By Meban A Kharkongor and Sandra Albert
Yesterday, April 28, 2020, a young man, aged 29, was brought to a hospital in Shillong. His body was still warm but there was no pulse, he was not breathing,and he was declared dead shortly afterwards. He had been suffering with severe abdominal pain for the past 5 days but had hesitated coming to hospital.When he was finally brought in, it was too late. He died from a bleeding stomach(peptic) ulcer.His doctor was in despair, “this is something that no young person should have died of in this day and age.” And so we note down another preventable non-Covid death.
Sadly this is not the only one. Several doctors have reported more instances of patients coming to the hospital only in the late stages of a treatable disease. A person with a brain infection such as meningitiswith ‘altered sensorium,’where a person is disoriented and has incoherent speech, should be brought to the hospital immediately. But now these patients are being brought in several days later when even the best of treatment willbe inadequate.
Some with heart attacks reach the hospital by the third day of chest pain when much damage to the heart muscles (myocardia) has already occurred. In the case of heart attacks the first hour, or the ‘golden hour,’ is the optimum period for starting treatment to prevent myocardial damage.
The same is being seen in other conditions: the elderly who have fallen and broken their hip or thigh bone, would usually be surgically managed promptly, as the idea is to make a person mobile and independent quickly. But now they await, flat on their back groaning in pain, for implants to arrive from Guwahati. This delay causes a myriad of complications which could have otherwise been prevented. Diabetics who need drugs are not getting them adequately and on time. Of patients with Tuberculosis, who pose a considerable challenge already in Meghalaya – we have no summative idea on where their treatment is going. The consensus among clinicians is that gaps that existed in the health system on that score is widening.
In the current scenario of COVID-19 holding sway in the minds of the government, people and media, we need to pause and consider the wider implications for people with other diseases. On the plus side of a lock down, there have been fewer death from road traffic injuries, from pollution and from side effects of medical drugs. But there are a lot more disorders out there that are not getting the attention they deserve. This is resulting in preventable deaths (mortality) and additional suffering (morbidity) due to illness.
Changes in health seeking behavior
Even in the best of times, health seeking in India is not optimal. But is the health seeking behavior that has been encouraged by Government and non- government institutes especially in rural areas being slowly undone? The number of deliveries in our hospitals has come down drastically. Deliveries in the home setting if assisted by skilled birth attendants would largely be fine. But about 20% of deliveries tend to be ‘complicated’. They would benefit from health facility based professional support and this is the group we are worried about if not attended to in time. This relatively small group contributes most to morbidity and mortality among mothers. So why are they not being brought to hospital? It could be a lack of transport, fear of getting Covid in hospital, lack of funds to meet incidental expenses or other causes which we are yet to know.
The number of babies being brought for vaccination is also dwindling. Immunization is the most effective measure we have in avoiding mortality and morbidity from vaccine preventable disease. But during a crisis, immunization is likely getting low priority in the minds of parents. If this continues, parents might start to think that it is fine to miss vaccinations. Unfortunately, the consequences of such changes in attitudes will only be seen much later. Prior to the Covid-19 crisis we already had a situation of considerable vaccine hesitancy;defined by the World Health Organization as a “delay in acceptance or refusal of vaccines despite availability of vaccination services.” These services are currently being offered free by the government as part of the Universal Immunization Programme.
Patients have reported that village administrations in many areas are forcing a patient to be in a 14 day quarantine (some have even reported that they will not be allowed re-entry into the village/locality) if she/he had travelled to Shillong and visited any hospital for treatment. Apparently, some village headmen are making ill-informed decisions. What consequences such actions will have on health seeking behavior of our people is yet to be seen.
Rationale of the lockdown
While it is desirable to bring the Covid crisis under control, and it appears that Meghalaya’s administrative apparatus has been largely successful. The new Rapid Response System proposed by the CM is surely a good move to further improve our health system; let us continue to develop, be informed and learn iteratively from the initiative. But now it is time for the health system to look at all the other issues holistically. Use the Covid crisis to learn and improve but let’s not forget that others too desperately need our care and concern.
The rationale of the lock down was to give us time to get the health system prepared, refine our surveillance and contact tracing measures and detect cases early for isolation and control. We have done that. Two weeks have passed and most immediate contacts except for the 11 close ones in the ‘case cluster’ in Shillong have tested negative. It is time to get life back to some semblance of normalcy. How much longer do we need to tell our non-Covid patients that there is nothing much that can be done for their loved ones and resort to blaming the dire situation upon COVID-19.
Restoring confidence in the healthcare system
Let us continue our fight against COVID-19 by intensifying awareness and education, and ensuring that our people receive correct information about disease prevention and control. But let us also work to restore confidence in the healthcare system byhelpingthe large section of our population who continue to require healthcare during these difficult times. It is time to remove restrictions on movements within the state while promoting personal protection measures, avoiding of crowds and restoring some form of public transport.
(Dr Meban A Kharkongor is a consultant in the Medicine Department at Dr H. Gordon Roberts Hospital, Prof Sandra Albert is Director, Indian Institute of Public Health Shillong)