 1: Epidemics and Pandemics since the Middle Ages
COVID-19 Pandemic has stretched healthcare infrastructure of even the most developed countries, and is expected to cause economic recession unparalleled in the recent history
On March 11, 2020, the World Health Organization announced that the COVID-19 virus was officially a pandemic after barrelling through 114 countries in three months and infecting over 118,000 people. And the spread had been unabated ever since. COVID-19 is caused by a novel coronavirus—a new strain that was not previously found in humans. Symptoms include respiratory problems, fever and cough, and can lead to pneumonia and death. Like SARS, it spreads through droplets from sneezes and by direct or indirect contact with an infected person. It is believed that the first case for this virus was reported in China on November 17, 2019, in the Hubei Province, and it went unrecognised. Eight more cases appeared in December with researchers pointing to an unknown virus. In the next three months, the virus kept spreading – by direct and indirect contact to many people in Hubei. As we live in a global village, international travel is believed to have taken the infection around the globe. It reached such a scale that by March 2020, WHO recognized that this virus infection has reached a pandemic proportion.
The COVID-19 pandemic is straining health systems worldwide. The rapidly increasing demand on health facilities and health care workers threatens to leave some health systems overstretched and unable to operate effectively. During the 2014-2015 Ebola outbreak, the increased number of deaths caused by measles, malaria, HIV/AIDS, and tuberculosis attributable to health system failures exceeded deaths from Ebola. With over 1.6 million positive cases across the world, the number of people infected by this virus has been greater than any other pandemic in recent history. Though the case fatality ratio for COVID-19 has been lower than SARS of 2003, the greater spread of this infection has resulted in a significant total death toll.
“The best defence against any outbreak is a strong health system”. COVID-19 is revealing how fragile many of the world’s health systems and services are, forcing countries to make difficult choices on how to best meet the needs of their people.
Governments of different countries are reacting differently to this pandemic. On one extreme is Sweden, where while the people have been advised to follow social distancing and certain other precautions, life is going on as usual with all workplaces, educational institutes and malls etc. open. On the other hand, are the countries like India, where there is a total lockdown barring essential services. India has also suspended all travel- domestic as well as international as part of this lockdown.
An epidemic of this proportion needs a certain infrastructure to deal with. None of the countries, whether developed or developing or poor, have such an infrastructure. In fact, the Covid-19 infection has exposed the so-called developed countries’ systems to the maximum. From logistics of essential commodities to healthcare facilities, everything is super-strained in almost all the nations.
India’s response to the COVID-19 pandemic
India’s response to the COVID-19 pandemic is one of the most stringent in the world, based on data from 73 countries. India has scored a perfect 100 on the “Oxford COVID-19 Government Response Tracker (OxCGRT)” that aims to track and compare government responses to the coronavirus outbreak worldwide, rigorously and consistently. South Africa, Israel, New Zealand and Mauritius are some other countries that scored a 100 in the tracker.
At the very first level the Indian government was quick to activate its health management system and issue necessary travel advisories. Screening of all travellers coming into India from affected countries was initiated as early as Jan 2020. Even when a person reported no symptoms, govt machinery was activated to track and check their progress for next two weeks by at-home visit and phone calls. Though initial directives for quarantine were not taken seriously by some, as the days progressed the government became more and more vigilant and followed up with strict actions. In the meanwhile, India embarked to ensure that most of its stranded citizens, especially workers and students stuck abroad in various countries, were flown back.
India suspended all travel, domestic as well as international, by 20 March. On 24 March, India announced a total lockdown for three weeks. Well-coordinated action plans include careful airport checking, active health laboratories and the quick establishment of quarantine facilities across the country. The strategy of the government has been to stick to the ‘prevention is better than cure’ model.
While currently all the energies in the country are focused on controlling the transmission and curtailing morbidity and mortality due to the pandemic, here we take a look at how this infection and its fallouts can impact the healthcare scenario in India.
1. Fast-tracking of implementation of targets for public health emergencies within National Disaster Management Plan
Guidelines for biological disasters have been in existence since 2008 and Biological & Public Health Emergencies (BPHE) was added as a part of the National Disaster Management Plan (NDMP) itself in the most current version updated in November 2019, with the objective of enhancing the resilience of health systems by integrating disaster risk reduction into all levels of healthcare. However, within two months of releasing these guidelines, it was clear that the planning and implementation was required as of yesterday.
