Article In Brief
Neurologists in India discuss the challenges of battling COVID-19 in the setting of complex and decentralized health systems, poor economic conditions, and gaping disparities by caste, class, and gender in access to health care.
In India—where almost 1,000 AAN members practice and more than 1,000 US neurologists have completed their medical school education—the COVID-19 pandemic is now said to be spreading more quickly than anywhere else in the world. Over 6.7 million people have been diagnosed with COVID-19, and with only one government physician for every 10,189 people—one-tenth of the World Health Organization recommendation of a ratio of 1:1000—some experts say many patients have been left to fend for themselves.
By mid-September, the daily cases in India had risen to almost 100,000, as the government eased restrictions to recover from the economic devastation brought on by the pandemic.
To get an on-the-ground look at conditions in the country, where approximately 2,000 neurologists serve a population of 1.4 billion, Neurology Today spoke to a half-dozen neurologists who agreed to share their experiences. Many more were too stretched thin to talk. Those who did described the challenges of battling the virus in the setting of complex and decentralized health systems, poor economic conditions, and gaping disparities by caste, class, and gender in access to health care.
Ravindra Kumar Garg, MD, DM, is professor and head of the neurology department at King George's Medical University—a 3,000-bed tertiary care teaching hospital— in Lucknow, the largest city in Uttar Pradesh, the most populous state of India. With 270 million residents, the state had at press time about 6500 new cases of COVID-19 per day and 100 deaths per day.
In his department, faculty and residents of all non-clinical, para-clinical, and clinical departments have been recruited to care for COVID-19 patients. Most were severely affected by the pandemic either directly or through relatives. Three of his colleagues had confirmed COVID-19, and two senior faculty members were admitted to the ICU. Many residents acquired COVID-19 while at work and were isolated in separate wards. “All have recovered; however, that was a very traumatic period for their families and for us,” Dr. Garg said.
Lucknow has three large teaching institutions and was adequately equipped with facilities for ICU care before the pandemic. “However, with the advent of COVID-19, these facilities were far short of what was required,” he said. “At the start of the pandemic, the health infrastructure in my state was not up to the mark,” said Dr. Garg. In several districts, there were no ventilators; in others, ventilators were either non-functional or lacked the trained personnel to run them, he explained.
“Now, the government has ordered these three institutions to have at least 1000 beds dedicated to severe COVID-19, and the availability of ventilators has increased many-fold,” he continued. “Still, these facilities are grossly insufficient when keeping the enormity of the pandemic in view. Likewise, the availability of neuroimaging facilities is a major issue for patients with neurological complications, although newly-commissioned COVID-19-dedicated hospitals are now equipped with the latest CT machines.”
“Health care in India, and in my state of Punjab, is a huge mix of different medical systems with private and public arrangements,” explained epilepsy specialist Gagandeep Singh, MD, DM, FAMS, FRCP, a professor of neurology at a private hospital affiliated with Dayanand Medical College in Ludhiana. “There are Western styles, Ayurveda, homeopathic, Unani, and even mystic practitioners.”
“The per capita income is very low in India compared to high-income countries,” he said. “Most people are dependent on daily wages and hence, were unable to sustain themselves during the complete lockdown, which began on March 24. Rapid and steep economic sliding led the government to ease restrictions, which, in turn, led to the flare-up in COVID cases,” he added.
“In India, poverty has been the root cause of many diseases like tuberculosis, diarrheal disease, malignancies, and other deficiencies,” said Manish Modi, MBBS, MD, DM, professor of neurology at the PostGraduate Institute of Medical Education & Research in Chandigarh, India, which serves a population of more than 150 million people.
“Poverty has been one of the major factors leading to delayed treatment and invariably leads to complications at the presentation. Most people cannot afford to seek medical help despite free facilities by the government and they usually land up with complications. Follow-ups are difficult due to monetary constraints, which leads to poor outcomes in these patients.”
Moreover, Dr. Modi said, the living conditions for many impoverished people—due to poor ventilation in crowded localities and sharing of rooms and washrooms in single-room homes—has contributed to the spread of COVID-19.
When COVID-19 first hit and teleconsultations were started, Dr. Modi said they published helpline numbers in all the newspapers and patients were asked to register on these numbers and seek opinions from spcialists. The specialists reviewed their symptoms and tests through WhatsApp, and sent a copy of the prescription and tests that needed to be done as part of a work-up. But he noted only 400 to 500 patients of 2,000 took advantage of these services.
