Physiotherapy - The Journal of Indian Association of Physiotherapists

: 2020  |  Volume : 14  |  Issue : 1  |  Page : 1--4

Living in a different time

Akhoury Gourang Kumar Sinha 
 Editor in Chief, Professor, Department of Physiotherapy, Punjabi University, Patiala, Punjab, India

Correspondence Address:
Akhoury Gourang Kumar Sinha
Editor in Chief, Professor, Department of Physiotherapy, Punjabi University, Patiala, Punjab

How to cite this article:
Sinha AG. Living in a different time.Physiother - J Indian Assoc Physiother 2020;14:1-4

How to cite this URL:
Sinha AG. Living in a different time. Physiother - J Indian Assoc Physiother [serial online] 2020 [cited 2021 Mar 4 ];14:1-4
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The world is passing through an unprecedented time. The arrival of a highly infectious disease in the world scenario – ushered in a new era that is threatening to change the world order and giving birth to several new norms. On February 11, 2020, the WHO gave a name for this disease – COVID-19 – and declared it a Public Health Emergency of International Concern on January 30. 2020. Since then, many words unheard before – lock down, social distancing, quarantine, isolation, hand wash, face mask, personal protective equipments (PPE), ventilator etc. have become part of daily use vocabulary.

On December 31, 2019 – when China first announced the arrival of a pneumonia of unknown cause – no one had imagined the aftermath this disease would be going to unleash on the human civilization. Unknown clinical course, uncertain health consequences, deaths, no effective treatment, no vaccine, and a very high transmissibility rates, compelled governments across the world to impose strange measures of varying degrees for minimizing human-to-human contact in a bid to curb the spread of the virus. However, the virus kept spreading its wings and as of now, cases of COVID-19 have been reported on every continent except Antarctica. It is now one of the most feared infectious diseases in the human history.

The pandemic, of course, is placing significant demands on health-care resources, but its effects are far reaching and beyond imagination in terms of its economic, political, and sociological fallouts.

The first case of this virus was detected in India on January 30, 2020, On March 12, the first death of a man of 76 years due to COVID-19 was reported. On March 22, 2020, India observed a 14-h voluntary public curfew and on March 24, a nationwide lockdown for 21 days, limiting the movement of the entire 1.3 billion population of India, was imposed. Subsequently, the lockdown was extended four times till May 30. From June onward, the country started the gradual process of unlock down.

The sudden lockdown gave no time to most of the people to prepare for the long-term confinement. In the initial days of the lockdown, the society struggled to meet the requirement of ration, vegetable, fruit, milk, and medicine. However, within a week's time, the supply chain of essential items was mostly restored and new order of marketing and sales took effect. Nonetheless, as the period of lockdown got extended – week after week – the concern for livelihood acquired significance. The closure of market, business, and industries has left millions jobless. The absence of transportation and access to markets made the situation critical for informal workers, micro and small enterprises, farmers, and the self-employed. The condition was worst for daily wage earners – those working in construction sites, factories, and street hawkers who were earning their livelihood in streets by selling petty items. Government and nongovernment organizations distributed rations and cooked food to millions of such individuals. Nevertheless, within weeks, with saving getting subsumed in meeting the daily expenses, difficulty in paying rents for housing, uncertain future, and threat of plausible death looming large, there began the process of reverse migration. Thousands of workers started walking on the highways to cover thousands of miles in a desperate attempt to go home. These events by and large contributed to the spread of disease to the so far unaffected areas. Gradually, the frontline workers – doctors, nurses, paramedics, and police and administrative officers – also started getting affected with COVID-19.

The impact of COVID-19 on the health-care system has been unprecedented. For the first time in its history, the All India Institute of Medical Sciences, New Delhi, had shut down all its outpatient departments. The other premier institutions also followed suit. The attention of the entire health machinery was focused on measures to ensure physical distancing, purchase of personal protection kits and arrangement for isolation wards, and separate accommodation for doctors and nurses attending patients and suspects. The hospitals catered mainly to cases that came to the emergency with few outpatients having chronic and serious health issues. All the elective surgeries had also been put on hold.

In later weeks, when the rules were relaxed and hospitals were allowed to function, the footfalls of patients were not as before. The fear of getting infected with COVID-19 prevented many from visiting health-care facilities and also made many hospitals in the private sector hesitant to provide services. In India, about 70% of curative health services are offered by the private sector, and closure of the entire chain left many patients in lurch. On the other hand, across the country, health-care professionals faced the growing stigma and subsequent inconveniences from their neighbors and landlords over the fears of being the carrier of dangerous disease. Many health workers were evicted from their homes.

