Dr Priyadarshini Singh, head, accident and emergency department at Delhi’s Indraprastha Apollo Hospitals says this is simply “unprecedented”. Comparisons with other viruses seem unfair. “With swine flu, recovery was a consolation. People got cured and went home,” she says. With Covid-19 though, even recovery does not seem to guarantee much. Since the early days of the pandemic, the Union health ministry has been projecting high recovery rates for Covid-19—93.52 per cent as of November 18. Doctors, however, say they are bracing for the next big challenge—among those who recovered from a severe bout of Covid-19, some end up coming back to the hospital.
Hospitals struggling to cope with the deluge of Covid-19 patients are also trying to handle the additional challenge of post-Covid issues with special clinics. At Indraprastha Apollo Hospitals, for instance, doctors are baffled by a small percentage of post-Covid cases where the patient reported no co-morbidities, implying that even the ‘healthier’ among us are not particularly insulated from the serious effects of what experts term ‘long Covid’. The pulmonology team has treated four such cases in people with no co-morbidities in September. One of them, as Singh recalls, proved to be particularly challenging.
“This patient is 64 years old, and reported no history of major co-morbidities such as high blood pressure or diabetes,” she recalls. Two weeks after his hospital admission, he tested negative, but his lung function started to deteriorate. Lung fibrosis and infection in the blood meant that he could not maintain oxygen saturation in his body, and hence had to be put on the ECMO machine. “Post-Covid lung fibrosis meant that he needed lung transplant, which was challenging since the transplant had to be done at Hyderabad where the patient’s family chose to have the procedure done,” says Singh. “Airlifting him from Delhi to Hyderabad had to be done while ensuring that the ECMO circuit was not disturbed and the supply was not interrupted at any point.” Though such a procedure has been done in the country and at the hospital previously, Singh and her team held dry runs to ensure that the transition was smooth and error-free.
The doctors at Apollo may have surmounted this challenge, but the onslaught of the virus—and now its after-effects—have been relentless for health systems in India, and across the world. Hospitals have had brief spells of relief before getting overwhelmed, again. “In Delhi, the Covid-19 surge is back. In the hospital, it is a war-like situation every day,” says Dr Sandeep Budhiraja, group medical director, Max Healthcare. Since March-April, the challenges have been tremendous—getting health care workers trained in infection control pratices, designing clinical standard operating procedures (SOPs) for a new disease where not much was known, ensuring that the staff had enough PPE and auditing the new processes. The early days were particularly difficult in that respect, recalls Budhiraja. “Initially even the stigma faced by health care workers was demoralising,” he says. “I recall how our doctors were turned away by residents of a south Delhi colony when they arrived at the accommodation that had been arranged for them since they could not go home after Covid duty.”
Not that the health systems in India had not had a definite advantage. “It is true that this is a new disease, and though we do not know much about it, we did have a relative advantage in that we had some time to prepare ourselves. We could work on our clinical SOPs and infection control practices, since we had some information streaming in from our European counterparts,” says Budhiraja.
Critical care experts agree. The use of steroids and blood thinners to prevent clotting, for instance, immensely helped doctors manning the ICUs, and consequently, helped save lives, says Dr Sumit Ray, head, critical care, Holy Family Hospital, Delhi.
Despite a few advantages, India’s health care infrastructure has been left wanting, says Budhiraja. “We are not geared up for pandemics,” he says. “There is a need to create segregated infrastructure to deal with infectious diseases. As of now, we do not have that,” he says.
Separate infrastructure would help mitigate issues such as bed shortages that became so apparent during this pandemic. “For a 500-bedded hospital, for instance, there will be 100-150 ICU beds,” says Budhiraja. “Each floor will have a maximum of one or two isolation beds, where airflows are adjusted in a way that is required for a highly infectious disease such as this. At this point, our systems are not prepared for a situation where you need 250 such beds for a highly infectious disease.”
Creating exclusive facilities for infectious diseases does not mean they have to lie idle until an outbreak occurs. “Innovative solutions have to be found where such infrastructure can be used in normal times, but can also be quickly converted when an infectious disease strikes,” says Budhiraja.
