As the Tsunami of COVID cases in the Indian subcontinent shows signs of finally receding, what used to be a painful routine for many US residents of Indian origin like me, has thankfully become less common. We aren’t spending long hours every night checking on loved ones on WhatsApp, or calling family members in India, scrambling to coordinate oxygen procurement, medication or hospital beds for extended families, friends or acquaintances. I would worry about my parents, who live in India and are in their 70s, fearing that one of these nights, maybe I might receive a call that I dread. I had difficulty reconciling with the fact that survival and outcomes post hospitalization are based on the assumption that access to medical care was not an uncertainty, as it had become for many people in India. We still go over extreme rituals of non-pharmaceutical interventions, including likening using a mask like an undergarment- taking it off only in privacy of seclusion. We try to estimate exposure based on who was around who else, for how long, how close, hoping details are not lost in translation. I sigh sometimes, aware that the virus is unforgiving, and I may be clutching at straws. I would feel helpless in my inability to influence things, insulated myself in a cocoon, vaccinated, surrounded by things resuming to normalcy. My 80 year old father himself, received his vaccine 3 months after I did, due to shortages in India.
I am aware that the privilege of knowing physician colleagues would have assured reasonably good care for my parents in another time. The severe shortage of acute medical care on ground made me feel more deeply aware of what a disadvantage the common folk of meagre means in India face. The reason this pandemic has become such a pestilence is because it has exposed deeply pervasive inadequacies and inequities of healthcare system in India.
The moral test for a government is how the country treats its most vulnerable. The underprivileged in India seek healthcare primarily through government run hospitals, and cannot access care in more expensive private hospitals. These facilities are chronically underfunded, plagued by poor staffing and lack of supplies and infrastructure. Yet the smartest medical students and residents train at these institutions. The National Health protection scheme seems to be focused on supporting care in private medical facilities. In India, access to care in private sector does not necessarily result in better care for a large majority of rural and urban Indian people .
India spends a mere 1% of its GDP on healthcare expenditure. The domestic government health expenditure per capita is $74 in India at PPP, and India has 0.53 beds per 1000 people. Reports at different times estimate that there are around 80,000–100,000 ICU beds and approximately half that number of ventilators in the country. With the current number of COVID infections, a simple back of the envelope calculation shows that even if a fraction of those infections ends up needing intensive care, the country is in no position to provide the level of care they need. The healthcare system was clearly duct taped and arthritic even before the pandemic. The pandemic has just pulled the plug on whatever threads were holding this creaky system together. The truth has been staring at us, but we had chosen to look away. I looked away when as an ICU registrar I was tasked with triaging ventilators in a large municipal hospital in Mumbai during a post monsoon leptospirosis epidemic. I felt thoroughly exposed as inadequate in making such vital go/no-go decisions, and the experience left me hollowed out at an emotional level. I looked away when I was unable to resuscitate a stuporous young male with cerebral malaria who coded waiting outside the CT scanner because the bulb on the only laryngoscope for a medical ward with 50+ patients did not work, while people hurried along the crowded hospital corridor during evening visiting hour. We all looked away when we were given the task of treating an unending line of patients who came in during the monsoon admission surge, willfully accepting to lay on floor beds, with family members holding an IV set when poles ran out and even bagging their intubated family member when ventilators were unavailable. How did I, and other people, allow ourselves to be desensitized to such a travesty, when we were exposed to this all along?
Resident doctors who provide most of the clinical care at government run medical college hospitals. They are often re overworked, underpaid and face enormous stressors including inhumane working hours, and patient caseloads. What I chose to accept during this period when I was a resident was that submissiveness to adverse circumstances helps disconnect from the stress of the immediate situation. Over time this becomes an ingrained habit- if we cannot change things, we become used to it.
The dramatic scenes of patients dying due to lack of oxygen remind us that there is an Infection Fatality Rate with oxygen and one without oxygen for COVID. What we have witnessed in this period of oxygen shortage is a grotesque natural course of illness revelation with system too paralyzed or dysfunctional to be able to grapple with what it was dealt with. The visuals of helpless family members and medical staff trying to do what they can, remind me however that we have been there, in smaller measures in the past.
Pandemics hold up a mirror to human beings to show who we really are. They are inflection points to reset our trajectories. Inaction at this time is accession. While the pandemic surge numbers show signs of initial decline, this is not a time to introspect deeply, and to organize and plan for the future. As physicians we need to use our position to voice our concerns, to advocate for our patients and to pressure governments to invest more into healthcare, including critical access to the most vulnerable.
