COVID-19: Stigma, lack of clarity put elderly, people with comorbidities at risk

With 4,184 new COVID-19 cases identified since May 4, the government’s plan to pre-empt the appearance of new cases through surveillance measures is dependent on people voluntarily reporting symptoms to the authorities.

It is an Achilles Heel to a plan that could potentially defeat containment efforts.

In an interview with DH recently, Dr CN Ashwath Narayan, Deputy Chief Minister, Karnataka, said the government had been “focusing on improving health facilities and the general health status of people while ensuring that people do not get infected.”

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This last point is manifested by an ambitious statewide survey to identify all vulnerable households in the state under the aegis of the Department of Health and Family Welfare. Jawaid Akhtar, Additional Chief Secretary to the state government, described the survey as a “proactive measure” to identify all vulnerable households in the state and provide “support” if necessary.

It was a statement echoed by Dr Omprakash Patil, Director of the Department of Health and Family Welfare. “Once the vulnerable households are identified, we follow-up with them via a phone call. If people report symptoms, we move them immediately for testing, and if they test positive, treatment,” Dr Patil said.

As of June 4, the survey was 80.64% complete, with the government having identified 58.87 lakh households as being vulnerable and requiring follow-up visits. The matter of a household’s “vulnerability,” Dr Patil, pointed out, is determined by having at least one member or more suffering from fever, cough and cold, high blood pressure, diabetes, cardiac problem. Senior citizens and pregnant or lactating mothers also fall into the list.

Follow-up surveillance is normally done via the Quarantine Watch App, with varied staff including panchayat officers in rural areas, augment by revenue department staff in urban areas to conduct the follow-up calls.

However, experts pointed out that there has already been a predilection for some people with symptoms to not report them to the authorities. The pandemic in the state is replete with examples of COVID-positive cases who have attempted to hide the symptoms of the disease from the officials, and if not hide, at least flout regulations.

This is borne out by statistics released by the Home Quarantine Enforcement Squad on May 24, which revealed that 2,510 people had been removed from home quarantine and placed in institutional quarantine for violations of quarantine. Then there is the lack of acceptance by community members which could also prompt people to hide their symptoms, a medical expert said. This was the experience of a recently diagnosed Covid-19 patient in Kolar who contracted the disease at some point in late May.

“As soon as people in my area discovered that I was positive, I have been getting non-stop messages from them demanding to know why I have returned and why I was endangering the entire community,” he told DH.

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He added that while the local police had promised to take action against those making threats against him, he nevertheless felt uneasy about going back home once he was cured of the disease.

For the system to work, it needs the cooperation and the empathy of the people said Minister of Health Education Dr K Sudhakar, who expressed confidence that the state’s surveillance systems would prevent the situation from spiralling out of control.

However, the minister also described the current situation as “difficult” when asked what measures the government had in place to thwart those who fail to report symptoms of the disease. “If they do not report, I can only say that it is sad,” the minister said.

This real unwillingness to report could potentially break down the government’s efforts to nip what is a rapidly escalating situation in the bud.

Dr Arvind Kasturi, Head of Community Healthcare, St John’s National Academy, warned that fear of the disease is potentially making people less inclined to report the symptoms to authorities.

This was made glaringly clear in a recent case in Chikkamagaluru, where a false-positive result for a government doctor resulted in nearly 1,300 people (many of whom were asymptomatic) being hauled off to institutional quarantine.

Pradyumna Pradeep, a resident of the district, said that among those hauled off was his 82-year-old father who was not allowed to take with him his daily medication. Speaking to DH, Pradeep alleged that the sick and the elderly were placed in the same facility as Covid-positive patients. “It was outrageous,” he said, adding that this treatment had severely eroded the trust of people in the system.

“I don’t think anyone will report symptoms in the future,” he said.

A senior health officer, speaking on the condition of anonymity, admitted that the statewide system of surveillance is challenged because of a lack of resources. “What is being done, is the best that can be done,” he said.

A recipe for disaster?

These flaws, coupled with the lifting of the 75-day nationwide lockdown today which is being seen by the government as the light at the end of the tunnel, could instead turn out to be a speeding train headed to disaster especially for senior citizens and people with comorbidities.

Experts across institutes have warned that the loosening of lockdown restrictions at a time when a vaccine for Covid-19 does not exist and where social distancing norms are challenged by population densities, could pose a devastating
danger to senior citizens and even
middle-aged individuals with comorbidities.

Dr M K Sudarshan, a senior member of the Karnataka State COVID Task Force, said that with the onset of Unlock 1.0, we will see a larger chunk of the working-age populations return to their places of employment. This could, according to Dr Vishal Rao, who is involved in plasma therapy for COVID patients, create conditions where “young people will bring the disease back home to infect the elderly.”

Dr Rao suggested that a repository of people over the age of 65 for a care plan be created in order to have a contingency for when things go wrong, adding that while the most at-risk people are above the age of 65 or those who live in a nursing or long-term care facility, that the list of vulnerable people is now far larger.

Residing in the centre of the danger zone are people with chronic lung disease or moderate or severe asthma, people with severe heart conditions, people who are immune-compromised (including through immune deficiency, poorly controlled HIV and cancer treatment), people with severe obesity (with a body mass index of 40 or higher), people with diabetes, hypertension, chronic kidney disease undergoing dialysis, people with liver disease including alcoholic and viral hepatitis and people with chronic neurological conditions such as Parkinson’s and Alzheimer’s.

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Is this expanded list a product of undue caution? Not at all, the data says. According to the Bengaluru municipal authorities, four new-found Covid-19 cases in Bengaluru this past week alone were cancer and kidney dialysis patients who had returned to private care from neighbouring districts following relaxations in inter-district travel.

Worse, the existing mortality rate appears to portend to a Covid-19 landscape where transmission rates are higher, and the number of deaths greater if safeguards are not followed.

Taking Karnataka as an example, as of Friday evening, 641 out of the 4,835 Covid-19 cases registered so far were senior citizens over the age of 60, who have disproportionately borne the brunt of fatalities: 33 out of the 57 deaths registered so far (excluding two suicides).

Twenty-two of the deaths had comorbid conditions ranging from Chronic Obstructive Pulmonary disease to tuberculosis, although diabetes was the most common condition.

“The unifying factor among those deaths is that they had serious comorbidities and the fact that they came three to four days too late for treatment,” he said.

With the demise of the lockdown, the erstwhile high rates and numbers which had previously been denied to the disease could now potentially be up for grabs by the Sars-CoV-2 virus.