Several Short term (ST, by 2022) Medium Term (MT, by 2027) and Long Term (LT, by 2030) objectives and responsibilities mentioned in the plan are all in the right direction and would have been a saviour had the outbreak waited another five to seven years for these to be implemented as per the plan, such as “Dovetail norms & regulations relevant for BPHE with DM act 2005” (MT), “Establishment of early warning system” (MT), “Establishing and maintaining community based network for sharing alerts” (MT), “Develop a clearly defined interagency emergency response plan with roles and information flows clearly marked out” (MT), “Partnering local institutions with national institutions/experts” (LT), “Stockpiling of essential medical supplies such as vaccines and antibiotics etc.” (LT), “Establishing adequate decontamination systems, critical care ICUs and isolation wards with pressure control and lamellar flow systems”(ST), “Adequate PPE for all the health workers associated with the responding to biological emergencies” (ST), “Upgradation of earmarked hospitals to cope with emergencies” (LT), “Mobile telehealth services & Mobile Hospitals” (LT), “Specialised healthcare and laboratory facilities to address biological emergencies/incidents” (MT), “Establishing and strengthening quarantine facilities” (LT).
While one can rue the fact that we recognised these requirements within a structured framework too late, the silver lining is that the crisis has made us implement some of these, in some manner or the other, immediately instead of waiting another five to ten years as planned in the NDMP. The best part is the lessons in managing this crisis at hand will help in a faster and more practical execution of several great initiatives identified in the NDMP just before the pandemic. We can also hope to see a legal framework for dealing with such emergencies come up much earlier than the targeted timeline of 2027, as also a policy on stockpiling and upgradation of certain facilities.
2. Community Awareness towards Hygiene will have positive impact in the long-term, though in the short-term likely to increase PHC burden significantly
Since the days leading to the full-blown pandemic, intensive campaigns are being run promoting hand hygiene to prevent transmission of infection. This has led to very high levels of awareness and compliance to this seemingly small routine of clean hands but one which in the long run can have far-reaching implications for transmission of various other infections as well. All signs point to a protracted period of contagion and perhaps seasonal returning peaks as well, which means reasonably long cycle of special emphasis on hand hygiene, face mask, hygienic social habits and disinfection. These long cycles of focus on hygiene combined with Swachh Bharat Abhiyan may have positive impact on improved health of the society, although extent of benefit will be difficult to measure tangibly. On the flipside, in the short-term, a tremendous increase in burden on primary care facilities and GPs can be anticipated as over-cautious people throng them even on mild symptoms.
3. Gaps in Care of patients of other ailments, especially chronic diseases in the short-term can lead to long-term burden on healthcare
As urgent takes precedence over important, the entire system focused on prevention, diagnosis, treatment and containment of COVID-19 infection is likely to miss opportunities for timely diagnosis and treatment of other diseases. Patients of chronic disease, being wary of going out, or facing difficulties in movement due to lockdown restriction might miss on treatment, ending up with long-term sequelae. These can eventually increase the possibility of complications and worsening of disease, raising the overall burden of diseases of the country to a certain extent. Recently we also read about BMC shifting some patients of cancer and other disease to makeshift arrangements under a flyover in Mumbai to accommodate rising number of COVID-19 patients in the city. Unavailability of several government set-ups that have been earmarked for COVID-19 has also limited the availability of emergency treatment of acute conditions for the less privileged whose only fall back for healthcare needs are public facilities. Postponement of Elective surgeries and procedures could have adverse impact on quality of life while the patients wait for the right time to get the treatment they need.
4. Strengthening of Government Infrastructure and Public Private Partnerships over next few years, but in the near-term, ongoing plans will see a major realignment
It is no secret that healthcare infrastructure in India is sub-par and highly inadequate to meet the needs of its large population. In terms of accessibility and quality of healthcare service the country ranks 145 among 195 countries globally. Countries that spend upwards of 8-10 per cent of GDP on healthcare are also crumbling under the huge burden of this pandemic, giving shivers to the governments across the developing world, including India., India spends a meagre 1.4 per cent of GDP as public expenditure on healthcare. Recognizing the inadequacy of this for serving such a huge population, the government had laid out ambition to increase the spending to 2.5 per cent of GDP in the next two to three years. While progress has been made in the recent past in augmenting the infrastructure and manpower through opening new tertiary institutes, increasing seats in medical colleges and implementing expansion of primary healthcare setup across the country under Ayushman Bharat, a lot still needs to be done. This need is acutely being felt now while we prepare for a scenario if the situation goes out of hand further, and this realization will hopefully accelerate implementation of healthcare infrastructure strengthening. At the same time, in the short-term since a huge spend is being utilized for managing the pandemic, budgetary allocations on current plans will get realigned.