However, this has not deterred the health-care professionals to explore the use of innovative and improvised way of providing care. The use of modalities of telemedicine gained prominence. Hospitals, clinics, and practitioners made good usage of internet-based videoconferencing tools to offer consultation and advice. Work from home became a new norm that encouraged hosting of web-based seminars (webinars) and expert's interaction using online video tools. A good number of experts used their time of confinement to house in making educational videos and putting them on the public domain through YouTube. The Government of India (GOI) also used an online platform to impart training for handling the various aspects of COVID care. It is expected that this trend of telecommunication would continue to increase in the coming days.

The effect of the lockdown on physiotherapy practice in India has been variable. Physiotherapy practitioners of India can be broadly grouped under three broad categories – physiotherapists employed in government sector, physiotherapists employed in private sector, and self-employed physiotherapists. Each group has a different story to tell. From the beginning of the lockdown on March 25 till May 4, clinics of physiotherapy, both private and public sectors, remained closed due to strict lockdown guidelines.

COVID-19 is primarily a respiratory illness, and there may be a role of physiotherapy in the direct management of this condition. The guidelines prepared by Thomas et al.[1] is a valuable piece of literature to highlight this point. GOI guidelines for clinical management of COVID-19 also recommend active mobilization of the patient early in the course of illness for reducing the incidence of intensive care unit-related weakness.[2] The COVID centers of premier hospitals of the country have utilized the services of physiotherapists in the direct clinical care of COVID patients. The physiotherapists working in government sectors were also deputed in supervisory capacity for looking after the logistics and operational aspects of patient screening, quarantine, and various nonclinical duties of managing the COVID care centers. In response to the government's call for COVID volunteers, about 2188 physiotherapists have registered themselves.[3] India has witnessed the death of at least two physiotherapists due to the COVID infection.

Worldwide, the WHO and other organizations issued guidelines of preventive measures to be followed during patient handling.[4],[5] These guidelines necessitate wearing of PPE of different levels depending on the kind of risk anticipated and sanitization of self and working areas. These guidelines also prescribe no contact until very essential. The care and consultation shifted to video and audio call and other means of electronic communication. Many senior physiotherapists offered consultation and advice through online means.

Some self-employed physiotherapists and also those working with home care agencies attempted to provide home care services by wearing protective equipment and observing all the social and personal etiquettes required during such epidemic. However, there was a constant fear for contacting the virus among the patients and the treating physiotherapists. As a matter of fact, some physiotherapists did get affected with COVID-19 and some patients treated by them also got infected. Subsequently, the physiotherapists, the patients, and all those who came in contact with them were quarantined.[6] Most physiotherapists had temporarily stopped visiting clients to ensure their safety as well as follow social distancing.

For self-employed physiotherapists running small physiotherapy clinics, the pandemic was very challenging. In the initial days, there was complete shutdown of clinics. At later weeks, when rules were relaxed, some clinics were opened, but the footfall of patients was minimal. A lot of physiotherapy treatments require hands-on approach that makes the implementation of norms of social distancing extremely challenging. The clientage of physiotherapy centers consists mostly of the elderly and children – the most vulnerable population for COVID-19. Therefore, it was natural for them to avoid visiting clinics unless very essential. As a result, the income of clinics reduced considerably, but the expenditure remained the same. Most of them had to pay high rents for space taken in commercial establishments, to repay the loans taken from financing agencies for starting the clinic and also to pay the salaries of employees. No income for 3 months and the uncertainty of patient flow in the near future make the task of sustaining the enterprise very difficult. The requirement of maintaining a high level of sanitization and personal protection further added to the running cost. As a matter of fact, most of the physiotherapy clinics are reeling under severe financial crunch.

To provide relief to millions of small businesses reeling under the impact of the COVID-19 lockdown, the GOI has announced Rs. 20 lakh crore stimulus package to save the lockdown-battered economy. Economic package for medium, small, and micro enterprise (MSME) sector made provision for collateral-free automatic loan of 4-year tenure with a moratorium of 12 months on principal payment with 100% credit guarantee cover.

There is an urgent need of a similar package for physiotherapy service providers because in terms of need and operation, there is a similarity between private physiotherapy establishments and the service sectors of MSME. It is imperative that the GOI announces such relief package for physiotherapy and other small health sector enterprises.

Educational institutes across the country were shut down, and many were converted as quarantine centers. Physiotherapy institutions were no exception. Ongoing examinations were postponed. The research activities came to a grinding halt. Many research projects involving patients got struck in the midway. However, the education institutions adopted alternative strategies using e-learning platforms to cater to the needs of students. Online interaction, web-based seminars (webinars), and interviews of senior physiotherapists were put on air. Some institutes also conducted web-based conferences. However, at the moment, the effectiveness of these measures is difficulty to assess. Logically, online teaching cannot replace the hands-on training – the essential requirement of physiotherapy practice. It remains to be seen how the teaching and research activities of academic institutions shape up in the coming days.

