The unseen cost of covid’s long shadow on India

For several months, India has been so consumed by its fight against covid-19 that every other health-related concern had taken a back seat. This long gap—or more precisely, a covid-induced shadow—has already worsened the “routine" ailments of many.

“We are already starting to see an upward trend in OPD footfalls and elective surgeries compared to last month," Garg said. “We hope things will get back to normal pace like before by September this year," she added.

But many public health experts are less sanguine. The health deficits of the early 2020s might leave behind generational ripples, even threatening the steady gains that the country had notched up in the larger, decades-old battle against a slew of ailments, say the experts.

The already heavy burden of non-communicable diseases (NCDs)—diabetes, hypertension, kidney ailments and stroke—is almost certain to rise, according to some public health practitioners.

For more than a year now, the collective attention, resources and energy of the health system have squarely focused on the fight against the coronavirus. Even normal immunization schedules and health services for women and children have suffered because of the battle against covid-19, which has so far infected more than 30 million Indians.

In the long run, the widening gap between the need for “routine" health services and its actual availability will exact its own toll. And these scars on the nation’s health will far outlast the pandemic. Those suffering from long covid (post-infection complications) are already crowding out other patients in some clinics. Without adequate attention, things will only get worse, say doctors.

To be sure, a rapid ramp up in vaccination and concerted efforts to mitigate the third wave of covid will certainly help. It would offer some breathing room for healthcare institutions to re-focus their attention toward the treatment of NCDs and more common ailments, thereby plugging at least some of the gaps.

But another round of interminable delay in treatment, or limited treatment, could be catastrophic for those suffering from cancer, heart disease, and other neurological and renal ailments, said Harsh Mahajan, president, NATHEALTH.

Rising risk factors

The warning signs are hard to ignore. For instance, the recently published National NCD Monitoring Survey (NNMS), which was funded by the health ministry and conducted by the Indian Council of Medical Research and other government institutions, showed that two in five adults have three or more risk factors for NCDs.

One in four adults—and 6.2% of adolescents—are overweight or obese; almost three out of 10 adults suffer elevated blood pressure and 9.3% have excess blood glucose. The longer they stay out of the health system’s radar—either due to fear of covid or due to limited access—the more susceptible they would become to illnesses.

The NNMS calls for a rapid spike in the use of telemedicine and teleconsultation, particularly for the treatment of cancer, diabetes, heart disease and stroke.

India already runs a National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) under its tertiary care programmes. The functioning of NPCDCS was seriously hit by the pandemic. The efforts of non-government organizations that are engaged by the programme to undertake mobile screening for NCDs were undermined by travel restrictions.

“The lockdowns and restrictions on movement have (also) changed the lifestyle of people. This has resulted in obesity, and increased (the) risk of diabetes and hypertension," said Dr Anoop Misra, chairman of the Fortis Centre for Diabetes, Obesity and Cholesterol, who also heads the National Diabetes, Obesity and Cholesterol Foundation.

“During this (period), many have had restricted access to medical advice. Hence, many of them have tolerated symptoms/problems and have delayed the diagnosis and control of diseases. A recent study that we did showed that onset of diabetes during the covid era is more severe than in the pre-covid era," said Dr Misra.

“After the partial reopening, more patients are coming in with complications associated with diabetes (relating to the eyes, heart, kidneys). These are patients who were either shut in by the lockdown or those who found it difficult to procure medicines and insulin," he said.

Dr Misra fears an increase in the incidence of both communicable and non-communicable diseases in the near future due to deficits in access to health.

Patients stay away

A study published in The Lancet journal in May, which covered 41 cancer treatment centres in India, showed a sharp reduction in oncology services between March and May 2020, compared with the corresponding period in 2019. The largest decrease was observed in the number of new patient registrations—which plummeted from 112,270 to 51,760 (a drop of 54%).

A larger reduction in patient numbers was observed in the major cancer centres located in large metropolitan cities than in the smaller cities.

The study, which was done by the National Cancer Grid, indicated that the decline in access will result in 83,600-111,500 missed diagnoses and as many patients will require treatment for a more advanced form of the disease in the next two years. It predicted the need for an additional 98,650-131,500 cancer deaths within the next five years.

