Medical care has been disrupted by the novel coronavirus. Fear, anxiety, uncertainty and confusion have all overtaken clinical services. The private sector, which delivers the major part of medical services, is now functioning at a skeletal level and patients have considerable difficulty in accessing medical care. Tamil Nadu has one of the better health systems in the country and has demonstrated that it can provide high quality care through public-private collaboration in the areas of maternity, cardiac and trauma care. As the number of COVID-19 cases in Tamil Nadu has crossed 50,193, with 576 deaths (June 17), there is a need to pull together the resources of the public and private sectors into a functioning partnership, to provide good clinical care, ameliorate suffering and prevent deaths.
A neglect of the primary task
Until now, the focus of the government has been on prevention of the epidemic through testing of suspects, isolation of cases and institutional quarantine of contacts. Hospitals have focused their efforts on prevention by admitting asymptomatic contacts and mild infections. With the focus on prevention, doctors have been unable to attend to their primary task of providing good clinical care to reduce morbidity and prevent deaths.
The majority of COVID-19 infections are mild and resolve on their own. Serious illness occurs in the elderly and those with multiple co-morbidities such as diabetes, heart disease and respiratory problems. The primary cause of death in COVID-19 pneumonia is respiratory failure. The mainstay of treatment in moderate and severe illness is clinical monitoring, oxygen therapy to correct hypoxemia (low oxygen levels in the blood), and good supportive care. Even in those above the age of 80 years, the mortality rate is only 15%. Patients who require ventilator treatment have a mortality rate of over 50%. Good supportive care for sick patients is essential in preventing deaths.
Hospital services have to focus on in-patient management of moderate and severe pneumonia, prioritising intensive care unit (ICU) beds for potentially reversible illness. We need to ensure that every patient with moderate and severe COVID-19 pneumonia has access to the optimum level of care, to prevent deaths and ameliorate suffering.
Combating fear
Because of the labelling and stigmatisation of those diagnosed with COVID-19, the public are reluctant to come to hospital and may come late or die at home. We need to send out a clear message that hospitals will provide good quality care for COVID-19, at affordable cost and ensuring confidentiality.
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For this to happen, the government must work with the private sector to make care accessible and affordable. The Tamil Nadu government’s efforts to cap the cost for different levels of COVID-19 care in private hospitals is a positive step. The government should financially assist the private sector by reimbursing basic patient care costs for providing COVID-19 care.
Medical staff taking care of COVID-19 patients are anxious that they may acquire the infection and transmit it to their family members. Deaths of hospital staff due to COVID-19 have been reported, although the mortality risk is lower than that of the general population. Medical staff involved in COVID-19 care should be adequately protected with appropriate personal protective equipment, or PPE, and should be trained in infection control and clinical care protocols. They should be encouraged to communicate with a patient and the family within the restrictions.
A wish list
In Tamil Nadu, we should shift the discourse from the focus on prevention and reducing the number of cases to an equal priority for providing COVID-19 care. Every citizen in Tamil Nadu who has serious COVID-19 pneumonia should be able to access high quality care. In order to implement a universal COVID-19 care programme, the government health system should collaborate with private hospitals.
Towards this we suggest that: all private hospitals which have the potential, should take care of COVID-19. They should be given requisite incentives and subsidies to that end; every patient should be able to access medical care for COVID-19 from a private or public hospital; only patients with moderate to severe COVID-19 pneumonia should be admitted; ICU care should be prioritised for COVID-19 patients who have potentially reversible illness; confidentiality of the patient should be protected; the government should support the basic cost of COVID-19 care in private hospitals as well; city hospitals should pool their ICU resources for the care of COVID-19 pneumonia; staff providing COVID-19 care, should receive adequate training and be provided appropriate PPE, and, finally, families of staff who die due to COVID-19 should receive appropriate compensation.
These initiatives can only be realised with appropriate leadership from the government. The private sector has to be fully involved in clinical care of the COVID-19 epidemic. We should work towards making COVID-19 treatment available, affordable and effective. Our response to the epidemic must combine good science, clinical reasoning and a humane response to save the lives of the people of our country.
Anand Zachariah is a Professor of Medicine at the Christian Medical College, Vellore. George Thomas is an Orthopaedic Surgeon at St. Isabel’s Hospital, Chennai. The views expressed are personal