Depending on big hospitals to provide most of Post-COvid care is setting ourselves up for failure. Community-based facilities, in or near PHcs, would be more accessible
Even as governments and epidemiologists in several countries are worrying over a second wave of Covid-19, clinicians are concerned that SARS-CoV-2 does not waive off the suffering of patients when the acute episode is over. Several persons who have recovered from that attack are now complaining of continuing ailments that vary in severity but last long after the virus has been seemingly eliminated from the body. This condition is now being referred to as ‘Long Covid’ by doctors, patients and media. Persons experiencing symptoms of prolonged illness are being designated as ‘Long Haulers’.
Estimates of what proportion of patients fall into this category vary from surveys in different countries, depending upon the symptoms being reported. A survey conducted in Bristol, UK, had 81 out of 110 patients reporting continuing symptoms three months after their discharge. In another study in Italy, of 143 hospitalised patients, it was reported that at least one symptom persisted two months after discharge. Many persons who could not get tested, but had an illness very suggestive of Covid-19 are also among those reporting their drawn-out battles against the disease.
Chronic fatigue was the most common symptom in most reports, with breathlessness and muscle aches also featuring prominently. Effects on mental health have also been reported, ranging from intermittent ‘clouding’ of the mind to loss of cognition. A combination of muscle pains, debilitating chronic fatigue and brain fog goes by the name of myalgic encephalomyelitis. Diabetes has been observed as a result of damage to the pancreas. Deep vein thrombosis has been reported, disabling by itself, but dangerous when clots travel to the lungs to cause a pulmonary embolism. Several hospitals have reported heart attacks and strokes in the acute phase, with considerable residual disability.
Multiple reports have emerged, noting chronic sequelae varying from 5% to 90% of hospital discharged patients a month after discharge, depending on the type of search conducted for symptoms and signs. Contrasting with this are reports which are not confined to hospitalised patients. They observe that majority of infected persons recover with mild or no symptoms. However, even persons who have seemingly recovered well clinically have been noted to reveal damage to the heart or lungs on investigation. Areas of fibrosis have been noted in the lungs on CT scans. Heart muscle injury has been observed on imaging studies, as a result of direct injury by the virus or immunologically mediated inflammation of the heart muscle. Even at younger ages, the virus seems to leave footprints of damage which are visible only on investigation. The long-term effects of such damage still need to be studied.
The persistence of symptoms, with varying degrees of disability, poses a challenge to the health system in terms of providing chronic care. In many, these symptoms are superimposed on pre-existing conditions like high blood pressure, diabetes or cardiovascular disease. Even in those without the prior disease, a constellation of symptoms will call attention to the derangement of multiple body systems. This calls for the provision of chronic, continuous, integrated care. Are we capable of delivering that?
Hospitals in big cities are preparing themselves for delivering long-term care to such persons, through special post-Covid clinics. However, there will be many who will not have access to such hospital care, even in the cities. Major hospitals will have their hands full dealing with acute cases and non-Covid patients. In smaller towns and villages, such facilities will not exist. The challenge of chronic care threatens to overwhelm both patients and care providers. Even under usual conditions, hospitals are configured to provide acute episodic care. They also perform surgeries and advanced diagnostic procedures. Obstetric care is getting increasingly institutionalised. Hospitals are, however, not designed to provide chronic care for healing or palliative care. That is the arena of primary care.
Depending on big hospitals to provide most of the post-Covid-19 care is setting ourselves up for failure. Under the National Tobacco Control Programme, the government had set up tobacco cessation clinics in big hospitals. Which daily wage worker, office employee or student visit a hospital to get tobacco cessation services? Community-based facilities, located in or close to primary healthcare facilities, would be more accessible. Would tuberculosis control succeed if medicines were to be distributed only in large hospitals? Easy access is an essential ingredient for the success of any health service.
This is where the strength of our primary care system will be tested and its weakness exposed. Ideally, such patients should be provided with care at home or near home. When multiple health conditions co-exist, the affected person should not be made to chase an army of specialists. Indeed, much of the required care can be provided in a primary care setting. That also makes continuity of care and integrated care possible, bringing familiarity between the patient and provider and an understanding of the interaction between the various health problems in an individual as well as between their prescribed treatments. It is well recognised in theory, but not well heeded in practice that a drug prescribed for one condition can aggravate or complicate another condition.
Think of a 62-year-old person with high blood pressure and diabetes and symptoms of osteoarthritis of the knees. If a male, enlargement of the prostate with urinary symptoms may be a bother. If a woman, post-menopausal symptoms may be causing concern. In such a situation, even those existing combinations of health problems will require regular composite care that does not involve rushing to the hospital frequently. Similarly, post-Covid symptoms too need care close to home, even if the patient did not have co-morbidities earlier. As more Covid-19 survivors return home, the need for primary care grows.
There are models for such care in the health systems of other countries where multiple health conditions co-exist in a person, usually more common among the elderly but not limited to them. Trained nurse practitioners and physician assistants are among those who provide such integrated chronic continuous care. If they are technology-enabled, they can perform point of care diagnostic testing, monitor progress and use decision support systems loaded on to their handheld devices to provide management advice. They can tele-consult with specialists as needed. Management and clinical outcomes of hypertension, heart disease, diabetes and asthma have been shown to improve through such close to home support in primary care.
We cannot foresee how long the threat of Covid-19 will loom large over our health system and society. However, even after this virus exits or loses steam, there will be other threats to health which will call for strong primary healthcare systems. Let us not lose this opportunity to start investing in strong rural and urban primary healthcare systems. They will help to promote, protect and preserve health in the population and to restore health substantially in those who have suffered an illness. Even if some persons need advanced care at some stage for an illness, primary care is where they need to return to. Long Covid too shows us that the distance from home to the point of regular care should not be long.
Author is a cardiologist and epidemiologist & President, PHFI. He is the author of Make Health in India: Reaching a Billion Plus. Views are personal