‘COVID-19 Patients Are Delaying Doctor Visits Because Of Stigma’

COVID-19 patients are delaying visits to the doctor because of the stigma associated with the disease, said Anita Mathew, a senior consultant, physician and infectious disease specialist at Fortis Hospital in Mumbai and Rommel Tickoo, the associate director of internal medicine at Max Healthcare in Delhi.

It is necessary to change the mindset around the disease so that patients come early to doctors and their treatment is easier, they said. We spoke to these doctors to understand how COVID-19 has progressed in Mumbai and Delhi, the hospital capacity and stigma.

Edited excerpts from the conversation.

Dr Mathew, take us through what you have been seeing since patients with COVID-19 have been coming to you?

AM: So, let me go back to about a month and half ago, when we started with the COVID pandemic in the city. At that point in time, all the cases that we were getting were with travel history. As against that, we now see a bit of community transmission. So, we are seeing people who have had absolutely no contact with anyone with a travel history coming to hospital, with a history of cold, cough or whatever--usual things that we tend to see in patients with COVID.

In terms of the severity of the disease, some number of severe patients in the form of ones who are coming to us with an ARDS [Acute Respiratory Distress Syndrome] or lung involvement is something that we are seeing of late coming from the community. One of the reasons why I think these patients have not gone to healthcare centres to look at treatment options when they have had a mild cold-cough is the stigma that is attached to the disease. Everyone is worried that if they go to the hospital, they are told to do the test, and that is the reason they are refraining from coming to the hospital. So, the numbers we are seeing right now are basically more severe in terms of disease progression, basically because of late presentations to the hospital.

Dr Tickoo, what is your sense in Delhi? Are you seeing similar trends?

RT: Yes, it is more or less the same. But what we have noticed is that we have a mixed bag. It is not that only the elderly have an issue, but we are seeing patients--40-50 year olds--also having ARDS, pneumonia. They are also on ventilators. So it is a sort of mixed thing. The presentation varies--mild, moderate, severe. We have about 90 patients right now, 10-15 are in ICU [Intensive Care Units], and seven-eight are on ventilators...they have pneumonia and ARDS. So definitely the rates of complications are lesser, they are not showing too much of mortality. But there are cases where the numbers are increasing in the last few days.

It [the number of patients in ICU] is not very high but like the doctor rightly said, they come to us only when they are in the second stage. They do not come to us when they have fever, or cough, cold for whatever reason--and as she rightly said that one of the reasons is… a lot of people call me and say shall we do the test, and I say yes, but they say we want to avoid it because there is too much of stigma attached.

What happens because of that is, when they actually come to the hospital, they have pneumonia or they are breathless. That is why some of them land up on the ventilator and in the ICU. If they would have reached us earlier, and taken medical advice whenever it sort of started, then we can save many lives. So, there is a lot of stigma and people do not want that.

Without generalising, these are those patients who are not even going to their family physicians and then may be going or not going further? Or, are they just keeping quiet completely?

RT: Most of the nursing homes and smaller centers are closed right now. So, the only option is either to go to a major corporate hospital or to a government-based setup. They try and avoid both the scenarios as much as they can.

Dr Mathew, what is the kind of mortality you are seeing, and among what kind of patients?

AM: Both the patients that we lost, one of them was pretty elderly--we did not have much time to salvage him, he came in pretty bad and died within a couple of hours. The other was a relatively young guy but the difficulty was he had an underlying malignancy. So, these are the patients who are more likely to succumb. By and large, the rest of them, with God’s grace, have gone home or are on their way home.

Do you have a sense that the disease is almost uniformly affecting everyone or is it still affecting older people more than younger people?

AM: The disease by and large is going to affect all. Some will be symptomatic, asymptomatic or mildly symptomatic, right. Obviously, with ageing, your immune system is not going to be as robust, you obviously will have some amount of comorbidities--when I say comorbidities, I mean hypertension, diabetes, heart disease and so on. In these scenarios, which are likely to be seen in patients above 60, you are likely to see more mortality. But other than that, I do not think it is going to spare any age group. It is going to be across all age groups. It will be less symptomatic in patients who are younger, especially children.

