The COVID-19 pandemic has massively disrupted our lives. Besides direct devastation of health, the epidemic and the lockdown have had myriad indirect effects, be it on the environment, livelihoods, or supply chains. There has been a lot of discussion around the lack of capacity of our health-care system to fight this epidemic. But the impact of COVID-19 and the lockdown on the ‘business’ of health care has not been examined. This has an important bearing on the larger arena of health care for our citizens in the near future.

Care and the COVID impact

Indian health care has been increasingly privatised over the last few decades. This has led to intense market competition. A uniquely unregulated form of health care has thrived. It has also been marked by several questionable practices. These have been under the media and public glare leading to a huge trust deficit. Will the changed milieu have an impact on this? How will this affect care of other conditions?

COVID-19 has led to a dramatic reduction in the numbers of patients seeking care. This is especially true of planned, non-urgent problems including procedures and surgeries. Many patients are scared to visit health facilities fearing COVID-19. While this has caused collateral damage, with the condition of some patients worsening or taking an unfortunate turn, there may indeed be those who have avoided interventions without any deleterious impact. In other words, they have been spared of procedures for debatable indications. For example, the large number of women who undergo an unnecessary hysterectomy has reduced. The incidence of Caesarean sections is reported to have gone down. Similarly, procedures such as coronary stents, knee replacements or cosmetic surgery which reflect supplier-induced demand have almost stopped. ‘Routine’ admissions for ‘observation’ or ‘insurance claims’ have got curtailed.

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Strangely, even emergency medical cases have declined during the lockdown, with a decrease in the cases of heart attacks or strokes presenting to hospitals. While some of these may have been true emergencies involving those who suffered at home, perhaps the unpolluted air, decreased work stress, or home-cooked food has had a bigger impact on health than we assume. Or maybe we were over-diagnosing and over-treating certain emergencies. Investigating these important questions and critically analysing their answers may make future health care more beneficial to patients.

The cartelisation of health care has been naturally curbed during the pandemic. ‘Cut practice’, with doctors and hospitals prescribing tests, drugs, referrals and procedures in return for commissions, is entrenched in India. This leads to significant negative consequences, be it increased patient expenses, patients not reaching the right doctor or not getting the appropriate investigation, and also an erosion in the doctor-patient relationship and the image of the fraternity. It puts ethical doctors in a quandary, making them cynical about their profession. However, during the pandemic, the availability of doctors, beds and proximity are now the chief drivers for patient referrals, rather than the commission route. Most practices have had to take a forced ‘detox’ of sorts from this addiction.

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Like in life, there are several grey areas in treatment decisions, where doctors are not sure of the best way forward for the patient. For example, terminal patients with widespread cancers are often prescribed chemotherapy, which can cause side-effects worse than the disease, without impact on life span or quality of life. Oncologists often end up prescribing chemotherapy to such patients instead of symptomatic treatment to alleviate the pain and weakness because of the urge to ‘do something’, or even financial imperatives. The dangers of chemotherapy with COVID-19 lurking in the air has made everyone weigh its pros and cons with more caution than usual.

The widely prevalent practice of a ‘health check-up’ which does not have proven public health value but is a tactic which targets health-obsessed ‘clients’, has also got derailed. The focus has instead fortunately moved back to the basics of preventive health such as diet, exercise, good sugar control, and quitting smoking and tobacco. The pandemic may have finally taught our population the importance of not coughing or spitting in the open. These may indeed have more far-reaching benefits in a much larger population.

The two sides to the churn

The COVID-19 epidemic has centre-staged the need for a robust public health system and increased investment. While disrupting care, it may have unwittingly lead to some ‘desirable’ changes by the circumstantial curb on unwarranted medical practices. This churning may even led to genuine reflection among health-care providers. The question is whether this effect will linger on. Will lessons learnt during the epidemic nudge us towards rational and ethical care?

However, there are dangerous fallouts of the disruption as well. The breakdown of overburdened health-care facilities, negative impact on the morale of health-care workers, and the collapse of private sector institutions (under financial strain) are all real. With hospital and doctors incomes falling during the pandemic, there may be a resurgence of unethical practices with a vengeance as the industry tries to make up its losses. This is already evident in the huge bills that patients with COVID-19 are being slapped with, often by creating additional billing heads. Though prices in the private sector have been capped, loopholes in the system may be found, such as profiteering on personal protective equipment. Artificial demand maybe created in an effort to increase footfall. Thus, the epidemic’s ‘positive’ impact on unnecessary practices may get washed away as ‘normalcy’ is restored.

In general, the medical fraternity in India has risen admirably to the challenge of COVID-19. The call of duty has led many to don Coronavirus warrior outfits and set aside commerce for now. It has forced them to consider alternative paradigms. Public respect for the profession has also improved. If we can seize this chance to correct undesirable practices, which have become an albatross around our neck, it may help the return of trust in the doctor-patient relationship, which was under severe threat before the pandemic. In the middle of gloom, this is a window of opportunity. Is this just wishful thinking or a genuine possibility? We should know soon.

Dr. Akshay Baheti is a radiologist practising in Mumbai. Dr. Sanjay Nagral is a surgeon practising in Mumbai