With no cure and no vaccine coming in the near future, it is obvious that the world has to learn to live with COVID-19. This calls for long-term major changes in behavior, lifestyle, and policy. At the personal level, the norms of social distancing, mask wearing, hand hygiene, surface decontamination, limited physical contact, restricted travel, and taking all precautions against the infection should be internalized as they are the only available means of preventing the spread of COVID-19 and are going to stay for longer in the near future. Given the job requirements of physiotherapists, this looks difficult but not impossible. The way of handling patients, and the choice of therapeutic modality, would require a changeover. Minimal manual therapy, exercise therapy with personal exercising equipment, and judicious use of electrotherapy modalities would be the sensible choices. Finishing the history and interviewing part of assessment and guidance over telephone, generation of online prescription, and supervision of exercise would help to minimize the close contact with patients without compromising their care.

At societal level, many customs and practices would go redundant. Namaste has already started taking precedent over hand shake and hugging may become a thing of past.

At national level, the GOI has given call for atmnirvar bharat (self-reliant India). This would necessitate several changes in the policies and practices. From physiotherapy point of view, the following four important steps need to be taken urgently: (a) encouraging Indian manufactures to make instruments for therapy and research, (b) creating a mechanism for standardization and certification of physiotherapy equipment, (c) creating registries of chronic patients, and, last but the not the least, (d) expediting the formation of a statutory regulatory body for physiotherapy.

Indian companies do manufacture physiotherapy equipment. However, lack of quality assurance that emerges from the absence of a standardization and certifying body compels the users to procure imported equipment. The Quality Council of India and the Bureau of Indian Standards have the mandate of certifying the safety standards of industrial products. However, these organizations have not any set standards for electrotherapy equipment. With standardization and certification, a quality assurance can be obtained from Indian manufacturers. This would go a long way in making India self-reliant in physiotherapy manufacturing machines. Engagement of Indian companies in manufacturing research-related equipment is minimal, and most of research organizations import these equipment. It is imperative that these equipment are manufactured in India. After all, why can not a country that has capabilities to send satellite to moon and mars, make quality electromyography, isokinetic and gait analysing equipments? Definitely as a nation, we have technical capabilities. What we lack is the focus and priorities. The focused interaction between technologists, engineers, and clinical users and targeted manufacturing of equipment is the need of hour if we want to make India self-reliant.

A patient registry is a powerful tool to observe the course of disease and to measure quality of care. Mostly, these registries have surveillance and research objectives. However, at the time of crisis, these registries can be tapped to provide targeted delivery of services while observing all precautions. Currently, only few registries exist for cancer, injury surveillance trauma registry, maturity onset diabetes of the young, and Stroke. It shall be in the interest of the nation to expand the registries. A population-based registry containing the records of people diagnosed with cerebral palsy, rheumatoid arthritis, cardiac ailments, parkinsonism, multiple sclerosis, etc., is the need of the hour.

The efficiency of a health-care delivery system do not only depend on the performance and quality of medical doctors but also on the quality and competency of several allied health professionals. The COVID-19 pandemic has again underscored this point. However, Indian efforts with regard to the regulation and registration of all human resources in health can best be described as dismal. The country does not have a mechanism for recognition, registration, and standardization of a variety of health professionals including physiotherapists. The Allied and Healthcare Professions Bill, 2018, is pending before the parliament. It is important to enact this bill at the earliest so that we can have a registry of professionals. A registry of physiotherapists and physiotherapy clinics across the country would not only help locate these service providers in the hour of need, but would also enable us to offer service and facilities to them in case of need. The need to strengthen the public health-care system cannot be overemphasized. At the same time, the private health sector should also receive protection. Without establishing a proper statutory framework that includes all and excludes none, it is not possible.

The amount of fear COVID-19 has generated is little beyond comprehension. It is true that COVID-19 is extremely transmissible, however a comparison with other pandemics in terms of mortality and morbidity rates makes it a lesser evil. The case fatality rate of COVID-19 (2%–6%) is very less in comparison to plague (90%–95%), SARS (9.8%), MARS (38%),[7] cholera (50%–60%), and bacterial meningitis (50%). With regard to lack of vaccine, it has to be remembered that a vast majority of infectious diseases do not have vaccines. The world is living with Chikungunya, dengue, Cytomegalovirus, HIV/AIDS, malaria, leprosy, etc., which, in fact, produce more suffering than COVID-19. As a matter of fact, COVID-19 has a less severe clinical picture. Mortality is mainly associated with older age, comorbidities (hypertension, diabetes, cardiovascular disease, chronic lung disease, and cancer), and secondary infections. In more than 80% of patients, COVID-19 is a self-limiting disease.[1] Therefore, the keyword should be caution not fear. The extreme responses may prove counterproductive.


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