Ever since he was a child, Nanni Singh’s 25-year-old son has camped out at the Sir Ganga Ram Hospital in Delhi, every alternate Saturday. The day is fixed for regular blood transfusions required to supplement the defective Red Blood Cells his body produces. After Covid-19, these designated hospital visits have brought a fair share of worry for Singh, a Gurugram-based events industry professional, who is afraid to bring the virus home to her aged mother, and even more afraid that blood may not be available for her son’s needs every time.
Mirroring Singh’s bi-weekly urban trek, Venkateshwaran’s family, residents of the Sitheri Panchayat in Dharmapuri district of Tamil Nadu, travel 50 km to the Dharmapuri Medical College Hospital for blood transfusions for his nephew, as that is the only facility with a dedicated ward for this purpose. Terming the lockdown ‘torturous’, he describes in detail the immense difficulties they faced in accessing treatment—from the unavailability of ambulances to blood banks drying up for lack of donors.
Singh’s son and Venkateshwaran’s nephew were born with thalassaemia, a rare genetic blood disorder that requires frequent blood transfusions and regular monitoring for effective treatment. Thalassaemia is just one of many chronic, non-communicable diseases (NCDs), including the likes of cancer, kidney failure, Alzheimer’s disease, asthma, diabetes and fertility issues among others, that are being sidelined with increasing focus on Covid-19 care and prevention. Data collected by the World Health Organisation (WHO) show that around 300 million people are at the risk of dying from NCDs in India. Cardiac diseases, respiratory disorders and cancer are the reason for more than 60 percent of deaths in India, with 26 percent of this number belonging to the age bracket of 30-70 years.
The Lancet medical journal, known for its in-depth analyses, conducted a Global Burden of Disease (GBD) study, analysing 286 causes of death, 369 diseases and injuries, and 87 risk factors in 204 countries and territories, to better understand underlying health conditions in a global population and their impact on Covid-19. This prompted Richard Horton, the journal’s Editor-in-Chief, to describe the problem as a ‘syndemic’, where the Covid-19 death toll was exacerbated by rising levels of pollution, high global rates of obesity and diabetes, and an unprecedented increase in the incidence of chronic lifestyle diseases.
The reason for this ‘syndemic’?
Delay in diagnosis due to fear of contracting the virus and unavailability of healthcare professionals who are diverted to Covid care, coupled with lack of access to Covid-free facilities and hampered treatment structures. Over the past year, anything that is not related to Covid has been relegated to the fringes of the healthcare system.
The root of the problem
Gouri Das of Khaira area in Odisha’s Balasore district received her first chemotherapy cycle in April, but has faced numerous hurdles getting the second one. The lack of testing facilities for stomach and lung cancer patients in Balasore forced this 49-year-old to travel 150 km to the Acharya Harihar Post Graduate Institute of Cancer at Cuttack. This facility refused to accept the RT-PCR test report of the District Headquarters Hospital asking for a fresh one instead. To add to her woes, she could not even find a place to stay at Cuttack for two days—the period required to get her tests done before being admitted to hospital.
While many hospitals are turning patients away on the pretext of Covid tests, the ailing also refrain from seeking medical help for fear of contracting the disease. Unfortunately, this results in a chicken-egg situation, with those suffering from non-Covid chronic NCDs caught in the crossfire. “Since non-Covid patients are reluctant to visit hospitals out of fear, private hospitals are using all their beds for Covid patients. As a result, dialysis and other services are not being offered anymore at many private centres. In Rajapalayam alone, two private hospitals have stopped offering dialysis completely, as there are no patients. Most patients can manage with teleconsultation, but critical non-Covid patients are really suffering,” says Dr G Ganesan, a private doctor based in Tamil Nadu.