For months, patients have struggled without any answers for even the most basic questions—where to go for emergency medical help, or how to travel for treatment when no public transport is available, said Dr M. V. Padma Srivastava, head of the department of neurology at the All India Institute of Medical Sciences (AIIMS), New Delhi.

“No wonder we saw a steep drop in the number of stroke patients too. An even fewer number got adequate treatment. Emergency personnel had no time for acute strokes. Stroke physicians and stroke-care teams did not know how to go about the stroke-care business while following all the protocols of PPEs (personal protection equipment), cross infections, and exposure risks," she said.

Neuro-imaging quarters and neuro-intervention specialists were reluctant to attend to patients because inadvertent exposure to a covid-19 patient meant long sanitization protocols, which were being enforced at the CT/MRI areas and Catheter labs. CT is short for computerized tomography; MRI stands for magnetic resonance imaging.

“Acute stroke care in some centres which remained non-covid (facilities) could remain relatively unaffected. But these were far and few between. Mostly, the routine services remained suspended and stroke rehabilitation and stroke prevention, adequate and optimal control of stroke risk factors have all taken a beating," Dr Srivastava said.

“The repercussions and the consequences are yet to be fully ascertained," she said. People with comorbidities are thought to be more susceptible to infection by the coronavirus (in future waves), said Dr Srivastava.

A World Health Organization (WHO) survey released in May 2020 projected a likely increase in deaths due to heart ailments, cancer, diabetes, and other diseases because restrictions on mobility and the preoccupation of hospitals with the treatment of covid-19 patients have left millions of people untreated.

In India, around 30% fewer people with cardiac emergencies could reach health facilities in rural areas in March 2021 than last year, as prevention and treatment services for NCDs were severely disrupted by the pandemic, showed the survey.

Population control

Phase 1 of the fifth round of National Family Health Survey (NFHS-5) contained some good news: it reported an increase in the use of modern contraceptives in all 17 states that were surveyed, even as the unmet need for family planning declined in all states, except Meghalaya and Andhra Pradesh.

“This is indeed encouraging and motivates those engaged in strengthening the family planning programme," said Poonam Muttreja, executive director of the Population Foundation of India, a non-profit organization.

But the gains that have undoubtedly been made could now face a covid-induced debacle. During the second wave, acceptance of family planning services fell steeply. Also, the conversion of primary and community health centres into covid-care facilities and the burden on frontline health workers has meant that the public sector delivery of essential reproductive healthcare has effectively come to a standstill.

According to government data, about 13% of Indian women of reproductive age (15-49 years) have an unmet need for family planning services. This means that women who want to avoid pregnancy do not have access to modern contraception methods.

Health minister Harsh Vardhan recently admitted that while healthcare systems around the world were being challenged by a rising demand for care amidst covid-19, the pandemic has placed unprecedented pressure on India’s medical facilities.

“Our health facilities and workforce are currently inundated by a plethora of activities related to controlling the pandemic. In doing so, essential health services which communities expect from the health system do get compromised," Vardhan said. “However, focusing on covid-related activities and continuing to provide essential services is important not only to maintain the people’s trust in the health system, but also to minimize any increase in morbidity and mortality from other health conditions."

Missed deadlines

One of the best illustrations of the broader hit on health due to the pandemic is the fallout on the fight against tuberculosis, which continues to be one of India’s most critical health challenges due to its devastating health, social, and financial consequences—for both the patient and communities at large.

India reported a 24% year-on-year fall in tuberculosis registrations last year, according to the India TB Report 2021. The country has already been battling under-reporting due to widespread stigma. The pandemic has now left a larger number of people outside the net, which makes prevention and eradication that much harder. India’s pre-pandemic aim was to eradicate tuberculosis by 2025, five years ahead of the global target date. With an estimated 2.64 million tuberculosis cases, India has the largest caseload globally.

India is also likely to miss the deadline for the elimination of neglected tropical diseases (NTDs) such as kala azar and lymphatic filariasis, which was set for this year. The pandemic has also set back the treatment prospects of malnourished children. India has a system of in-patient care for children who are suffering from severely acute malnutrition.

“This in-patient care, available at malnutrition treatment centres located at the block level, is inaccessible to most due to covid-19 curbs," said Sujeet Ranjan, executive director of The Coalition for Food and Nutrition Security. “If the pandemic experience has taught us one thing, it is that community-level healthcare needs to be seriously strengthened," he added.