An Indian family doctor in COVID-19 – A virus that magnifies inequality

DISCLAIMER: I do not intend for these blogs to be seen as giving clinical advice nor as judging public health policy but rather to recount the lived experiences of family medicine physicians from across the world. I recommend you still follow your local guidance but this goes without saying.

Date of interview: 2nd April 2020

Number of confirmed cases at time of interview: 1636

Number of deaths at time of interview: 38

Dr Pratyush Kumar is a family doctor in Bihar state in North India and the secretary of the WONCA  working party on rural practice and is the inaugural Chair of WONCA Rural South Asia (WoRSA). I got to only know him recently when we worked together on webinar organised by WONCA World about COVID-19 where Pratyush did some myth-busting and I presented something with Dr Kim Yu from the U.S on physician mental health.

India is a fascinating country with a rich history and a unique culture. I’ve been twice, once to visit friends in Mumbai and Goa, and a second time for a surgical camp in a very neglected area by the Burmese border called Nagaland. It’s a fantastically intense place with a dense population (you need to let go of any concept of British personal space) and it is one of those places that you have to go there to really believe it. India has been in international news for probably not the right reasons recently with the religious violence a few months ago so would the Indian leadership be able to bring the country together in the face of COVID-19?

India is coming to the end of its first week out of three in lockdown. Public transport and religious places of worship have all been closed and only essential services such as healthcare facilities and grocery shops have been left open. Like the UK, there is a COVID-19-specific phone number where patients can call for advice. The criteria of testing has been slowly expanding – much like the rest of the world – from those with a positive travel history, to those with contact with positive cases, to health professionals with symptoms to now those with severe respiratory illness. The tests are offered free of charge at the government centre although Pratyush mentions that it is possible to go to a private clinic and pay for a test (around $60).

According to Pratyush, Bihar is the third most densely populated state but it is in the bottom three for health indices. Approximately 60-75% is rural and access to healthcare has always been an issue which is exacerbated by the lack of public transport. He believes that COVID-19 exposes underlying health inequity so those with malnutrition, poorly managed co-morbidities and incomplete vaccine schedules are those most at risk. The topic of privilege and inequality has come up regularly in my interview series of family doctors working against the coronavirus. Working from home involves having a white collar job and good internet; self-isolating means having sufficient space in the house to sleep separately; being able to hoard means earning enough money not to live hand-to-mouth. For some people, these recommendations are not an easy option and this holds true for both the UK and India. Government policies need to be consistent in order for quarantine to work so there’s no point telling people to stay at home if they risk starving at home. Pratyush tells me that the government and several Non-Governmental Organisations (NGO’s) have promised to deliver food packages which will be essential to stop daily wage labourers from leaving their house. As doctors and politicians, we have to recognise that the priorities and compulsions of our patients are not always in line with our priorites which is painfully seen in the UK when people are meeting in parks because it’s sunny. Clear consistent messaging is the only way forward.

Having seen on international news how migrant workers in India had all packed onto trains and buses to travel home for quarantine, I obviously share my concerns about the spikes in cases that this may cause. Pratyush reassures me that the migrant workers in his area are placed in camps for two weeks in isolation before returning to their villages. He also mentions that the villages are often refusing to accept returning members too so he seems less worried than I am. He also mentions however that the closure of the Nepali border has left stranded workers from both sides who found themselves on the wrong side when the closure was announced. This displacement and temporary camps is going to be challenging to manage and I can only imagine will introduce another layer of complexity to the Indian response.

There is scarcity of Personal Protective Equipment at the moment which is very much due to sudden increase in demands. The Indian government has also recommended hydroxychloroquine as prophylaxis for healthcare professionals although such advice has been debated due to lack of proper evidence (Mr Trump, take note…).. Although the medicine was in shortage initially fora few days because of panic buying, it’s now back in stocks. Another thing that I really pick up on during this conversation is India’s immense manufacturing power. When I am asking Pratyush if he worries about the medicine or personal protection equipment shortages that we are facing in Europe, he nonchalantly shrugs it off by saying that the pharma industry and factories will just make more. I’d forgotten that India is the global manufacturing powerhouse alongside China and can re-route their own industries to keep up with demand. It really appears that Pratyush and I have different worries!