When 44-year-old Dinesh (name changed) started experiencing breathlessness, the resident of Tiruchy district assumed he had contracted Covid-19. His RT-PCR test, however, was negative. Ten days later, he experienced shortness of breath again, along with pain in his chest, which prompted him to call a doctor. As his doctor was being treated for Covid, he was referred to another professional who directed him to the nearest health facility, which in turn sent him to a multispecialty hospital in Tiruchy city. That was when he finally learnt he had suffered a heart attack. When he was told he should have come 10 days earlier, he blamed his delay on the fear of Covid. “Many diseases are poorly managed with patients avoiding visits to hospitals due to prevailing situations. Even doctors are promoting home management,” says the Chairman of the Research Cell of the Indian Medical Association, Dr RC Sreekumar, based in Kerala.
The Health Management Information System, managed by the National Health Mission (NHM), tracks indicators on the utilisation of health services from over 2,00,000 health facilities. These include primary health centres and district hospitals in every district of the country, and are updated almost daily. Over the last year, their reports recorded a significant decline in patients utilising hospital facilities for maternity care, child immunisations and perhaps most worryingly, outpatient visits for treatment of serious conditions, including cancer and heart disease, with the number being as stark as 69 million visits less than the previous year.
A 45 percent decline in the number of patients registered for treatment of tuberculosis and a 60 percent decline in the number of men being screened for HIV, are other worrisome indicators. The number of major and minor surgeries also fell by over half in this time period. Though no sharp increase in deaths is recorded through NHM numbers from NCDs, these figures do not account for the long-term impact of chronic patients missing out on essential healthcare.
Dr Monica Bhagat, Medical Director, Bhagat Medicare Centre and Nursing Home, Delhi and Co-Founder of UV Pure, has treated 3,500 home-isolated Covid patients through teleconsultation in the last 15 months. While treating them for Covid, she came across numerous patients with chronic diseases. She says, “I have seen bedridden patients being cared for only by their domestic help, elderly patients dying at home due to lack of proper treatment, and those suffering from difficult diseases like Alzheimer’s without access to specialists who have been diverted to Covid duties. I have also seen many patients of chronic kidney disease deferring dialysis, and those terminally ill with cancer losing their lives.”
An operational Crisis
Elective surgeries have been either stopped or delayed, worsening pre-existing health issues. Despite being a doctor who has his own hospital, Dr Gunasekar Vappulapatti, CMD, GVG Invivo Hospital, Bengaluru, is unable to schedule a knee replacement surgery for his mother, suffering from immense pain for the last few months. “If doctors like me are facing these problems, imagine the situation for common people. Fortunately, with Covid cases on the decline, we are planning to open an operation theatre for non-Covid elective surgeries soon,” he says.
Telangana, known as the hub of super-speciality hospitals in the Telugu belt, has become an extended Covid facility with the top 50 government and private hospitals turned over exclusively to Covid care. Members of the Telangana Junior Doctors Association of the Gandhi Medical College protested the forced diversion of their practical lessons solely to Covid cases. They felt they were losing out on learning about other health complications, which would ultimately affect their academic results.
As incongruous as it sounds, Dr Krishna Mohan Kammala, an orthopaedist with a private practice in Hyderabad, has been treating bone injuries and fractures through teleconsultation. “I send handwritten notes through WhatsApp with a list of diagnostic tests and then suggest the treatment. Many diagnostic centres stopped offering regular tests and banned walk-ins. I receive about six SOS calls from my patients every day, and I can do nothing but suggest medicines and treatment modalities such as cold/hot compresses and massages.”
This neglect does not bode well for the future. A study conducted by 25,000 surgeons around the globe, and published in the British Journal of Surgery has concluded that patients waiting for elective surgeries should be the first to receive Covid vaccines. A timely dosage could reduce nearly 60,000 Covid-19 related deaths in the times to come. As an example, these researchers point out that people undergoing surgery for cancer usually have a 2.8 percent mortality rate, but if they contract Covid, that percentage goes up to 18.6 percent. In the first wave of the pandemic in India, up to 70 percent of elective surgeries were postponed, which meant the delay or cancellation of an estimated 28 million procedures.
