More than 500 allopathic doctors and nearly 50 nurses in India have died due to COVID-19. What explains the increased risk they face, and what is the way forward?
As on October 13, COVID-19 has infected 71 lakh Indians and caused the death of over a lakh of them. However, the infections and deaths due to COVID-19 have not been uniform across the population. Certain segments of the populations are seeing higher rates of infection and death. One such group is the health workers.
“Globally, around 14 per cent of COVID-19 cases reported to WHO are among health workers, and in some countries it’s as much as 35 per cent,” WHO director general Tedros Adhanom Ghebreyesus said on the briefing for World Patient Safety Day on September 17. This is despite health workers comprising a miniscule proportion of the whole population. Health workers who are at risk include doctors, nurses, paramedical staff, ambulance personnel, frontline health workers such as ASHAs, ANMs, safai karamcharis and mortuary workers.
In India, the central health ministry on September 15 said in Parliament that 155 families of health workers, including 64 doctors, have applied for compensation under the Pradhan Mantri Garib Kalyan Yojana insurance scheme for death of health workers. A day later, the Indian Medical Association (IMA) published a list of 382 allopathic doctors who died treating COVID-19 patients. On October 2, it updated the list to 515 allopathic doctors.
Given that India has just over 0.7 million allopathic doctors, 515 deaths due to COVID-19 translates roughly to an eight-fold higher risk of death by COVID-19 among allopathic doctors in comparison to the general population. Other professional associations such as the Trained Nurses Association of India have also been cataloguing the loss of nurses.
There are numerous reasons why we see higher infections among health workers. Before we list these, it might be worthwhile to note that there could be a bias at work here as health workers also often have preferable access to testing compared to the general population. But this may not explain the entirety of the disproportionate infections. For example, a recent study published in The Lancet shows that even after correcting for the bias, health workers in the United Kingdom and United States of America have a three-fold higher risk of contracting COVID-19 compared to the general population (Nguyen et al., 2020). Let’s review the reasons for this.
Firstly, when the whole of India went into lockdown and people were confined to their homes, health workers were one of the groups of essential workers who continued to go to work and, in particular, were exposed to people with COVID-19 at close quarters and in closed spaces. Hence, they were in and continue to be in positions of highest risk of catching the infection.
This is where the importance of personal protective equipment (PPE) such as masks, gloves, goggles, face shields and whole-body suits comes. But world over, because of the sudden increase in demand for PPE, these were short in supply, were rationed, and a lot of health workers were forced to work with limited supply of PPE. Further, no PPE is 100 per cent effective, and there have been concerns about the quality of PPE that many health professionals received. Hence, the second reason is insufficient or inadequate PPE.
Thirdly, many health workers, because of the increased demand, are working longer hours and hence exposed for a longer duration to patients with COVID-19, thus increasing their risk.
Fourthly, many healthcare settings do not follow proper infection prevention and control practices.
Finally, pre-existing medical conditions such as diabetes among some health workers place them at a higher risk for symptomatic/serious infections with COVID-19.
The reasons we should be particularly concerned about COVID-19 infections among health workers are many. Firstly, each health worker contributes to the care of a number of patients each day. When health workers become unwell with COVID-19 and are out of work, the number of people the health system serves effectively each day goes down by a certain proportion. This results in longer waiting periods, lower quality of care, and stresses the health system further.
Such an impact on the productivity of the health system will be higher in places where there is already a shortage of health workers. Based on a WHO study from 2016, in India, despite 70 per cent of the population residing in rural areas, only 40 per cent of health workers are present there. As the COVID-19 pandemic spreads through rural India, the ability of the health system to cater to the rising need will be further compromised because of COVID-19 infections and deaths among health workers.
Secondly, for the same reasons that health workers are at a higher risk of catching COVID-19, health workers also have higher chances of spreading COVID-19 to others — other health workers, non-COVID patients and their own families.
