Covid-19 – call to put back people in the centre and not the disease
Vijayaprasad Gopichandran and Sudharshini Subramaniam
This blog is a different experiment. Sudharshini and I write our individual thoughts as two sub-blogs and then I synthesize our ideas to create a collective message. This is a follow up to our previous blog titled “Social Distancing….you must be kidding me”.
134 to home-isolation and many more to go…
Tense and nervous patients were sitting in the Covid-19 isolation ward of my hospital. The government of Tamil Nadu has recently come out with an advisory for home isolation of patients with asymptomatic, pre-symptomatic or mildly symptomatic Covid-19. I walked in, part of a team of doctors, into the ward to see all of them, talk to them and triage them to identify those who can be sent for home isolation and those who need to be admitted into the hospital. The dominant feelings among all were fear, anxiety and worry. All of them wanted to get out of the hospital. We evaluated all of them and successfully discharged 134 of them home, after they signed an undertaking to strictly home isolate themselves. This was an act of great accomplishment for me. Not just because we released people from their worries and anxieties, but because I have performed a very sensible act. I will describe the nature of work that we have been doing in the past weeks and that will help me explain this feeling of success.
The past several weeks has been an emotional roller coaster for me. We have been in the frontline of the Covid-19 response in coordinating the disclosure of laboratory tests to patients, bringing them for admission to the hospital, facilitating their hospital admission, following them up during their stay and finally planning their discharge. This work has led to some physical exhaustion. But worse than that is the psychological exhaustion that I have experienced while interacting with anxious, scared, and worried patients who have Covid-19.
Almost all of them whom we have admitted in the hospital and subsequently discharged and sent home, have been asymptomatic with respect to respiratory system. They were all apparently healthy people in a good state of health, except for the fact that their nasal swabs showed presence of the viral RNA of SARS CoV2. But they were forced away from their homes in the harshest possible manner, with a lot of drama of ambulance with sirens wailing and health workers in hazmat suits entering their streets and their homes and manually escorting them to the ambulance. Even as the people walked out of their homes and boarded the ambulance, sanitary workers would spray disinfectant on the path that they trod, sanitizing the virus along with any shred of dignity that was left in them. Immediately following their forceful removal from the neighbourhood, the health officials would put the entire area under a strict lockdown as a containment zone. On the days that I spoke to the patients on phone during their hospital stay, they would painfully recollect these harrowing experiences. Sometimes families would be separated and admitted in different hospitals. This would worsen their loneliness and distress.
The most traumatic conversation that I would have with a patient would be the one just before they are discharged to go back home. They would recollect the drama of the day they were ‘caught’ by the health officials to be admitted in the hospital. They would be worried whether they would be accepted again in the society, whether they would be allowed to enter the neighbourhood. While discharge is supposed to be a happy event, many patients would breakdown and cry at the thought of having to go back to the society, because of the fear of stigma.
I have asked myself so many times, “Why are we admitting all these healthy people and causing so much distress?” In this background, when the new advisory on home isolation of asymptomatic and mildly symptomatic patients with Covid-19, and when we released the first batch of 134 patients, I really felt that I did a purposeful job.
A tinge of Covid-19 everywhere
Sudharshini and I have been discussing our everyday work with each other as a mechanism of venting. Every time I heard her narrate the traumatic experiences of people being forced away from their homes in the most humiliating manner and the mental agony and trauma that they were experiencing, I felt the angst that this was causing her as a counsellor and as someone who was talking and listening to the patients. One evening she told me, “I think enough is enough. We are in fact causing more damage to the lives of people by doing all this (Covid-19 response), than any good”. I listened to her silently, as I always do. Her questions and concerns are usually intense and a silent and active listening is often what I can offer her. But what struck me most was, I had the same feelings as her from my own experience of working in the triage clinic in my hospital.
There is a tinge of Covid-19 everywhere now. The other day there was a 50-year-old woman whose HIV medications had run out. She lives near our hospital. So, she just dropped in and asked me to help her. She was not a beneficiary of the employees’ state insurance system and so was not entitled to care in our hospital. But I spoke to my friends in the state health system and organized medicines for her. I was distraught to see her panic and fear of missing the HIV medicines, which could mean serious complications.
The staff nurse from our rural clinic called to report that a patient whom I had seen several weeks ago had come to show his chest Xray. She sent me a picture of the X ray on my phone. It showed a cavitary lesion in the right lung, indicating tuberculosis of the lung. When we sent him to the nearest TB center in the town, they turned him away because they were scared to take a sputum sample for TB for fear of catching Covid-19 virus. After several back and forth phone calls to the laboratory technician, nurse, doctor in the public health facility and finally a phone call to the district tuberculosis officer, we managed to get his sputum tested and started him on anti-tuberculosis medicines. What would have otherwise been a routine visit to the hospital and a seamless process of diagnosis and treatment of tuberculosis turned out to be a huge bureaucratic nightmare, thanks to the Covid-19 tinge.
This morning, I saw a man brought to my hospital severely breathless because the private hospital which was performing his haemodialysis refused to do it unless he produced a Covid-19 negative certificate. There was the undeniable tinge of Covid-19 in this man too. As I carry on my work trying to help these people in whatever small way I can, I cannot but agree with what Sudharshini said, “I think enough is enough….”
On 15 March 2020, we wrote a blog titled “Social distancing…. you must be kidding me”. In the blog, we wrote the ground realities of social distancing in India. While the realities that we wrote about resonated with many people, we were also heavily criticized for advocating against restrictive lock-down measures. We are about 2 months further into the pandemic from the time we wrote that blog. All that we feared, and all that we were gravely concerned about have unraveled themselves over the past couple of months. We have seen gross injustice meted out to migrant laborers who are on a mass exodus by foot from Mumbai and Delhi, all the way to their villages. We are seeing an uncontrolled explosion of number of people infected with the novel SARS CoV2 virus, especially in densely populated urban areas, despite one of the harshest lock-downs in world history.
Now the country has been locked down for more than 40 days. This cannot continue without causing more damage. The authorities are now talking about ‘learning to live with SARS-CoV2’. This is a wise change in stand at a very crucial point of time. Better later than never. We cannot hide from SARS-CoV2 forever. We need to get out now. We need to get back out there to do routine medicine and routine public health. Covid-19 cannot continue to be our top priority forever. We need to get back in business treating our tuberculosis, malaria, dengue, diabetes, hypertension, COPD, asthma, and all the illnesses which contribute a major chunk of our burden of diseases. We need to carry on our immunization, antenatal care, delivery, post natal care for our mothers and children. Covid-19 should now occupy that background checklist which we routinely tick off, to ensure our own and our patients’ safety and nothing more.
Yes, Covid-19 is going to infect many more among us. It is going to kill some. But that is how all infectious diseases are. They infect many and kill some. We face the infections, we fight them. We develop immunity and fight them. We develop vaccines and drugs and fight them further. The virus undergoes mutations and develops drug resistance. We improve our armament and fight more. That is the nature of infectious diseases and SARS-CoV2 is no exception. This is not a call to stop thinking about and working against Covid-19. This is a call to stop obsessing about it. This is a call to re-start the practice of medicine and public health like before, with some precautions and some reorientation. This is a call to drop the “corona-hibernation” into which much of routine medicine and public health has gone. This is also a call to place people in the center of the medical and public health enterprise and not the disease.