India is grappling with the effects of the COVID-19 pandemic, both from the disease and from the stringent steps taken to contain it. With each passing day we are seeing first, second and third order effects from some of these measures, many of which could not possibly have been factored into initial ‘projections’ or ‘plans’. As a result there is a need for dynamism and nimbleness at the decision making level.
COVID-19 cases in India continue to rise each day despite one of the most massive lockdowns seen in recent times. In the face of a new pandemic disease where knowledge is constantly evolving, it is absolutely imperative that we avoid the anchoring bias -- when we rely too heavily on a single piece of information, quite often the first piece of information we encounter. This stands true with regard to our assumptions on drugs that can be used, the manner in which we utilise lockdowns and other containment measures, our targeted testing and isolation strategies, as well as our estimation of healthcare capacity.
Supportive Care: The Mainstay Of Treatment
There have been many drugs touted as potential treatments for COVID-19. The drug that received the maximum airtime is hydroxychloroquine. Based on the available evidence, hydroxychloroquine’s effect on treating or preventing COVID-19 is ambivalent at best and harmful at worst. It should be used with caution and further studies relating to its efficacy are awaited. However, based on what we’ve seen so far, it is unlikely to reveal itself to be a wonder drug in the fight against COVID-19.
The new drug in the news is remdesivir, an antiviral drug that has been recently granted emergency use authorisation by the FDA with the ICMR following suit. This authorisation was granted on the basis of data (which is yet to be published) that indicated that it may offer an improvement in recovery time from COVID-19. The same data did not show any significant mortality benefit from the drug. Details of its distribution channels and cost are still a work in progress. Again, more studies are awaited and while this initial data is promising, it seems unlikely to qualify the drug as a ‘knock out’ treatment for COVID-19.
The use of convalescent sera or antibodies from patients (plasma therapy) who have recovered from COVID-19 is another modality of treatment under investigation, with multiple studies ongoing across the world, including India. Convalescent sera, if proven to be effective or somewhat effective, would require large scale blood banking facilities, multidisciplinary coordination between blood banks, infectious disease specialists, hospital administrators and the need to ensure a safe supply chain. The viability of such a solution at scale is suspect with our existing infrastructure capabilities.
The race to a vaccine is ongoing. Experts have stated that an effective vaccine, if produced at all, is at the very least a year away if not more.
Considering these factors, our short and medium-term strategies cannot rely on either ‘wonder’ drugs or vaccines for the medical management of COVID-19. The core of management of COVID-19 will remain supportive care. This is going to test the ability of our healthcare system to safely provide basic symptomatic care. At one end of the spectrum, it entails treating fever and pain for the mildly ill. At the far end, it means being able to provide higher levels of support such as increasing levels of oxygen therapies to ventilators and organ support.
Need To Build Healthcare Capacity
Initially there was a surge in the government's effort to step up capacity to manage COVID-19 patients within government hospitals. Many states have completely converted their government hospitals or demarcated sections towards treating COVID-19 patients; some have created new designated COVID-19 hospitals in certain districts. In some districts that have seen a surge of patients the government has enlisted the help of a few private hospitals. The lockdown in India has ensured that the numbers of patients in most districts has not overwhelmed available capacity to manage patients, for now. While this has been a commendable achievement, one of the early objectives of the lockdown was to build healthcare capacity to enable India to manage more COVID-19 patients in addition to the patient load we already need to manage. From a purely numerical standpoint, we are still very early in the course of the pandemic in India.
It is estimated that over 60 per cent of healthcare delivery in India today takes place within the private healthcare infrastructure (this percentage is much higher in urban settings). In the ensuing lockdown, with restrictions on accepting patients and elective procedures, the private healthcare industry has taken a body blow.
