Shortage of doctors, lack of training may pose hurdles

Experts say the country is at a tipping point, and training hospital staff on infection-control and identifying labs and hospitals for exigencies is critical

NEW DELHI : With six confirmed and seven yet to be confirmed new coronavirus (Covid-19) cases, India is experiencing limited local transmission, experts said, where all infections have occurred locally but can be traced back to a patient zero who was infected in another country with ongoing transmission.

The country is at a tipping point where the outbreak can head either way, and training hospital staff on infection-control and identifying labs and hospitals in both the government and the private sector for exigencies is critical, the experts added.

“Local transmission can still be contained with self reporting, contact tracing, home quarantining and isolation because once indigenous transmission that can’t be traced back to a source begins in smaller towns and rural areas, it will be very difficult to contain, as is evident in South Korea, Italy and now the United States,” said Dr Randeep Guleria, director and professor of pulmonary medicine at All India Institute of Medical Sciences (AIIMS), New Delhi.

“Before that happens, apart from identifying hospitals and trained medical staff, we will need to convert wards into isolated ICUs and ensure large scale availability of ventilators to treat the 5% of patients who need hospitalisation,” he added.

India is ill prepared to contain widespread Covid-19 transmission in the community because of a huge shortage of doctors, healthworkers and hospital beds, especially in rural areas and densely populated underserved states. India has 1.1 million allopathic doctors registered with the Board of Governors/State Medical Councils/ Medical Council in December 2019, according to the National Health Profile 2019.

“Assuming 80% availability, it is estimated that around 9.26 lakh doctors may be actually available for active service,” said

minister of state for health and family welfare Ashwini Kumar Choubey in the Lok Sabha last year. The availability is always lower because some retire, some move to hospital administration, while others go overseas without getting their names struck off the register.

For a population of 1.36 billion, this makes the doctor-population ratio 1:1,457, which is lower than the WHO recommended norm of 1:1,000. For people living in rural areas completely dependent on government hospitals and clinics, the government allopathic doctorpatient ratio is 1:10,926, according to the National Health Profile 2019.

In addition to doctors, India has a little more than two million (2,048,979) registered nurses and midwives, many of whom need infection control training to care for patients with airborne infections. “My concern is large clusters of cases, of which around 20% will need hospitalisation and around 5% will develop severe pneumonia that will need ICU support. In such a case, the challenge will be scaling up treatment capacity keeping in mind infection control as Covid-19 infection in healthcare personnel in China and in Canada during the Sars outbreak is disproportionately high,” said Dr G Arunkumar, director, Manipal Institute of Virology, Karnataka.

“The availability of physicians and nurses varies widely across the country, with the central, northern, eastern, and northeastern states being poorly served. Rural areas have an especially severe shortage of qualified health professionals,” added Dr Srinath Reddy, president of the Public Health Foundation of India. The training, accreditation and quality assurance of health professionals and health infrastructure also varies widely within states, cities and neighbourhoods.

Covid-19 diagnosis is currently being done at India’s network of 19 viral influenza surveillance laboratories. “India has enough labs for testing and can make another 19 labs functional within two days, and take the number to 50 labs within days,” Union health minister Harsh Vardhan said on Monday.

The All India Institute of

Medial Sciences is part of the network of labs testing for Covid-19, along with the National Centre for Disease Control in north Delhi. “AIIMS tested at least 300 samples over the weekend, so diagnosis is not a problem. If and when there’s more demand, diagnosis can be outsourced to the private sector,” said Dr Guleria.

The risk from airborne infections in labs, ICUs and isolation wards during outbreaks carries huge risk for health workers. “When patient load increases during outbreaks, health personnel are often drawn from

other departments. But even trained staff may overlook an infection-control step when a patient suddenly needs supportive care, such as revival from a cardiac arrest,” a health ministry official said on condition of anonymity.

“China can build a 1,000 bed hospital in a week, but can we do that? No. We are lucky these cases have been identified in large cities. If it had been a smaller city or town, we would have realised we had a problem after patients had started to die,” said a doctor at RML hospital, requesting anonymity.

› Rural areas have an especially severe shortage of qualified health professionals

DR SRINATH REDDY, President of the Public Health Foundation of India