India has a moral responsibility to ensure that necessary supplies of Personal Protection Equipment are available to the healthcare workers and all efforts are taken to provide best medical care if they fall ill.
One of the most disturbing images from the COVID-19 outbreak in India was that of a supposed hospital housekeeping worker in an improvised hazmat suit made from plastic covers used for disposal of biomedical waste. Though the photo was unverified, it reflects the overall situation in most parts of the country regarding the availability of Personal Protection Equipment (PPE) for healthcare workers.
Like many other countries, India was also grossly underprepared for the size and scale of the outbreak. It is easy for everyone to blame the government for the unavailability of PPEs, but these are extraordinary times and no one could anticipate such a vast outbreak even by the end of January.
India’s investment in improving the capacity of health systems have consistently fallen short of the targets laid down in the National Health Polices of 2002 and 2017. The impact of underspending is seen in the fragile public health system and a high out-of-pocket expenditure for accessing healthcare services.
As per the World Bank estimates, the number of hospital beds in India is approximately 0.7 per 1,000 population. Compare this with countries such as Iran (1.5) and Italy (3.4), whose health systems have been overwhelmed by the COVID-19 pandemic; and we can see the reason why all public health experts are worried.
A similar picture emerges when we look at the number of physicians, nurses and health workers too. The number of physicians per 1,000 population is only 0.8 in India, while it is as high as 4.1 in Spain which has been ravaged by the outbreak.
The bottomline is that our health systems are not as strong as those in High Income Countries (HICs) and that our healthcare personnel will have to struggle in case of a large outbreak. The responsibility of propping up a dysfunctional system can burden the healthcare workers and the government needs to take unnecessary pressure off them by taking care of their basic requirements, such as Personal Protection Equipment.
Reports from Italy show that healthcare workers constitute almost 10 percent of the total number of COVID-19 patients in the country. Apart from this, the infection can also knock off a significant proportion of healthcare workers from the already depleted frontline workforce. Since the infection is largely asymptomatic, healthcare workers can potentially be vital links to transmit disease from a COVID-19 patient to a person who may come to a hospital for an entirely different indication. All of this shows that providing adequate supplies of PPEs to healthcare workers is in the larger interest of the nation, and the decision-makers should see it as a priority.
The healthcare workers need surgical masks for use in patient screening and N95 respirators when doing procedures such as intubation and ventilation, which can generate aerosols. The World Health Organization (WHO) also recommends gowns, gloves and protective goggles (and/or face shields) for those involved in caring for the COVID-19 patients.
However, if we do a rapid survey among tertiary care hospitals in India, we can see that many places have run out of surgical masks and respirators, not to mention the other PPEs. Even in healthcare facilities, which take care of suspected COVID-19 patients, there is pressure on healthcare workers to limit the use of PPEs as the stocks are dangerously low.
Right now, we are in an early phase of the outbreak and several models predict large increases in the number of COVID-19 patients. If the availability of the PPEs in healthcare facilities are not restored fast, we will be facing a difficult time with the morale of health workers getting affected.
The lockdown announced by the Prime Minister can buy us time by blunting the progress of community transmission in the short term. We should not see the lockdown as a solution in itself, rather use the time to ramp up the medical capacity to treat patients, do mass testing and arrange for PPEs. Therefore, the next three weeks will define India’s response to the COVID-19 outbreak and provisioning PPEs for healthcare workers should be one of the main pillars in the mitigation strategy.
How can we ensure the supply of PPEs within this short time-frame?
Possible options include repurposing of manufacturing capacity available in the public sector, asking private industrialists to pitch-in (already some of them have assured help for making surgical masks), giving incentives for private companies to ramp up production or even innovative approaches such as using the tailoring units available in prisons. Micro, Small and Medium Enterprises (MSMEs) and Self-Help Groups (SHGs) who are producing PPEs can be given provisional exemption from the 21-day lockout.
The Centre, state and local self-government institutions can surely find out innovative methods to increase production and supply, as PPE production is not technology intensive. Of course, the medium-long term improvement in supplies can happen only through diversification of procurement, provision for surge capacity in production and overall strengthening of supply chains.
When people celebrate the contributions of healthcare workers and glorify their ‘resilience’, it all feels quite empty when our frontline nurses and doctors cannot work without fearing for their own health. It is just like sending a soldier to the border without the right weapon! Therefore, India has a moral responsibility to ensure that necessary supplies of PPEs are available to the healthcare workers and all efforts are taken to provide best medical care if they fall ill, in spite of using recommended personal protection measures.Philip Mathew is a physician and a public health researcher. Views are personal.
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