While the government’s decision to create “care centres” in community settings was welcomed to some extent, experts say that trained manpower remained a key deficiency. “The SOPS and all are important, but we need trained people, too,” says Budhiraja. “At our hospital, we had a good number of staff available, but even that seemed insufficient at times.” Two kinds of specialists are the need of the hour—experts in family medicine and critical care, he says. “Take the National Health Service in the UK, for instance,” says Budhiraja. “There, the experts in family medicine are postgraduates that run the entire show. We need trained doctors like that; an MBBS is not enough.”
Besides the shortage of manpower and infrastructure, doctors say they have also had to deal with fluctuating protocols for testing and treatment. Take, for instance, the constant dilemma over the use of plasma therapy. Though the Indian Council of Medical Research’s Placid trial suggested no benefit with plasma therapy, some confusion over the timing of its use and the right kind of donor and recipient has remained.
While some have written off the procedure, others including All India Institute of Medical Sciences director Dr Randeep Guleria have said that more data is needed to come to a definite decision. On November 18, the ICMR issued a statement reiterating that since its own trial had shown no benefit, the treatment was a “futile intervention” and advised against its “indiscriminate use”. The advisory, however, stated that the therapy could be used in specific conditions where the donor had high concentration of neutralising antibodies in their plasma, while the recipient had no antibodies against the virus. Budhiraja says that since no definitive treatment for Covid-19 was available, doctors decided to go ahead with this treatment modality. “Plasma therapy is not new,” he says. “It has been used in SARS, MERS and Ebola as well. In fact, the monoclonal antibodies that are being widely discussed for treating Covid-19 are actually a synthetic form of antibodies similar to what are present in convalescent plasma.”
It is next to impossible for any health system in the world to be prepared for something like Covid-19, says Dr Om Srivastav, director, infectious diseases, Jaslok Hospital and Research Centre, Mumbai. But the need to have definite strategies in place cannot be overestimated. “If you look at the past few years, the biggest burdens on health care systems across the world have been from outbreaks of infectious diseases, whether it was H1N1, Zika virus, Ebola, Hantavirus,” he says. “The need for state-of-the-art infectious disease facilities and a multidisciplinary approach is definitely needed.”
In India, of course, the challenge is to strike a balance between the rising cases of non-communicable diseases and that of infectious diseases. “It is true that our burden is high on that front, too,” says Srivastav. “But even those who suffer from non-communicable diseases such as heart diseases and diabetes will probably succumb to an infection only. Besides, this is not the last pandemic that the world will witness. There will be many more.”
For now, though, Covid-19 is here to stay. Srivastav says that we still know very little about the virus. “I would say only 2 per cent is known, and that too is a generous figure,” he says. “The complications of post-Covid will be seen over the next 5-10 years, or even longer. Those effects will be seen in the lungs, brain, spine, blood vessels, and endocrine systems, too. A small percentage of the recovered cases of Covid-19 will experience respiratory [issues] owing to lung fibrosis, and transplant will be the only option to offer them any quality of life.” The burden that Covid-19 has placed on us in a short time of 8-9 months just cannot be compared to any other disease, and the after-effects are at least 100-fold as compared with other infections, he says.
There is hope with the vaccine, though a cautious one. “It is still too early to assess what benefit the vaccine would provide, what will be the duration of that benefit, whether the strain of the virus will mutate in the future, and what is the efficacy of the virus,” says Srivastav. “The long-term effects of the vaccine will also take time to reveal themselves. Any assessment of the vaccine should only be done in April-June next year.”
Which is why the standard advice of wearing masks, maintaining physical distance and hand hygiene remains as relevant as ever. “Over the past few months, we have learnt a lot, beginning with the fact that we need to take this infection seriously,” says Srivastav. “It has shown the fragility of our own immune systems, and so there is something to be said about keeping yourself as fit as possible. It has shown us the importance of wearing masks, and that self-medication is not a good idea at all. It is human nature to trust one’s own judgment first. Covid-19 begins with a runny nose, headache and symptoms of a common cold. The tendency is to think, ‘oh, this will go away.’”
Except that the world has known better now. It has learnt that this is a virus whose attack itself is not as devastating as the effects of immune system overdrive that it leaves the body with. In the coming months, governments and public health experts will need to drive home the message of prevention even more fiercely, so that the overwhelmed health systems are able to cope with Covid-19, and other diseases, too.