“There is a crisis of lack of availability of safety equipment, such as gloves, masks, gowns, shoe covers, protective suits for doctors and health workers in the country, and their procurement is behind schedule,” Yogesh Jain, founding member of Jan Swasthya Sahyog (People’s Health Support Group), a non-profit working on public health issues in Chhattisgarh told Gaon Connection. “And, this is not just a supply issue, but a life-threatening shortage, which may compromise the lives of many health workers in the country,” he added.
Somewhat similar thoughts echoed by Anant Bhan, a researcher on global health, bioethics and health policy. “Right now, either the personal protective equipment are not available in adequate numbers, or are priced very high,” he said. “Not everyone needs protective body suits and goggles, but all healthcare professionals and workers need some form of protection and it is imperative to make it available so that these people do not get infected while screening, testing or treating coronavirus patients,” he added.
With a “spurt in number of confirmed cases” in the country — 482 coronavirus patients till the last count— state after state is enforcing lockdown or sealing its borders; some like Maharashtra, Punjab, Chandigarh are already under curfew. At least 32 states/Union Territories covering 560 districts in the country are completely shut down allowing only essential services to operate.
As epidemiologists and public health experts warn of a further surge in coronavirus 2019 (COVID-19) cases, the role of healthcare providers becomes critical in slowing the pace of the spread of the virus and trying to keep the fatalities low.
Gaon Connection spoke with medical doctors, health researchers, public health experts, health workers’ representatives to understand their critical needs the government must address on a war-footing.
Shortage of safety equipment
The first and foremost concern is the shortage of safety equipment, technically known as personal protective equipment or PPE, for people in the healthcare sector, said Sanjay Nagral, a Mumbai-based surgeon and chairperson of the Forum for Medical Ethics, who regularly writes on issues related to public health and medical ethics.
Personal protective equipment include face masks, gloves, goggles, protective suits, etc. “Everyone in the healthcare sector needs some level of protection, be it the security guard at OPD, ambulance staff, the person transporting medical supplies/test samples, or doctors and nurses treating coronavirus patients,” said Bhan. “There is a need to categorise people in the healthcare sector based on the level of protection they need, and supply them the desired safety equipment at the earliest,” he added.
A recent report in The Caravan points out how the Indian government failed to create stockpiles of PPE despite the World Health Organization (WHO) issuing guidelines informing countries to expect a disruption in the supply of PPE.
On February 27, the WHO issued guidelines stating: “The current global stockpile of PPE is insufficient, particularly for medical masks and respirators; the supply of gowns and goggles is soon expected to be insufficient also. Surging global demand−driven not only by the number of COVID-19 cases but also by misinformation, panic buying and stockpiling − will result in further shortages of PPE globally.” A month earlier, on January 30, the global health body had declared “the current outbreak constituted a public health emergency of international concern”.
The Caravan report points out “the Indian government waited till March 19 to issue a notification prohibiting the export of domestically manufactured PPEs and the raw material for the same.” It was on January 30 that India reported its first COVID-19 case from Kerala.
“In spite of the lead time, the Indian government failed to create a stockpile of PPEs and this administrative callousness will be compromising the lives of so many healthcare providers in the country,” said Jain. “Clapping for healthcare providers is fine. But what they need is safety equipment so that they don’t have to face a dilemma between their professional calling and personal safety,” he added.
Jain went on to say in spite of the shortage of safety equipment, most physicians will still endanger their lives and treat COVID-19 patients.
Susana Barria, trade justice campaigner with Public Services International, the global union federation of workers in public services, makes an important point about the needs of health workers. “Most references to healthcare professionals are often limited to doctors and nurses. But we must remember there are other people who work at the hospitals. These include ward boys, cleaners, aayahs, etc. In a pandemic, it is important to keep them safe, too,” she said.
Most hospitals have contracted out their cleaning staff and outsourced to some private contractors. “In such a scenario, the safety of these health workers will be whose responsibility — the hospital administration or the private contractor?” she questioned.
“Informalisation of employment relations has created vulnerable workers who might not be receiving the kind of protection they require during a pandemic. In addition to those working in hospital settings, frontline community health workers in Mumbai have to move around residential areas to identify possible coronavirus patients and they do not even have proper masks, gloves and sanitiser,” she added.
Disruption of supply chain amid lockdown
Healthcare professionals are extremely concerned about the lockdowns enforced by various state governments. They fear this may affect the essential medical supplies. “We must remember that healthcare sector is more than doctors, nurses and health workers. There are chains of people attached with the health sector and there should be no supply chain disruption,” said a Mumbai based doctor.
“Today I received a call from two of my patients who said they were unable to get non-invasive ventilator, as the supplier had shut shop as workers were not reporting to work. How are doctors going to respond to the humongous challenge under such circumstances?” he asked requesting anonymity.
