Vijay Gopichandran, Sudharshini Subramaniam, Vinod H Krishnamoorthy
Today the rural clinic was very busy. Between the three of us who were in the clinic, we saw more than 100 patients, some of them with very complex problems. One of the patients we saw today was a 50-year-old lady, Kamala (name changed for confidentiality purposes) with fever, cough, and breathlessness for a week. Even as you are reading this, we know the word that is ringing in your mind – Covid-19. The lady belongs to a very poor family, as do most of our patients. She has no history of travel anywhere beyond the nearest town, nor did she have a history of contact with anyone with travel or diagnosed Covid-19. So, we started treatment, as we would for a typical community-acquired lung infection. To anyways be on the safer side, in case community transmission of the virus had started without us noticing it, we advised her and her daughter on home isolation. The daughter’s reaction surprised all three of us in the clinic.
“Doctor, what you are saying is not practical. Our house is a little hut and all four of us live in the same room. We have enough room just to lie down and sleep. Keeping a 1-meter distance is impossible. Three of us are women and it is not safe for women to sleep outside the house. There is also the threat of scorpions and snakes outside.”, she said.
“Ok, at least keep your mother at home till she becomes better. Otherwise, she will actively spread the infection to others wherever she goes”, we responded.
“But doctor, all four of us go to work. Even if all of us go to work every single day, we barely make enough money to sustain us. My amma goes to graze the few goats that we have. Rain or shine, sick or healthy, she must go out to graze the goats”, she replied.
At the end of this little conversation, we understood how impractical social distancing is, for a vast majority of the poor population with whom we work. Right after this lady came another woman, of about the same age. She did not have a fever. But the conversation we had with her, made us understand that even she wouldn’t have managed to home-isolate herself or distance herself from others if she were to make a decent living. We realized that for the poor, the more they were close to others, the better their chances of navigating their complex lives.
“I work as a gardener in the public garden in Village A. I got there at 8 AM every morning and come back by 5 PM in the evening. For this full day’s work, I earn Rs. 320 per day. Even now I just finished half a day’s work and earned Rs. 200. I have brought that money with me to buy my medicines.” she said. For this woman, a day’s wage means better food, medicines for her diabetes and the ability to travel to the clinic to get a monthly physician’s visit for her diabetes. The loss of even a day’s wage would mean poor diabetes control and complications. Such people already live in a very precarious balance of health and illness.
In the past month or so, we have seen information about Covid-19 setting the social media and mainstream media on fire. There is coronavirus everywhere in the news. In the past few days, we have had some interesting discussions and debates with friends about this pandemic and what it means for public health in India and the world. There are people who are spreading alarming information about the projected number of cases, the projected mortality rates, etc. One particular social media post warned that health systems like that of India will come crashing down, people including health care providers will die, and doctors in the ICU will make judgments about who will receive treatment and who will die. On the other hand, there are people who have commented that Covid-19 is a very mild illness and has a low mortality rate. They have remarked that there are far more serious and deadly diseases out there which are the reason for more serious concern. Every day, we have been reading this news and updates and have been moving back and forth between being alarmed, and not so alarmed. Today’s ground reality experience was a slap on my face. Kamala taught us all that what the social media is abuzz with, is a lot of armchair speculation. The reality of the poor and marginalized is very different. Let us take each of the preventive measures that we are advocating to halt the spread of Covid-19 and see how it will impact the poor and marginalized in the field.
While the news, media reports, and social media are filled with news about people hoarding toilet paper and masks, one part of the ground reality in a country like India is completely ignored. That issue is the problem of water scarcity. We spoke to a woman today who does not have a continuous water supply at her home. There is no running tap water for her to wash her hands. When there is no running water, how does someone practice hand hygiene? She must collect water in various vessels in her home and save them for the whole day, till she gets water in the tap outside her home the next morning. What does frequent hand washing with soap mean for such a family? The ability to bathe once daily itself is a luxury in many of these households.
As we were walking in the railway station to board our train to head back home, one scene stuck in our eyes and disturbed us. It was an overcrowded train compartment where more than a hundred people were cramped into an unreserved compartment, some hanging to the railings on the doorway of the compartment and most closely touching each other. The idea of social distancing is alien if not absolutely comic in this situation. Kamala’s story of a small hut with four people closely huddled into it is the reality is most households in rural Tamil Nadu. The Prime Minister’s Housing Scheme which builds affordable housing for the rural poor has provided a roof over the heads of so many in the country. But these houses are small overcrowded shelters. We have visited households where this small 400 square feet, single room shelter has up to 8 people living in it. It is practically impossible to home-isolate anyone in this context.
Most public health advisories that have been released in the past few weeks are highly urban upper and middle class centric. Kamala and her likes, who must get out there to work in order to make a livelihood, cannot work from home, and cannot isolate or quarantine themselves. They must make an everyday decision as to which will kill them – the lack of job, money, food, diabetes medicines – or the largely innocuous coronavirus. The decision seems obvious, even to me.
We read a news piece that highlighted the scarcity of ventilators and intensive care unit beds in Italy and how doctors there are making ethically difficult decisions on who should receive the ICU bed and ventilator and who should not. We are not very much aware of the Italian health system and so shall not comment on it. But making such rationing decisions is an everyday event in the hospitals in India. Every health care provider who has worked in a public hospital has been tormented by the ethical dilemma of rationing of a scarce resource. The dilemma of rationing of ICU beds and ventilators has always existed here, will exist during the Covid-19 pandemic and will continue even after this pandemic is over. This discussion about the scary scenario of the health care provider deciding who should live and who should die should take place during peace times. It must drive the efforts to build resilient health systems. Instead, it is creating a high level of panic now.
By creating a social shut down, and halting the spread of the virus, we will save lives, no doubt, but how many lives will we be harming in order to save those who may be killed by the coronavirus. We can learn about the harms of shutting down from past experiences of shutdowns due to other natural disasters. The most recent floods in Chennai in 2015, saw a shut down of the social and health care system for a couple of weeks. We read reports of so many poor and marginalized people suffering and dying due to a lack of access to health services. We read of interrupted treatments for diabetes, hypertension, tuberculosis, and AIDS, which require an uninterrupted long-term supply of drugs. Such interruptions cause significant harm. While the coronavirus itself has a low mortality rate, the shutdown and mandatory public health restrictions are likely to cause a more serious impact on the lives of the poor and marginalized. If a vast majority (more than 80%) of people who get the coronavirus infection are going to make it safely then we might actually be smarter in allowing the virus to take its course, closely watching and intervening for anyone who might have a turn for the worse. This may be better than harming a vast majority of the poor and marginalized, by restrictive measures. The restrictive public health measures are also unfair because, the poor and marginalized will bear a disproportionate burden, in order to mainly benefit the upper and middle classes.
In such times, it is prudent to practice medicine the way we always have. Do the best that we can, provide support, inform, and help people make informed choices. We must continue to practice isolation where possible, hygiene measures where possible, social distancing where possible. Imposing these on people will only cause more harm than good. What we need is a long-term sustained focus on improving our health system and social determinants of health. The Covid-19 pandemic has instructed us more than ever before, about the need for universal health coverage. Let us stop the infodemic of panic and go to work keeping practical ground realities in mind.
Vijayaprasad Gopichandran email@example.com
Assistant Professor, Department of Community Medicine,
ESIC Medical College and PGIMSR, KK Nagar, Chennai 600 078 INDIA
Sudarshini Subramaniam (firstname.lastname@example.org)
Assistant Professor, Institute of Community Medicine,
Madras Medical College, Chennai 600 003 INDIA