5. Internalization of Pharma Supply Chain & Make-in-India focus for Medical Equipment
Over the last few decades India has emerged as the pharma hub of the world, being the largest suppliers of generic medicines all over the world with a 20 per cent share in global supply by volume and 50 per cent of global demand for vaccines. Currently over 80 per cent the antiretroviral drugs used to combat AIDS are supplied by Indian firms, which is a significant contribution to mankind as otherwise less developed countries would not have been able to afford therapy for this global crisis. COVID19 crisis has again highlighted the contribution of Indian pharma industry as India opened export of hydroxychloroquine to scores of countries that can help save thousands of lives.
Despite being the strongest player in pharma, a major lacuna that developed over years in the Indian industry is over-reliance on Chinese APIs (bulk drugs) especially the fermentation-based products like Penicillin-G and a lot of intermediates (KSMs or key starting materials for APIs). This was already recognized by Indian pharma players when the Chinese started winding down industries and/or increasing prices to comply with the stringent enforcement of environmental laws. It was then that Indian players had started planning alternate sources for Chinese material, but cost being a major driver in the end market, the progress remained slow. With China’s perceived role in not sharing information that could have prevented the COVID19 global pandemic, there is an increasing sentiment in various countries to move their manufacturing out of China. Japan is in fact paying its companies to move their manufacturing out of China. This can thus be a big opportunity for India to internalize the entire supply chain for our own good as well as present ourselves as an end-to-end giant in the pharma supply chain. A strong pharma industry has always been a pillar of affordable healthcare in India and one can expect this trend to further strengthen now.
Another area where India and almost the entire world is over-reliant on China is medical equipment. We have seen cases of ventilators, PPE, masks, diagnostic kits – almost all equipment for sailing through the current crisis coming for China, which is a problem in times like these. In India, several non-medical equipment companies have risen to the occasion and converted their manufacturing to make ventilators and other equipment currently needed. The pandemic will eventually go, but the equipment will stay. Using these equipment efficiently over long term to improve our healthcare delivery is an opportunity. A push through make-in-India for medical equipment can further strengthen this trend. Medical devices can be a natural area for expansion of pharma companies, because of synergies of end customers even though new manufacturing skills will need to be internalized.
6. Medical Tourism will continue to see a downtrend, at least in the short-term
India has become a hub for medical tourism, especially for neighbouring countries, middle east, central Asia and Africa. In 2015, India ranked as the third most popular destination for medical tourism, when the industry was worth $3 billion. The number of foreign tourists coming into the country on medical visas sat at nearly 234,000 that year. By 2017, the number of arrivals more than doubled to 495,056, government figures show. These medical tourists come not just for advanced modern medicine treatment available in the country but also for rejuvenation through traditional medical practice such as Ayurveda. With international travel being a major cause of the spread of COVID19 pandemic, the writing on the wall is clear. The influx of tourists, including medical tourists will remain slow at least for a good part of this year. One can expect picking up only next year, that too if recurrence of peak does not happen again globally in the winter months which is quite a probable scenario as per the latest research.
7. Increased use of Technology, Telemedicine, Training of primary health workers and Mobile hospitals
In the midst of the Pandemic, MoHW, in collaboration with Niti Aayog, released Telemedicine Practice Guidelines enabling Registered Medical Practitioners to provide healthcare in remote settings using telemedicine. These guidelines recognize telemedicine as an enabler of healthcare access and affordability through faster access to appropriate interventions and access to services that may not otherwise be available. There have also been frequent online training sessions for nurses, paramedic staff and primary health workers for protocol to be followed for detection, isolation and communication regarding suspected infections. Increased use of technology and opening up telemedicine through transparent guidelines will improve access to healthcare even in remote locations in geographically diverse country like India. Going by recent comments by Niti Aayog senior officials, there is a possibility of carving out some further roles as paramedic functions that may not require a full MBBS degree. This could be an innovative way to augment trained healthcare manpower, although practicality of such a decision will emerge with time.
Additionally, recognizing the increased need of hospitals across the country, several ingenious approaches are being explored, the most interesting of which is converting train coaches into isolation wards to make mobile hospitals which can be taken to locations throughout the country as per requirement. Although mobile hospitals were a target in the NDMP 2019, such an innovative approach arose out of necessity and has benefits of moving as much capacity as required to various locations and is much faster and more efficient than road transport. If retained and built upon, this flexible concept has the capability of supplementing the healthcare infrastructure substantially.
Thus, as we face this humongous challenge and focus on sailing through with minimum damage to human lives, there are opportunities to be unravelled for improvement in the healthcare scenario in the country.