Dr Tikoo, what is your sense of the capacity we have today, given that the number of cases is rising and the number of serious cases that are rising?

RT: I think there are enough number of beds at present, the way the numbers are going up, we can handle it but there should not be any exponential growth, which is not happening at the moment. We should be able to handle it, we have these government hospitals, we have COVID-care centers and then you have the private ones. Our hospital has around 300 beds--the entire building is dedicated to COVID. And there will be more and more facilities created. As of now, we have all these facilities and we should be able to manage. I am sure that the government is looking at it, and if the numbers keep increasing, we will keep on ramping up our medical facilities at the same time.

So, with mild cases, they are planning to put them in COVID-care centers, makeshift buildings converted to COVID-care centers. Moderate to severe cases probably need bigger hospitals and tertiary care centers for the critical ones. So, it all depends on the symptoms. I am sure, right now, there are enough beds and enough ICU beds as well. We have 14,000 or 12,000 ICU beds.

Dr Mathew, Mumbai is a little worse off than all other places in the country. As someone who is on the frontline, how are you feeling...are you confident or not?

AM: Mumbai has two major problems. We have the biggest slum in Asia, Dharavi. So that is going to be a major challenge for us. The patients who come from these kinds of slum pockets, they probably will not have the means or the wherewithal to go to a private center. We have now, fortunately, started a COVID centre in Nair Hospital--one of our major teaching hospitals. They have, I think, dedicated 500 beds for ICU facility, and about 1,200-odd beds for ward kind of patients. Plus, with the other hospitals put together, we are fairly ok, but with the kind of population Mumbai has, probably we need more number of beds.

The exponential rise we are going to see, eventually it would come to a stage where we will have a lot of patients coming into the hospital. We may need to put in more beds over a period of time in terms of ICU and ward beds.

What about other things, like stock of medicines, oxygen for ventilators, in general not specifically your hospital?

AM: As of now, the present situation, yes. We are ok on it. I mean nobody has died yet because of a lack of a ventilator. We are good there as of now.

RT: Yes, same here. The medicines, ICU care, beds--everyone is getting what they need at the moment. Unless there is a flood of patients and there is exponential growth...then you will have to keep increasing [care centres] or ramp up [hospital capacity].

I know that you are obviously staying in touch with all your colleagues all over the country, including your own chain. Are you getting a sense there is any surge, that is not reflected in the data?

AM: I also work with the teaching hospital--Sion Medical College--so if you look at the numbers, we are not seeing the kind of number of patients who are coming in and dying immediately. Like what would happen with a leptospirosis, malaria, dengue kind of scenario. I do not think we are seeing a lesser number of patients, or it is a suppressed kind of data. Whatever data is coming in is pretty much ok and we would probably say that it is close to actual figures.

Yes, we are not testing asymptomatic individuals because that is not there in the scope of testing, I am not sure we have those many kits to randomly start testing everyone, but obviously there would be a fair amount of asymptomatic people as well, which we may not be picking up at this particular time point. But, by and large, anyone who is symptomatic is being tested.

One problem that both of you mentioned is that patients are not coming to you or the hospital at the right time. So what would you say to encourage them to do that or how can they convince their community or the people they are living with that they need to be doing this and they should not be viewed negatively?

RT: Well, what we can tell people is that there should be no stigma attached to the disease and it is a treatable disease. The sooner you come to the hospital or to healthcare authorities, the sooner you will be cured. Because mild disease is easier to treat. But once you are in the phase where you get pneumonia or you need ICU care or ventilation, it becomes that much more difficult [to treat]. This is more so for the elderly or the ones who have other vulnerable issues like diabetes, heart disease. So, there should be no stigma at all attached to it...once you are treated and are fine, you can go back to the community.

We should not victimise the patients, ones who have the disease. Better to get into contact with the doctor sooner--the moment you have fever, cough, within a day or two you should get in touch with your doctors. They will advise you accordingly whether you need hospitalisation, isolation and even whether you need testing or not.

AM: I would echo what Dr Tickoo said. That is exactly and precisely what we need to do. Also, if it goes within the community that a patient has become better and that person can convey that to the population in their own words, in their own way, that will have a positive effect, stigma might be a little lesser.

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