Why is medical care making Covid-hit sicker, poorer in India?

Jugaad” is a Hindi word which refers to using resources frugally yet creatively. From low-cost space flights to cost-efficient cardiac surgery, India has pioneered ways to maximise its limited resources. And yet, as front-line emergency physicians and infectious diseases physicians, we have seen a wasteful misuse of healthcare resources in India during the Covid-19 pandemic, which threatens the health and wealth of millions.

Emboldened by falling Covid-19 cases, the Indian government loosened restrictions by October 2020. By March 2021, there were signs that the virus was resurgent. According to the Johns Hopkins database, India has seen more than 2.8 crore cases of Covid-19 and more than 3.2 lakh deaths by May 31, 2021. More than 50 per cent of deaths have occurred during the second wave and models suggest that these numbers may be underestimates. Heroic Indian healthcare workers, many of them still unvaccinated, are persevering despite the unprecedented shortages of hospital beds, oxygen, and even fever-reducing acetaminophen. Unfortunately, clinicians are using government guidelines based on tenuous or even counterfactual medical evidence, that are resulting in systematic errors.

Anti-bacterial drugs like azithromycin and doxycycline are commonly prescribed despite a lot of evidence that they have no plausible benefits for the viral infection of Covid19. In addition to monetary costs, patients also face health risks from unnecessary antibiotics. For instance, azithromycin may promote dangerous and even fatal changes in the heartbeat pattern.

Antibiotic overuse also propagates anti-microbial resistance, already a major concern in India.

The latest Indian Council of Medical Research (ICMR) recommendations from May 18 still include repeatedly debunked drugs like ivermectin and hydroxychloroquine. These inclusions are entirely inconsistent with the current scientific consensus and should be removed promptly to avoid all confusion. We are heartened that nationally well-known medical leaders like Dr Randeep Guleria, the head of New Delhi’s All India Institute of Medical Sciences, have publicly opposed the use of these discredited Covid therapies. The ICMR guidelines should also be purged of these ineffective drugs to avoid confusion.

The ICMR guidelines also suggest use of remdesivir for in-patients. This drug has not been found to have any mortality benefit, and its benefit in shortening hospitalisation is studied only in the background of adequate supportive care, which is currently available to most Indians. And yet, many Indians are paying $65 (Rs 5,000) for a five-day course and even higher costs on the black market. Similarly, we are concerned about the recent premature emergency use authorisation given to 2-deoxy-D-glucose (2-DG.). Although the government cites success for this drug in clinical trials, these data have not been made available to the public.

Steroids, a cornerstone of Covid-19 therapy, are also being used improperly. The evidence on steroids is clear — they should be given to patients who need oxygen, at a specific dose, and for up to 10 days. In India, steroids are being given early in the disease -before oxygen needs are apparent, at higher doses, and for much longer periods. They can weaken the immune system, worsen diabetes, a disease one in eleven Indians have, and may be implicated in an alarming number of Indians developing a range of fungal infections, including deadly mucormycosis (which is being called black fungus). Fungal infections are not inevitable with steroid use — we did not observe such high rates of invasive fungal infections in the United States when using steroids as recommended by clinical trials.

Indians with Covid-19 are advised to take a large assortment of minerals and vitamins that again have not been shown to be effective. As physicians who cared for patients in the early days of the pandemic in the US, we understand the impulse to “do something” in the midst of so much death, devastation, and desperation. However, having also seen our relatives confused by interminable lists of drugs, we know that seemingly harmless nutritional supplements have opportunity costs — they draw attention away from what is essential. Additionally, given that more than a billion Indians subsist on less than $5.50 (`440) daily per capita, each addition to their medication list must be evidence-based and serve a clear purpose.

We have the utmost empathy for the Indian healthcare workers who are stretched beyond belief and lack the time to research their recommendations and follow the rapidly growing Covid-19 literature. We exhort the Indian public health leadership to promptly take three specific steps to support Indian clinicians.

First, increase public awareness of what to do to care for loved ones at different stages of the disease and keep patients out of hospitals when possible.

NGOs like Swasth and volunteer groups like India COVIDSOS have already developed accessible protocols that can empower Indians to care for sick family members at home, and community organisations to care for patients in Covid-19 care centres, an essential option when hospitals are overwhelmed. Second, the ICMR guidelines must be purged of any therapies that do not stand up to hard-nosed scientific scrutiny. Lastly, the Indian leadership should ensure regular clinical updates to support beleaguered Indian healthcare workers. These updates should come as digestible recommendations straight to the healthcare providers’ phones. Clinicians should be made aware of the cost and the effectiveness of the drugs they prescribe so they can personalise care and share decision-making with patients struggling with the financial burden of Covid-19.

Adversity is the mother of frugal creativity, and it is hard to imagine a time more adverse. Though despondent, we nourish the hope that India can mitigate further misery with jugaad, delivered with clear communication, and backed by scientific rigour.