We also talk about how lockdown has filtered out all the minor ailments from both our clinics. I feel slightly guilty as I only had five patients in my virtual clinic this morning and I am somewhat twiddling my thumbs. Pratyush has also noticed a significant decrease in his patients especially those with functional issues and we wonder whether patients will become more resilient as they recognise that things often get better by themselves and they don’t really need us. I really hope that this self-sufficiency lives on after COVID-19 stops being a topic of daily conversation and we are able to unmedicalise the modern community and reduce the previously growing burden on the healthcare system. But conversely, I also worry about those who do need healthcare but are staying away because they are scared. Those with heart attacks, strokes who would have done well if they had arrived in a timely manner. An analysis of all-cause mortality will be necessary in the post-covid breakdown.

I also really wanted to discuss the interface between traditional medicine and allopathic medicine because India is famous for spirituality and its associations with wellbeing practices such as meditation and yoga. I learn from Pratyush that there is a Ministry of AYUSH (Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homoeopathy) in India alongside the Ministry of Health which I find fascinating in itself so there is an integration at governmental level. The traditional medicine practitioners attend their own schools and actually have pharmacology training so are able to prescribe to a certain level. However, at the shop-floor level, practitioners and doctors work independently and separately. Throughout this COVID-19 crisis, the government has been clear that the population needs to seek allopathic (Western) medicine for treatment options. I didn’t ask Pratyush but I wonder what impact this would have on the rural communities where traditional healers may be more accessible than doctors in a country where there is a huge shortage of medical staff. In fact, I see that the government has been rolling out the testing for healthcare staff before patients and Pratyush mentions that healthcare professionals are offered hydroxychloroquine prophylaxis as standard. Doctors have been offered a 90-day insurance which covers anyone who cannot work because they have been infected and most has been offered extra salary or an advanced salary to work. It’s interesting seeing that India has recognised the need to get their staff on board by placing incentives. Feeling like the government has our back seems to be a running theme and is necessary to avoid burnout in what will be a very intense period.

I ask Pratyush what next for India. Their numbers are still low and things could go either way. He feels that these isolation measures are really important because the population in India is too dense that aiming for herd immunity is not an option. He feels that India has different issues in comparison to Europe. They do have staff shortages and their medical system is clustered in urban areas and it is an incredibly populous country. However, he points out to me that the average age expectancy is 65 in India and given that the elderly are disproportionately affected by COVID-19, he feels that this will be reflected in the overall mortality rates. Further to that, there is suggestion that the BCG vaccine is protective which would be a huge advantage for India if so, given the high rates of TB and the eradication programmes that have been ongoing. The high rates of malaria means that many are already on hydroxychloroquine which means that overall, although all of this is unproven, India may not have the tsunami that we are experiencing in Europe. Through my conversations with family doctors worldwide, I feel that the countries that have been dealing with infectious diseases have a different outlook on the coronavirus compared to those of us in Europe where infectious diseases have been almost entirely wiped out. I’m telling him about the anti-vaccine movements in the UK which demonstrates how far removed we have become from epidemics and outbreaks in my country. Perhaps this is why our populations are not dealing with it well with its stockpiling and sky-rocketing anxiety. It’s the first time that we don’t feel in control and perhaps the first time we have to understand the concept that disease can be mightier than the available medicine.

Pratyush and I reflect on how many people try to make direct comparisons between countries but we both think that this is futile. There are different demographics, different diet patterns, different living patterns and it appears that everything matters in the fight against this disease. The charts of confirmed cases and deaths only looks like a competition charts and we’re both feeling that you cannot impose the same restrictions as another country without thinking of all the implications.

I thank Pratyush for the time he gave for the interview and for all the work he does for WONCA. I also wish him and his colleagues in India my heartfelt wishes and I hope that one day we can meet in your beautiful and unique country.

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