There is no plausible way for hospitals to function without being prepared for the possibility of encountering COVID-19 and it will be impossible for the government to not enlist the help of private providers in managing COVID-19 patients. With falling revenues, many private hospitals are losing the ability to retain their healthcare personnel and are unable to make investments required to be prepared to manage COVID-19 patients in a safe manner. A highly transmissible respiratory disease such as COVID-19 is likely to be around for the next several months. Being prepared requires a robust testing and reporting system, which would enable hospitals, nursing homes, doctors to test their patients and rapidly access the results to determine further course of treatment and isolation. In order to shoulder this responsibility, the health of the private healthcare sector needs to be ensured. Furthermore, in addition to managing the COVID-19 caseload, these hospitals need to cater to the multitude of other diseases that are prevalent. Many patients with chronic diseases such as cancer, heart failure, diabetes, etc. have deferred their treatment and follow up, and this could have potentially negative effects on the patients’ long-term health.
Technology And Its Role In ‘COVID Times’
The COVID-19 crisis will unfortunately leave us with a trail of lost lives and livelihoods. Among the only few positive outcomes from this devastating catastrophe would be the increased uptake of healthcare technology.
Technology in healthcare has always theoretically been a sound idea and a promising solution to improve quality and accessibility of care. However, the lack of permeation of technology into day to day healthcare delivery and the fact that healthcare has lagged behind most other industries in adoption of technology has been a common refrain. The reason for this has been manifold, ranging from clunky technology solutions to misalignment of incentives of stakeholders that encourage adoption. The COVID-19 pandemic is arguably the single greatest impetus that the healthcare industry has ever received in its effort to become technology enabled.
During this time, telemedicine has seen an increase in usage. In its many forms, telemedicine has been in practice for the last two decades. However, it has largely remained on the fringes. In the past two months it has taken on the role of addressing patient concerns front and centre, with a large number of doctors and patients using it to address health concerns. While some functions of healthcare delivery will eventually return to in-person encounters, both patients and caregivers have discovered a new way of doing business and possibly a more efficient and safer one. Technology platforms and clinical services that centralise and improve quality and access to radiology, ICU care, pathology and eye care are on the rise. Similar solutions that provide access to specialist doctors in kidney, heart, chronic diseases and mental health, among others, will be the only way we can adequately service the healthcare needs for a population the size of India. Telemedicine’s regulatory framework had been pending for years, and it took less than a few weeks into the COVID-19 crisis for it to be formalised and published by governmental authorities. This augurs well for the industry and will only serve to further enhance investments and innovation in the field.
Similar trends are seen in remote monitoring, home monitoring and care, IoT devices and robotics, which will augment safety and improve access to expertise for patients. With data being called the new oil, digitisation has the potential to unleash a flurry of innovation in data science, further augmenting the ability of healthcare givers to improve quality of care. India has 1.3 billion people and the quantum of healthcare data that could be made available using digitisation could potentially trigger numerous innovative solutions that can address gaps in our healthcare system.
As a developing country, the lack of substantial investments in modernisation and building our healthcare infrastructure is becoming apparent. The lifesciences have never been the focus of much interest or investment in India. Today we see the consequences of that omission. But for a few innovators in the lifesciences who have persisted despite the prevailing atmosphere rather than because of it, we remain largely reliant on other countries for innovations in the field of cutting-edge medical devices, new vaccines, state-of-the-art molecular testing capability and new drug development.
Moving forward from this crisis, we have the opportunity to take a radically different path than the one we have traversed so far. With an impetus on investment in healthcare and a regulatory framework to spur innovation and entrepreneurship, we have before us the prospect of moving from a copycat and contract manufacturing hub to one that innovates its way into the future. The ball is in our court!
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Dhruv Joshi is the co-founder of Cloudphysician Healthcare, a healthcare technology company that remotely provides ICU expertise to hospitals that do not have access to ICU specialist doctors.
He trained in Pulmonary and Critical Care at the Cleveland Clinic Foundation, USA. He graduated medical school from St John’s Medical College, Bangalore, India, following which he completed his internal medicine training at the Good Samaritan Hospital, USA.