It is now well established that non-communicable diseases (NCD), like diabetes mellitus, hypertension,, respiratory and heart disease, particularly among the elderly, increase the susceptibility to Covid-19 disease. Mortality in 60%-90% of the Covid-19 cases is attributed to either one or more of these comorbidities. However, healthcare management for control of Covid-19 involves public health and policy decisions that may critically undermine the existing health needs of the most vulnerable NCD patients. Temporary closure of outpatient health facilities in some secondary and tertiary care hospitals have deprived millions of NCD patients of their regular medication and diagnostic health needs. The lack of robust primary healthcare facilities in most states, and the failure to maintain physical distancing norms due to inadequate infrastructure is also problematic. In the absence of effective public health interventions, socioeconomically vulnerable patients are likely to become non-adherent increasing manifold their risk of disease complications.
In this context, the feasibility of dispensing longer than usual drug refills for chronic NCD conditions at functional government health facilities, home delivery of essential drugs, running dedicated NCD clinics at PHCs, and utilisation of telemedicine opportunities for care and support to patients warrant aggressive exploration.
Keywords: Covid-19, NCDs, Medical ethics, epidemic, India
The novel SARS-CoV2 since its origin in December 2019 in Wuhan, China continues to cause large scale morbidity and mortality globally, through a respiratory infection that is transmitted via droplet infection and causes pneumonia-like illness (1). The resultant Covid-19 pandemic-related worldwide burden as of April19, 2020, stands at 23,74,141 positive cases and 1,63,272 deaths (2).
It is now well established that non-communicable diseases (NCD) like diabetes mellitus, hypertension, respiratory (COPD / bronchial asthma), and heart disease, particularly among the elderly, increase the susceptibility to Covid-19 disease (3). According to global estimates, a high risk of mortality in Covid-19 cases is attributed to either one or more of these comorbidities (4, 5). Risk factors for NCDs like cigarette smoking and the harmful use of alcohol may also increase the susceptibility to Covid-19 disease.
However, there is growing recognition that the lack of guidelines for effective programmatic management of NCDs during this pandemic can hinder efforts in combating both these ongoing epidemics (6). Furthermore, in developing countries like India, which cumulatively account for 80% of the global NCD burden (7), the challenge of maintaining continuity of care in NCD patients at the time of the Covid-19 pandemic acquires enormous significance in the context of patient health outcomes and upholding public health ethics.
Ethical dilemmas in managing NCD conditions like diabetes mellitus in resource-constrained environments involve issues relating to lack of continuous medication supplies, diagnostics for follow-up, and associated clinical inertia or the failure to sufficiently intensify the medical therapy when the patient is not meeting his/her therapeutic targets.
Socioeconomically disadvantaged patients are most vulnerable for failing to meet their self-care, particularly medication adherence requirements (8). However, healthcare management for control of Covid-19 involves public health and policy decisions that may critically undermine the existing health needs of the most vulnerable NCD patients.
Efforts in containing the Covid-19 epidemic have required the strict implementation of lockdown and physical distancing requirements to prevent contagious patients coming in contact with the susceptible cohort. Similarly, in India, authorities have announced a temporary closure of outpatient facilities in government secondary and tertiary care facilities, while some of them have been converted into dedicated Covid-19 hospitals (9). However, millions of NCD patients across India are dependent on the public health system for medication refills that are needed for the management of their condition throughout their life. Government hospitals cater to a considerable proportion of such patients who may lack any other means of procuring their medication supplies (10). Patients with lower socioeconomic status (SES) are vulnerable to medication non-adherence and adverse health outcomes but the problem can be particularly exacerbated during the ongoing Covid-19 epidemic due to loss of jobs and wages coupled with disruption in their usual sources of drug access. Consequently, any additional out of pocket costs imposed on such patients can reach a catastrophic level. Non-adherent patients having NCDs have a manifold higher risk of complications resulting from uncontrolled disease. However, when patient non-adherence is unintentional, and due to lack of access or affordability of medication, it indicates a failure to uphold the principle of distributive justice through equitable distribution of resources.
Robust primary healthcare can be a valuable alternative resource for obtaining follow-up care and medications for patients with NCD belonging to low socioeconomic status. Nevertheless, a significant proportion of primary healthcare facilities in India have suboptimal infrastructure, which is not conducive to maintaining the physical distancing requirement of at least 1 meter between patients (11). These include the lack of multiple entry and exit points, limited seating and queuing facility, especially at a time of higher than usual patient load, and ineffective airborne infection control measures. These risks are likely to be accentuated in districts having hotspots, clusters, or during community transmission of Covid-19. NCD patients may, therefore, continue to be at persistent risk of Covid-19 while attending PHCs/CHCs for meeting their health requirements. This undermines the principle of non-maleficence or doing no harm to the patient by failure to prevent unnecessary exposure to the risk of disease.
The feasibility of these urgent corrective steps needs to be explored:
• Developing equitable solutions for population-based NCD management at the time of the pandemic is one option. Dispensing longer than usual drug refills for chronic NCD conditions at functional government health facilities must be considered. Public health facilities in India usually provide short duration medication drug refills ranging from 2 to 4 weeks to patients with NCDs (10). Dispensing prolonged duration refills with quarterly patient follow-up has well-established safety without any detrimental effect on patient health outcomes (12). However, arranging a significantly larger volume of drug inventory at short notice would also require a considerable mobilisation of scarce resources. Nevertheless, the benefits of decongesting outpatient health facilities, and achieving social distancing in immunocompromised and vulnerable patients who are highly susceptible to Covid-19 is ample justification for pursuing such a policy.
• The government can also utilise the vast network of its quality assured generic medicine distribution platform, the Jan Aushadhi Kendras for distribution of medications, while temporarily waiving costs if necessary for poor patients (13). Non-government organizations, health volunteers, and community health workers can also contribute towards the doorstep delivery of essential drugs for NCD management to the socioeconomically vulnerable patients, the elderly, and those lacking mobility and social support.
• Preventing patients seeking NCD care from coming in contact with patients reporting with flu like illnesses or suspected Covid-19 cases is essential for their protection. This would also ensure higher beneficence while reducing the risk of violating non-maleficence. Nevertheless, running dedicated NCD clinics can be problematic due to the risk involving overcrowding of patients. In this regard, assessing the feasibility of outpatient operations, which minimizes the risk of nosocomial novel coronavirus infection among patients with NCDs should be considered by the medical officer in charge of the individual health facility.
• Telemedicine can be leveraged for the provision of medical consultation to NCD patients in the absence of physical appointments for the alteration of their drug regimen, interpretation of blood investigations, and adherence support. These facilities can be explored across various audio-visual, telephonic, and internet-based mediums (14).
In conclusion, the failure to address and sufficiently resolve the barriers in attaining acceptable levels of care and management of patients having NCDs at the time of the Covid-19 pandemic represents a grave public health concern. The situation also highlights a unique intersection of public health ethics with the principles of biomedical ethics. Formulation of any relevant health policy must avoid neglect and tighten focus on this highly vulnerable population for the fulfilment of their essential health needs.