Several cities across the country have shut down their public transport systems, including local trains, Metros, etc. “A large number of health workers use public transport to reach the hospitals. They must not face any difficulties in commuting. Adequate and safe transport arrangements must be made for them,” said Barria.
Nagral stressed nurses are even more important than doctors as they take care of minute by minute needs of the patients. “Similarly, services of ward boys and aayahs are also crucial to keep the health facilities clean and infection-free. The Shutdown of public transport, and the fear, may affect the attendance of health workers,” he said.
According to Bhan, lockdowns have to be built on evidence and rationale. “If in a particular area, there are a number of positive cases, then containment measures can be enforced and infected people isolated and treated. Putting larger areas and entire states under lockdowns is a bit questionable,” he said. He also reiterated the government needs a clear response strategy for COVID-19 based on scientific evidence and local data.
Dedicated hospitals for COVID-19?
As healthcare staff gets over-stretched to respond to COVID-19 pandemic, hospitals are feeling the crunch. “Many have cancelled their regular OPDs and are taking in only emergency cases; routine surgeries have been postponed, too. But, with coronavirus patient numbers increasing fast, soon the hospitals will be overburdened,” said Vivek Patel, a Mumbai based neurosurgeon.
Bhan said the healthcare system must prepare for the rising numbers. “Soon we could be overwhelmed with the rising number of COVID-19 cases. How and where do we quarantine those with exposure to infection or isolate confirmed patients? Where do we treat them? We have to ensure we do not expose other people to the virus,” he said.
“One way to respond to the present situation could be to have centralised services, meaning exclusive hospitals to treat COVID-19 patients with concentrated staff. But, in India that may be difficult as it would require people to travel long distances,” said Nagral.
He stressed on the need to harmonise public and private sector. “Public hospitals alone cannot respond to the present crisis. Private sector hospitals must stop profiteering in the current situation and offer their support. The government could consider funding or subsiding treatment of COVID-19 patients who approach the private hospitals,” he added.
We do not have enough hospitals in the country to handle infectious diseases, said Barria. “The government has to put private facilities to use. Spain, for instance, has requisitioned identified private hospitals and services in the country to respond to COVID-19,” she said.
Today, March 24, the Uttarakhand government has decided to take over control of all private hospitals having 100 or more beds, and reserving 25 per cent of these for COVID-19 patients.
Healthcare professionals with disabilities
On March 22, Doctors with Disabilities: Agents of Change, a pan-India organisation of health professionals with disabilities, which includes doctors, dentists and nurses with disabilities, wrote a letter to the Union health minister and the Union minister of social justice and empowerment, highlighting how the COVID-19 response has been disability non-inclusive.
In the letter, Satendra Singh, associate professor of physiology, University College of Medical Sciences & GTB Hospital, Delhi said advisories issued by the Government of India do not cater to health professionals with disabilities, and persons with disabilities.
“People with blindness and deafblindness depend heavily on touch and social distancing can be challenging for this section. However, neither National Institute for the Empowerment of Persons with Visual Disabilities, Dehradun, nor National Institute for Empowerment of Persons with Multiple Disabilities, Chennai has any guidelines on this,” reads the letter.
Doctors with Disabilities has demanded the nodal ministry [social justice and empowerment ministry] must direct all nine national institutes under its purview to utilise national fund created for persons with disabilities u/s 86 to create an urgent and massive drive for awareness generation on COVID-19. Same directive must be passed to states to utilise the state funds in consultation with disability sector.
They have also demanded the use of PPE for healthcare professionals during COVID-19 outbreak should be mandatory, and preferences should be given to health workers with disabilities involved in direct patient care.
Training and protection of frontline staff
ASHA workers, ANMs and anganwadi workers have been roped in to raise awareness about COVID-19 and disseminate information in rural areas. However, they lack both proper training and safety equipments, such as gloves and good quality face masks.
A recent report by Gaon Connection has recorded how ASHA workers are travelling from village to village to educate the rural people about coronavirus and its safety precautions, but they themselves have no safety equipment. Not even a basic mask.
Apart from this, these frontline staff are also paid very low wages. “ASHA workers are not regular employees, but scheme workers who are given financial incentives or honorarium by the government for their work and not regular salary like employees,” said Barria.
For the last few years, ASHA workers, ANMs and anganwadi workers have been protesting and demanding higher wages. “We have been demanding the legal minimum wage from the government. But the Central government has been deaf to our demands. It is not ready to compensate us adequately for the labour we put in,” complained S Varalakshmi, president of the Karnataka State Anganwadi Workers’ Association.
No army can fight on an empty stomach. And, no health worker should respond to a pandemic without safety equipment.