What was missing, he said, was “the human touch and empathy” that patients look for during a through exam.
What's more, Dr. Modi said, these services would not have helped the many poor people who do not own mobile phones or are illiterate and don't know how to operate a phone.
The lockdown created the greatest reverse migration in human history, according to Dr. Gagandeep Singh. “People who had over years and decades come to large cities from poor villages and some rural states for work, found themselves unemployed, and being daily wagers, were confronted with hunger and insecurity,” he explained. “They decided to move back to their parent states—thousands of miles from their location, and many by foot—that, itself, must have led to the spread of COVID-19 across the country.”
“There has been a major economic upheaval in the country, which is in fact continuing,” said Mamta Bhushan Singh, MBBS, MD, a professor in the department of neurology at the All India Institute of Medical Sciences (AIIMS) in New Delhi, the national capital. “Millions have lost jobs and sources of livelihood, and I am sure they must struggle to get adequate care, especially if they come from smaller towns or villages that do not boast of any level of functional healthcare infrastructure,” she explained.
Fragile Health Infrastructure
India has a decentralized approach to health care, where its states are primarily responsible for services. A June 2020 profile by the Commonwealth Fund reported that many households try to seek care from private providers and pay out-of-pocket due to severe shortages of staff and supplies. Cities and urban areas have a more robust private health care system compared to lower-funded public health facilities in rural areas, where more than 60 percent of the Indian population resides. Poor states have the most limited health care infrastructure, a high level of communicable and respiratory disease, and their residents have more comorbidities such as hypertension and diabetes, leaving them most vulnerable to COVID-19.
“Before the coronavirus pandemic, we saw a lot more patients in our clinics than our US counterparts: Daily rounds of 15 inpatients and 40 to 60 outpatients were fairly typical,” Dr. Gagandeep Singh said.
Underreporting of COVID-19
Dr. Mamta Singh, who runs an epilepsy clinic at AIIMS, pointed out that the Indian Council of Medical Research has conceded that for every reported confirmed COVID-19 case, there may be 80 to 120 unreported cases. “While the official numbers show one-quarter of a million people infected in Delhi, all emerging data is definitely an underestimation,” she continued.
The neurologists who spoke with Neurology Today all commended the rapid speed at which testing for COVID-19 was scaled up. “Testing has been ramped up from a few thousand a day in the month of March to nearly one million per day at present,” said Dr. Gagandeep Singh. “This is a good achievement, but if you consider the total population of India, we are doing less than one test per 1,000 people, much below the US and other countries.”
“People are not getting tested, either due to fear of being stigmatized by COVID-19 or because they are unconcerned or uninformed and refuse to believe that the disease can have intense consequences,” he explained. He also pointed out that testing has not yet reached villages, where more than 60 percent of the population resides, which he suspects is largely due to its stigma.
Dr. Garg also believes that the reported numbers of COVID-19 patients are far lower than the actual figures. “The local administration has started a massive contact tracing program with some success, but even after massive awareness programs by the local administration, a large number of asymptomatic cases or those with mild symptoms are not coming for testing.”
“People try to evade contact tracing of family members and friends by providing incorrect personal information, such as mobile numbers when they are tested for COVID-19,” he continued. “We need strategies to prevent further expansion of this pandemic. People are reluctant to use face masks, and large gatherings are frequently taking place despite a mass awareness programs initiated by the government.”
Disruption of Care
“Neurology services have been severely disrupted by the pandemic; all outdoor services have stopped, and instead, we are trying to provide consultations on mobile phones, through emails, and via our telemedicine facilities,” Dr. Garg said.
Although the number of ischemic strokes has gone down, disproportionately more patients with brain hemorrhage are presenting to the emergency department, he said. “Another major change we have noticed is that tuberculous meningitis patients are presenting with a much more florid and disseminated tuberculosis.”
Dr. Garg's emergency department is also seeing large numbers of patients with metabolic encephalopathies such as hypoglycemic encephalopathy and many of these patients are infected by SARS-COV-2 as well. (SARS-COV-2 testing is performed in all patients who arrive for emergency care.)
“Before COVID, there were six faculty members and six to eight neurology trainees in any of our clinics, which were held six days a week; each faculty and resident had a minimum of ten registered new patients and about 25-40 follow ups per day,” Dr. Mamta Singh said.