Blame it on Your Lifestyle
Around 180 million Indians suffer from chronic lifestyle ailments like cardiovascular diseases, diabetes and cancer, with the latter being of utmost concern. According to the World Cancer Report 2020, the incidence of cancer is likely to double in the next decade, especially in low- and middle-income countries. In India, the report predicts that nearly one in every 10 people is likely to develop cancer at some point and one in 15 likely to succumb to the disease.
Chronic conditions like high blood pressure, high blood sugar, obesity and high cholesterol suffered by millions around the world, as comorbidities of Covid-19, have caused more than one million deaths. Mostly driven by unhealthy diets and inadequate levels of exercise, these lifestyle problems will continue to wreak havoc on people long after Covid.
Aditya Kaicker, Co-founder and Chief Programme Officer of Breathe Well-being, a digital programme that helps people prevent, manage and reverse Type 2 diabetes, says, “Chronic diseases need continuous monitoring by medical professionals as the treatment and medicines are lifelong. Yet, people with chronic conditions are at most risk, therefore sceptical to step into hospitals, labs or clinics because Covid-19 is a much more immediate threat compared to their long-term conditions.”
A report published in the journal, JAMA Network Open, indicates that people in America are consuming alcohol 14 percent more often than they did pre-pandemic. With bars and restaurants shut, sale of alcohol through liquor stores and delivery services has increased by 54 percent. The Altria Group, makers of Marlboro cigarettes in the US, noted a rise in sales of cigarettes as well, with people increasingly shunning e-cigarettes and vapes in favour of traditional ones. Other countries have also recorded an increase in substance use. Apart from affecting physical health, excessive reliance on substances may worsen existing mental health problems, such as anxiety or depression.
Interestingly, doctors have also reported a rise in cases of patients with Vitamin D deficiency.
“I suddenly noticed an increase in people showing up with tiredness, lethargy and discomfort in bone and muscles. It turned out they were suffering from a deficiency of Vitamin D,” says Dr P Keerthivasan, Consultant Orthopaedics and Spine Surgeon, Kauvery Hospitals in Tamil Nadu. Vitamin D, known as the ‘Sunshine Vitamin’, is produced by the human body when exposed to rays of the sun, and its deficiency can cause a host of physical and mental problems. People suffering from spinal cord injuries have been unable to access proper medical care during the pandemic. At least 25 people with spinal cord injuries have died from complications related to bedsores since January 2021, according to data collected by the Spinal Injured Persons Association.
Mental Health Mishaps
Colin Gonsalves (name changed), a spry 76-year-old based in Delhi, prided himself on managing his affairs alone after his wife’s passing three years ago. His children live abroad and he refused to join them, despite frequent requests. The pandemic, however, changed everything. Forced social isolation and disturbing news of the deaths of friends and neighbours, made him depressed for the first time in his life. His son contacted the team at Samvedna Senior Care who stepped in to help with daily chores and as general companions.
Though mild forms of mental health disturbances are common, severe cases have been noted as well. The Director of Medical Education in Kerala, Dr Remla Beevi, acknowledges that there was a huge backlog of cases even after the first wave. Mental patients are worst affected as lack of accessibility to hospitals and medicine has aggravated their condition. Nasreen Ahmed (name changed), a media professional based in Mumbai, describes the last year as one of the toughest of her life. Being locked in a small apartment exacerbated her father’s Alzheimer’s condition, while her mother slipped into a quiet depression refusing to eat, and making herself severely ill.
A WHO survey records that the pandemic has disrupted or halted critical mental health services in 93 percent of countries worldwide. This survey of 130 countries is the first global data highlighting the impact of Covid-19 on access to mental health services and the consequent urgent need to adopt steps for rectifying the situation.
Change in Sight
Private and government health facilities around the country are becoming aware of these on-ground realities, and working to create structures that can address the various causes of this ‘syndemic’, while simultaneously preparing for a new wave. The Additional Chief Secretary of the Health Department in Odisha, PK Mohapatra, believes emergency procedures should never be compromised over Covid-19 scares. “It is the duty of hospitals to provide immediate and proper treatment to patients during the pandemic. Stringent action as per the Clinical Establishments Act will be taken against those found denying emergency treatment to non-Covid patients,” he warns. Dr Yeganathan, Professor of Surgery at Tiruchy’s Mahatma Gandhi Memorial Government Hospital, says that once it became clear the second wave was diminishing, the hospital redoubled its efforts to provide dialysis, chemotherapy, and perform heart surgeries.
