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.