AIIMS is a government-subsidized teaching institution that provides tertiary level care, she explained; treatment is almost free and if there is a charge, it is very nominal. A non-contrast CT head runs about three US dollars, whereas an MRI of the brain costs about 50 US dollars. All neurology services, except emergency admissions, stopped for about a week in the beginning of April after India went on nationwide lockdown.
“We had no teleconsultation services prior to the pandemic but in mid-April we started to conduct outpatient virtual visits,” Dr. Mamta Singh said. In July, they resumed physical (in-person) outpatient visits with prior appointments while teleconsultations also continued.
“The numbers both for indoor and outpatient never reached pre-COVID levels, and recently, there has been an increase of COVID numbers and non-emergency admissions have been again paused for the past two weeks, “ she said.
“The numbers are slowly picking up now,” said Dr. Gagandeep Singh. “Neurologic admissions are still down about 70 percent due to patient fear of exposure driven by poor faith in the health care system and also by economic deprivation as many people were left with little cash and have been unable pay out-of-pocket expenses.”
Arvind Kumar Kankane, MD, DM, associate professor in neurology at Maharani Laxmi Bai Medical College in Jhansi, Uttar Pradesh, practices in the government-run medical institution. “Jhansi district and the surrounding area is underprivileged, and approximately 70 percent of the population live in rural areas.”
“Before COVID, we were seeing almost 100 patients of various neurologic illnesses in each outpatient department, and admitted about five to seven patients daily,” he said. “All health services have been taken over by COVID these days and our superspecialty block building has been converted into a dedicated COVID hospital; the only services we are now able to provide patients is telemedicine outpatient evaluations and emergency services.”
The impact of COVID is also felt at the Sree Chitra Tirunal Institute for Medical Sciences and Technology in Trivandrum, where Sanjeev V. Thomas, MD, DM, professor and chairman of the department of neurology, practices. As a tertiary care center, it focuses on medical research and technology development under the federal government of India and has a 240-bed hospital that caters to cardiac and neurologic disorders, with active epilepsy, stroke, movement disorder and interventional radiology sections.
“At the onset of COVID, we had to restructure our outpatient and inpatient services and conduct all follow-ups via telephone, email or video,” Dr. Thomas said. “The hospital separated suspected COVID patients from those who were tested negative and cared for them in two different areas in the outpatient and inpatient locations. “
“Some patients were unable to attend due to travel restrictions or other limitations created by the pandemic,” he explained. But at the tertiary care center, economic factors do not generally interfere with care, he added.
One bright spot, according to those interviewed, was that personal protective equipment (PPE) was not in short supply. “The Indian small sector industry responded quite rapidly to the crisis by scaling up the production of masks and PPE,” Dr. Gagandeep Singh said, adding, “in fact, garment industries transitioned from cloth manufacturing to PPE manufacturing in order to meet the need.”
”One friend from the garment industry informed me that they now have a surplus and are unable to find buyers...this speaks volumes about the versatility of the Indian entrepreneurship,” he said.
It is also noteworthy, for reasons that are not yet clear, that India appears to have one of world's lowest mortality rate from COVID-19: 1.7 percent compared to 3 percent in the US, 11.7 percent in the UK, and 12.6 percent in Italy, according to Johns Hopkins University.
While the government claims the low mortality rate is a sign of success in handling the pandemic, some experts attribute the statistics to poor and incomplete death records and the fact that most people in India die at home, not in a hospital, so doctors usually aren't there to assign a cause of death. “But interestingly, universal BCG immunization may have a protective effect in COVID-19, resulting in comparatively low mortality despite the high infection rate,” Dr. Garg suggested.
Finally, as in many places globally, the high infection rate has fortified the medical community. One of many organizations to get involved is the Association of Indian Neurologists in America (AINA)—an organization whose mission is to advance the art and science of neurology and promote the best possible care for patients with adult and childhood onset neurological disorders in the USA, India, and other countries. The AINA has created CME talks for neurologists in India, and in an agreement with the Indian Academy of Neurology, trains young Indian neurologists in the US.
Sanjay P. Singh, MD, FAAN, FANA, chairman and professor of the neurology department at the Creighton University School of Medicine, is the current AINA president. He conducts free medical camps every year in underserved regions of India; these camps include free patient care and local physicians' training. “I am currently also advising the health department of a state government in India about the COVID response,” he said.