Some hospitals ensured that non-Covid emergency care was in place throughout the pandemic. “People are avoiding elective surgeries,” says Dr R Ravindra, Medical Director, Suguna Hospital, and past President of Private Hospitals and Nursing Homes Association, “but fractures, dialysis for kidney patients, deliveries, stroke, cancer care are all taking place at our hospital. Some of the resources have been diverted for Covid but we are taking care not to affect non-Covid emergency services.” At his hospital, 30 dialysis patients turn up daily.
There is no certainty when the pandemic will end, making it imperative for the community—both patients and doctors—to take responsibility and step forward for treatment of chronic non-communicable diseases. This is only possible through concerted efforts at preventive checks, regular monitoring, and adherence to prescribed medication, overseen by medical professionals. Irrespective of the severity of the expected third wave, comprehensive strategies need to be devised to manage all kinds of health problems. Fortunately, many healthcare centres are encouraging patients to come in for routine care, by introducing new safety protocols such as limiting the number of visitors, doing away with overcrowded waiting rooms and mandating Covid-19 tests in certain cases.
The government’s release of the Telemedicine Guidelines of 2020 shows an intention to balance the needs of patients of other diseases and disorders, with those suffering from Covid. However, implementation and belief in digitised services have been slow to pick up in some parts of the country. Timely screening and diagnosis of lifestyle and other NCDs is the need of the hour. Hospitals and patients both need to be made aware of the gamut of cutting-edge technologies, tools, apps and digital services that enable home-based care, through outsourcing as well as self-monitoring.
An awareness of the failings of our healthcare system is the biggest takeaway from the pandemic. Immense efforts are required to improve on these failings, yet it is not an impossible task. With the possibility of a third wave—albeit a milder one—looming large, large-scale vaccination
and infrastructure preparedness are our best hope. The ongoing vaccination ticker on the Ministry of Health and Family Welfare website indicates the total number of Indians vaccinated at almost 400 million, and government sources claim to have ordered a further 660 million doses for the adult populace that remains unvaccinated.
A focussed vaccination drive coupled with preparing healthcare facilities to deal with both Covid and non-Covid patients, swift adoption of teleconsultation technologies, and continued implementation of Covid-safety protocol, will hopefully keep the health-compromised Indian population safe in the waves to come.
WHO data show that around 300 million people are at risk of dying from NCDs in India. Cardiac
diseases, respiratory disorders and cancer are the reason for more than 60% of deaths in the country, with 26% of this number belonging to the age bracket of 30-70 years.
The pandemic has disrupted or halted critical mental health services in 93% of the countries worldwide
Around 180 MN Indians suffer from chronic lifestyle ailments such as cardiovascular diseases, diabetes and cancer, with the latter being of utmost concern. The World Cancer Report 2020 predicts that nearly one in every 10 Indians is likely to develop cancer at some point and one in 15 likely to succumb to the disease.
A study conducted by 25,000 surgeons around the globe, and published in the British Journal of Surgery, concludes that patients waiting for elective surgeries should be the first to receive Covid
vaccines. A timely dosage could reduce nearly 60,000 Covid-related deaths in the times to come.
A JAMA Network Open report indicates that Americans are consuming alcohol 14% more often than they did pre-pandemic. Sale of alcohol through liquor stores and delivery services has increased by 54%.
What is ‘syndemic’?
A syndemic is a situation in which two or more interrelated biological factors work together to make a disease or health crisis worse. The term syndemic is used among medical and anthropological experts. The biological factors that contribute to a syndemic can be communicable (can be spread to others) or noncommunicable (can’t be spread to others) in nature. Syndemic is increasingly used in the context of sociological and economic factors that contribute to syndemics. In 2020, the term syndemic saw mainstream attention after the scientific journal The Lancet repeatedly used the term in reference to the Covid-19 virus.
