A prescription of equitable and effective care
By, Anand Zachariah is a Professor of Medicine at the Christian Medical College, Vellore. George Thomas is an Orthopaedic Surgeon at St. Isabel’s Hospital, Chennai. The views expressed are persona
# Medical care has been disrupted by the novel coronavirus.
# Fear, anxiety, uncertainty and confusion have all overtaken clinical services.
# The private sector, which delivers the major part of medical services, is now functioning at a skeletal level and patients have considerable difficulty in accessing medical care.
# Tamil Nadu has one of the better health systems in the country and has demonstrated that it can provide high quality care through public-private collaboration in the areas of maternity, cardiac and trauma care.
A neglect of the primary task
# Until now, the focus of the government has been on prevention of the epidemic through testing of suspects, isolation of cases and institutional quarantine of contacts.
# Hospitals have focused their efforts on prevention by admitting asymptomatic contacts and mild infections.
# With the focus on prevention, doctors have been unable to attend to their primary task of providing good clinical care to reduce morbidity and prevent deaths.
# The majority of COVID-19 infections are mild and resolve on their own.
# Serious illness occurs in the elderly and those with multiple co-morbidities such as diabetes, heart disease and respiratory problems.
# The primary cause of death in COVID-19 pneumonia is respiratory failure.
# The mainstay of treatment in moderate and severe illness is clinical monitoring, oxygen therapy to correct hypoxemia (low oxygen levels in the blood), and good supportive care.
# Even in those above the age of 80 years, the mortality rate is only 15%.
# Patients who require ventilator treatment have a mortality rate of over 50%.
# Good supportive care for sick patients is essential in preventing deaths.
# Hospital services have to focus on in-patient management of moderate and severe pneumonia, prioritising intensive care unit (ICU) beds for potentially reversible illness.
# We need to ensure that every patient with moderate and severe COVID-19 pneumonia has access to the optimum level of care, to prevent deaths and ameliorate suffering.
# Because of the labelling and stigmatisation of those diagnosed with COVID-19, the public are reluctant to come to hospital and may come late or die at home.
# We need to send out a clear message that hospitals will provide good quality care for COVID-19, at affordable cost and ensuring confidentiality.
# For this to happen, the government must work with the private sector to make care accessible and affordable.
# The Tamil Nadu government’s efforts to cap the cost for different levels of COVID-19 care in private hospitals is a positive step.
# The government should financially assist the private sector by reimbursing basic patient care costs for providing COVID-19 care.
# Medical staff taking care of COVID-19 patients are anxious that they may acquire the infection and transmit it to their family members.
# Deaths of hospital staff due to COVID-19 have been reported, although the mortality risk is lower than that of the general population.
# Medical staff involved in COVID-19 care should be adequately protected with appropriate personal protective equipment, or PPE, and should be trained in infection control and clinical care protocols.
A wish list
# In Tamil Nadu, we should shift the discourse from the focus on prevention and reducing the number of cases to an equal priority for providing COVID-19 care.
# Towards this we suggest that:
a. all private hospitals which have the potential, should take care of COVID-19.
b. They should be given requisite incentives and subsidies to that end;
c. every patient should be able to access medical care for COVID-19 from a private or public hospital;
d. only patients with moderate to severe COVID-19 pneumonia should be admitted;
e. ICU care should be prioritised for COVID-19 patients who have potentially reversible illness;
f. confidentiality of the patient should be protected;
g. the government should support the basic cost of COVID-19 care in private hospitals as well;
h. city hospitals should pool their ICU resources for the care of COVID-19 pneumonia;
i. staff providing COVID-19 care, should receive adequate training and be provided appropriate PPE, and,
j. finally, families of staff who die due to COVID-19 should receive appropriate compensation.
# These initiatives can only be realised with appropriate leadership from the government.
# The private sector has to be fully involved in clinical care of the COVID-19 epidemic.
# We should work towards making COVID-19 treatment available, affordable and effective.
# Our response to the epidemic must combine good science, clinical reasoning and a humane response to save the lives of the people of our country.
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