Covid 19: We Should Speak to Doctors Used to Operating with Less and not Abundant Resources
by Suranya Aiyar
This article was originally published on July 18, 2020 in the Sunday Guardian under the title 'Covid-19 dwarfs even the world's best resources'
Pic: Pixabay. Free Use.
The World Health Organization (WHO) and public health
thinking in general works with fixed ideas of wealth and hospital resources in
evaluating health issues. But Covid-19 reduced to nothing the resources of the
world’s richest and most technologically advanced countries. This bears some
reflection.
Even though we think of richer countries
as being healthier than poorer ones, the annual death rates of countries are
surprisingly similar, despite the massive disparities in wealth. Going by
figures given out by the WHO, the death rate for most countries of the world is
close to 1 percent, with a few countries at the lower end at about .5%, and
even fewer countries at the higher end at 1.5% (Source: WHO burden of disease
figures for 2008).
The picture that emerges is by no means
one of a conquest of death or disease as countries get richer. Rather, there is
an epidemiological shift of the burden of disease from infectious to
non-infectious disease as countries transition from lower to higher levels of
wealth. This led to a lack of experience with infectious disease in higher
income countries that cost them dearly when Covid-19 came to their shores.
Doctors at the epicentre of the Covid
outbreak in Northern Italy were quick to intuit the misalignment of their
current medical practice, with the exigencies of a highly contagious disease
like Covid-19: “Coronavirus is the Ebola of the rich…..The more medicalized and
centralized the society, the more widespread the virus…” (At
the Epicentre of the Covid-19 Pandemic and Humanitarian Crises in Italy:
Changing Perspectives on Preparation and Mitigation, Nacoti et al., NEJM
Catalyst, 21 March 2020).
“the Coronavirus epidemics should indeed
lead to a number of reflections on the organization of healthcare and the way
contemporary medicine has lost sight of some diseases, such as infectious ones,
that were, probably prematurely, seen as diseases of the past….We have
definitely not won the fight against infectious diseases, but we have probably
forgotten about them too soon. In a high-technology setting, it is all too easy
to forget the overwhelming, often dark power of nature” (Hospitals
as health factories and the coronavirus epidemic, Giorgina Barbara Piccoli,
Journal of Nephrology (2020) 33: 189-191, 21 March 2020).
Covid-19
is a good reminder to countries like India not to lose sight of infectious
disease as it goes up the income ladder.
The WHO and public health field will look
at the numbers of physicians or hospital beds per thousand of population as a
determinant of the strength of a country’s health sector. But
a closer look at the state of medical services in different countries reveals
that there is no straight line between a country’s wealth and its hospital
resources, physician density; or its ability to combat infectious disease or
manage a high volume of patients.
Cuba probably has the most medial
resources per capita, its physician-per-1000-of-population ratio is the world’s
highest at eight, the second highest is Sweden’s whose figure is only half that
of Cuba’s at four (World Bank physician density figures).
Going by the World Bank’s Gross National
Income threshold, the relative wealth of Lower Income to the least wealthy
Higher Income Countries is 1:12, but their beds-per-1000-of-population ratio is
1:3.88. The number of beds-per-1000-of- population of Upper Middle Income
Countries at 3.41, is close to that of High Income Countries; and that of Lower
Middle Income Countries at 2.08, is only just under half that of High Income
Countries (data for beds-per-1000-of-population from The
Global Impact of COVID-19 and Strategies for Mitigation and Suppression, COVID
-19 Response Team, 26 March 2020).
If you compare the incidence of tuberculosis
as a percentage of the number of tuberculosis deaths given by the WHO, you get
a figure of about 8.5% for India, which is about the same as the figure for
Italy and Germany (about 8.5% and 8.3%, respectively), and lower than for
France at 10.6%; and only double that for the USA, 4.6%, and UK, 4.3%. The
figure for Kenya and South Africa, 4.3% and 4%, respectively, is as good or
better than that for the USA and the UK. The figure for Mexico is about 11%,
which is close to that for France. The figure for Sweden is exceptionally high
at nearly 17%. Even accounting for cases missed in South
Asia and Africa, this says something about how well doctors are coping with the
cases that do come to them, despite the relative lack of resources, and
larger number of cases.
Norway has shown zero tuberculosis deaths
in recent years, but the number of tuberculosis patients has remained unchanged
at about 300. This might be indicative of some difficulty in its ability to cure
tuberculosis, even while keeping its victims alive. 2002 was a terrible year
for tuberculosis in Norway, with 100 tuberculosis deaths estimated in that year
against an estimated incidence of 280 cases, giving a crude mortality of over
35%.
The four-times higher doctor-to-patient
ratio of Sweden to India’s did not stop it from having more Covid-19 deaths
than India as late as mid-May. In early July, Dharavi in Mumbai, Asia’s biggest
slum, had recorded about 2300 cases and 82 deaths from Covid-19. This is nearly
a third of the Covid deaths and about a quarter of the cases in Norway, even
though Norway has about the same to half the population of Dharavi (depending
on how many migrant workers fled from Dharavi during lockdown).
The calculations here of tuberculosis
death rates are not from the WHO, they are my calculations are based on the WHO
mortality estimates and case incidence for this disease for the year 2008, and
in the case of Norway, for the year 2002. The WHO and public health officials
will say that you cannot compare the country-wise data, or even the year-wise
data. But if that is the case, then why are they doing exactly this when it
comes to Covid-19? What do the numbers mean, if you can’t compare either
year-on-year figures for a country, or country-to-country figures with each
other?
In Covid times, it is also important to
recognise the value of our experience with large numbers. In a given year,
developing countries in South Asia and Africa see an infectious disease
incidence numbering in the lakhs and crores, while developed countries like the
UK, Germany, Italy or Spain see mere tens of thousands of cases. In absolute numbers,
even the incidence of non-communicable disease in developing countries is much
greater than that of developed ones.
At the 2400-bed All India Institute of
Medical Services in New Delhi, the average daily footfall is 15,000. According
to its Annual Report for 2018-19, it saw about 38 lakh outpatients, 2.5 lakh
in-patients and conducted 2 lakh surgeries. Compare this with the USA’s biggest
hospitals: according to a site called Becker’s Hospital Review, the New York
Presbyterian Hospital/Weil Cornell Medical Centre, which has 2200 beds, sees
43,000 emergency room patients and conducts about 77,900 surgeries annually;
the Florida Hospital in Orlando sees 32,000 in-patents and 53,000 out-patients
annually; the Methodist Hospital in Indianapolis sees 97,000 patients a year.
This is not to say that poorer countries have some kind of magic formula by
virtue of seeing more cases. But a better understanding of the kinds of numbers
developing countries face as a routine, would have helped both them and richer
countries respond more sensibly and moderately to the Covid-19 crisis.
We are not seeing the relevance of the differences in hospitals and medical practice that grow out of the differences discussed above in the disease profile of countries at different stages of development. Led by the world’s leading authority on disease, the WHO, we think of the differences only in terms of rich and poor; and resource-constraint or resource-abundance. We fail to see that the nature of medicine, hospital management and disease control practiced in developing countries with a large burden of infectious disease and an endemic lack of resources might actually have lessons for all of us in Covid times. We need to pivot for answers from looking at the richest countries in the world, to looking at the poorest ones. They are the ones with the relevant experience, whereas the richer ones have virtually none. We should have been speaking to doctors who function with less and not more resources, because Covid-19 dwarfs even the world’s best resources.
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