“Chronic diseases need continuous monitoring as the treatment and medicines are lifelong. Yet, people with these conditions are at most risk, therefore sceptical to step into hospitals, labs or clinics because Covid-19 is a more immediate threat than their long-term conditions.”
Aditya Kaicker Co-founder and Chief Programme Officer, Breathe Well-being, a digital treatment programme
“Many diseases are poorly managed with patients avoiding visits to hospitals due to prevailing situations. Even doctors are promoting home management.”
Dr RC Sreekumar Chairman, Research Cell, Indian Medical Association
“It is the duty of hospitals to provide immediate and proper treatment to patients during the pandemic. Stringent action as per the Clinical Establishments Act will be taken against those found denying emergency treatment to non-Covid patients.”
PK Mohapatra Additional Chief Secretary, Health Department, Odisha
“Once it became clear the second wave was diminishing, our hospital redoubled its efforts to provide dialysis, chemotherapy, and perform heart surgeries.”
Dr Yeganathan Professor of Surgery, Mahatma Gandhi Memorial Government Hospital, Tiruchy, Tamil Nadu
“If doctors like me are facing problems, imagine the situation for common people. Fortunately, with Covid cases on the decline, we are planning to open an OT for non-Covid elective surgeries soon.”
Dr Gunasekar Vappulapatti CMD, GVG Invivo Hospital, Bengaluru, who is unable to schedule a knee replacement surgery for his mother
TREATMENT DISRUPTIONS WORLDWIDE
Results of the WHO rapid assessment of service delivery for NCDs during the Covid-19 pandemic
Main Causes (75% Countries Reported Disruptions)
65% Decrease in inpatient volume due to cancellation of elective care
46% Closure of population-level screening programmes
43% Government or public transport lockdowns hindering access to health facilities
39% NCD-related clinical staff deployed to provide Covid-19 relief
34% Closure of outpatient disease specific consultation clinics
33% Insufficient PPE available for healthcare providers
32% Fewer number of staff to provide services
26% Closure of outpatient NCD services as per govt directive
25% Inpatient services/hospital beds not available
25% Fall in outpatient volume due to patients not presenting
20% Unavailability/stock-out of essential medicines, medical diagnostics, health products
18% Other causes
WHO recommendations to deal with it
Governments should include NCDs in national Covid-19 plans
Every country should issue guidelines on maintaining continuity of essential health and community services for NCDs
Monitoring access to essential NCDs
Implementation of digital health solutions for NCD self-care and medical care at home
Biggest Problems Faced by Healthcare Providers and Administrators
✥ Dramatic decrease of in-person visits
✥ Healthcare professionals forced into administrative roles due to staff reductions
✥ Providers preferring retirement instead of learning telehealth practices
✥ The loss of patient attribution to their organisation, which can impact their reimbursement and a variety of other factors
Top Concerns of Patients
✥ Fear of catching the virus
✥ Regular doctors/healthcare practitioners being unavailable for consultation
✥ Loss of employment and reduced incomes
✥ Regular healthcare facilities being converted to Covid-care wards
✥ Production disruptions in medications and other essential items
✥ Increase of substance abuse and unhealthy lifestyles due to lack of access to gyms/outdoor areas and sedentary lifestyles while working from home
Other Solutions
✥ Turn to telehealth between appointments and for routine check-ins
✥ Invest in devices and trackers that help you stay in control of your body
✥ Do not hesitate to hire healthcare services that recreate hospital set-ups at home
✥ Explore the option of remote healthcare
✥ Address every aspect of your health when you first notice symptoms, including
mental health
With inputs from Hemant Kumar Rout, Sushmitha Ramakrishnan, Sowmya Mani, Vignesh V, Antony Fernando, Sreemathi M, Deepak Sathish, Saravanan MP, Jevin Selwyn Henry, Unnikrishnan S, and Telangana and Karnataka bureaus.