In particular, the non-COVID patients they would be in contact with, either admitted to the hospital or coming to the outpatient department, will be a subset of the general population with a potentially lower immunity due to other illnesses. Hence, the chances of these patients contracting and dying from COVID-19 could be higher. Therefore, in view of reducing mortality, it is imperative that COVID-19 infections among health workers are prevented or diagnosed earlier, and those with infection are quickly isolated and treated where required.
Thirdly, in many health facilities, those at the frontline of COVID-19 duty are postgraduate students and resident doctors. Postgraduate students and resident doctors in general have long working hours, minimal breaks and less privileges. In addition, many of them have not been receiving their salaries on time. Being among the lowermost in the medical hierarchy, the chances of them reporting symptoms, asking for or receiving leave and being able to isolate in time could decrease.
Finally, studies show that the pandemic is resulting in increased mental stress among health workers due to exhaustion, fear of contracting COVID-19, fear of spreading the disease to family, infections among colleagues, violence, social isolation and social stigmatisation. These studies also show that this is resulting in an increased prevalence of mental health disorders among health workers at this time, particularly among women health workers and nurses (Pappa et al., 2020).
What can be done to deal with this issue can be discussed under four headings: prevention, treatment, relief and structural change.
In terms of prevention, it is imperative that adequate numbers of appropriate PPE are made available consistently without any short-term shortages for all cadres of health professionals involved in the COVID-19 response. This means there is a need for a dynamic and responsive supply chain. For example, hospitals that see a sudden increase in COVID-19 patients would see a sudden increase in PPE usage. An effective supply chain should be able to predict, or at least know quickly the increased need for PPE and be able to respond to that.
Secondly, it is important to know how to make the most efficient and appropriate use of PPE. This includes knowing the differences between types of PPE (Surgical masks, N95 masks, Hazmat suits, face shield, etc), the techniques involved in using them and the relative risks of each procedure (outpatient interaction vs intensive care aerosol-generating procedures). The union health ministry has released detailed guidance, classifying different scenarios based on risk levels, with recommendations for appropriate PPE. In addition, each PPE has a method of wearing it (donning), checking its fitness, and removing it (doffing). If any of the steps are done incorrectly, then its protective value can decrease considerably. Hence, health workers at all levels need to be trained about the same and provided regular refreshers and reminders to enhance proper adherence.
Thirdly, health workers who are at risk, such as those who are elderly, and who have chronic diseases or lower immunity because of other reasons must be particularly protected. This could be done by placing them in duties where their interaction with patients, particularly those with COVID-19, is minimised. For example, they could be manning control centres, telemedicine support, online teaching, etc. Also, workers and facilities for COVID-19 care and non-COVID-19 care must be separated as far as possible to prevent indirect spread from COVID-19 patients to non-COVID-19 patients.
In terms of treatment, systems must be put in place for screening and prompt testing of health workers. The organisational culture must be encouraging of allowing health workers with symptoms to report them and go on leave without fear of repercussion on their pay, education or chances of promotion. Essential workers must be treated on priority, so that they can be back on duty sooner.
In terms of relief, it must be ensured that all health workers are covered through effective insurance mechanisms, and that they or their families receive adequate and timely compensation in the event of death or disability. This must be made available to all essential workers who are putting themselves at risk.
In terms of structural change, it is important to tackle the shortage of health workers across the country, especially in rural India. Many tasks done by doctors can be shared with other health workers, a process called task-sharing, after training and appropriate supervision for the same. Examples for such tasks include screening, prescription of a limited set of medications, follow-up, and provision of psychosocial care. In addition, given the expertise in software technology within the country, there is a huge potential in using telemedicine, app-based health care services and artificial intelligence in filling this gap.
In sum, the COVID-19 pandemic is taking a toll on India and its health system. Deficiencies in the Indian health system are resulting in a disproportionate number of COVID-19 related infections and deaths among health workers. This can affect both the sustainability of India’s COVID-19 response as well as the sustainability of the health system itself. Immediate action need to be taken at all levels to tackle this issue.
Dr Harikeerthan Raghuram is a public health researcher and consultant. Dr Anant Bhan is a researcher in global health, bioethics and health policy.