Discussion
Covid-19 pandemic has posed a huge medical challenge about which there is awareness in society, but social and economic facets of the challenge also have to be kept in mind while devising strategies to deal with it.11 LMIC are struggling in their fight against Covid-19 pandemic as number of infected are rising with each passing day.10 Third world is showing an uptrend in five day moving average of the daily confirmed new cases with India leading in numbers at present, aptly necessitating the need for such a study. The current pandemic has stretched public health system with strains on man, money and material, especially the supply chains of PPE kits in every affected country.12 LMIC usually have a shortfall of public spending on healthcare7,13 and beyond doubt this pandemic is stretching the already strained healthcare system in these countries. With out of pocket expenditure forming a significant part of total healthcare budget, there is no doubt that the pinch is being felt by patients and healthcare providers alike.14 Large population, disease with high infective potential, escalating number of cases and scarcity of resources makes fight with Covid-19 in LMIC, unique in many ways.
High level of awareness about ‘Covid guidelines’ among ORLs who participated in the survey goes along the expected lines, with the extensive mass media exposure this pandemic has got across the globe.15,16 Lack of unanimity among participants about source of these guidelines underlines the need for a set of comprehensive guidelines addressing the practical, psychological and economical aspects of ORL practice in limited resource settings. These guidelines can be issued by one of the professional association or the statutory body like Medical Council of respective country or Ministry of Health.
Ear, nose and throat (Otorhinolaryngologists, ORL) doctors were among the first medical victims in Wuhan and according to press reports, ORL doctors continue to die as a consequence of contacting the infection during patient care.17 Undoubtedly majority of ORL in the present survey were not in favour of opening up of regular OPDs during the lockdown. However among those who favoured opening up, private doctors comprised significantly higher number, possibly explained by poor financial reserves of private healthcare establishments across the country.18 Apart from the popular perception of no pressure of resource generation on government doctors there can be another reason for government doctors not favouring regular OPDs: overcrowding in government hospital out-patient-departments in LMIC thereby making it difficult to follow social distancing norms. Infective potential of asymptomatic Covid-19 patients with possibility of getting infection and potential transmission to family members emerged as the major fear amongst ORLs in this survey. Similar fears for own and family member’s life has been reported by various authors in the present pandemic as well as previous epidemics like SARS.19 In house facility for Covid testing and treatment are the most significant factors that can alleviate the fear of ORL responding to the survey. Hence it will be safe to conclude that widespread availability of testing and treatment can go a long way in removing the fear amongst practicing ORL in LMIC. With about half a million Covid tests being done daily,20 in the country of survey (India) the figure does not compare favorably with the figures reported by various other counties.
This survey has found that majority of ORL know that ENT examination and surgeries carry high risk of viral exposure due to proximity and aerosol generation but still they are using only gloves and N95 mask as protective gear. They are not in favour of running routine out-patient-departments till they get adequate personal protective kits, to deal with present pandemic. Despite the shortage of PPEs and cost escalation, majority are performing emergency procedures, few even without proper personal protective kits. Apart from high professional commitment this may also indicate a severe crunch in availability and affordability of PPEs in LMIC.
Cost of treatment remains an important factor for those working in private sector compared to government sector as Indian healthcare system is very price sensitive because of out of pocket expenses by large section of population.14,21 Almost in every LMIC various reports in media have pointed to acute shortage and poor quality of PPE both in government and private sector, this may be adding to the fear of the ORLs. 22,23 Similar reports of short supply and rationing of PPE for protection of healthcare workers have come from various other countries also.24,25,26Long term interventions at strengthening the PPE supply chain at affordable cost have to be considered by the policy makers to tide over this crisis as well as prepare for any future outbreaks of diseases.
The cost of PPE is being borne by hospitals, which will strain the economic equation in a price sensitive setting like India and other LMIC, thus adding to the stress of those working as healthcare professionals in these countries. There are large numbers of reports coming regarding the poor financial conditions of private hospitals irrespective of the size of hospital. There are also demands of a relief package for healthcare industry in India as their balance sheets are being stretched.18 Even in United States and Europe, along with fear of overwhelming of healthcare infrastructure by sheer numbers, affordability of Covid-19 treatment by the patients and the financial viability of the private healthcare providers has added another dimension to the problem.27 In countries with limited resources, every policy intervention needs to take into account these factors so as to win war against Covid-19.The higher stress levels among the senior most and junior most doctors as compared with the middle level doctors, observed in this study, can be explained by the fact that the senior doctors have the responsibility of carrying out the services despite hospitals facing financial difficulties and deficiencies in the supply chain related to PPE, and the junior most ORLs are the frontline doctors and would be examining the patient first of all and thus have higher risk of contracting the infection.
The strength of this study is that this is the first such study from a LMIC that provides the evidence on psychological and economical impact of the Covid -19 pandemic among ORLs. However, larger studies with representative samples need to be planned to give generalizable results.