Surgical care delivery in India during the COVID pandemic

The article “Trends of surgical-care delivery during the COVID-19 pandemic: A multi-centre study in India” in this issue looks at surgical delivery in Indian hospitals across the two waves of the pandemic in India.[1] The authors’ work is necessary to plan for inevitable future stresses on the healthcare system. The SARS-CoV-2 pandemic exposed the unpreparedness of healthcare systems around the world to pressure and stress. The world had no clear strategy on how to respond with shortages of hospital beds, equipment, and protective equipment being the norm, leading to the loss of life for both patients and healthcare professionals.[2,3]

Surgeons had to contend with the increased morbidity due to SARS-CoV-2 infection in surgical patients. Resources were used to manage the immediate crisis leading to a decrease in surgical healthcare and deskilling of the surgical workforce as they were reallocated to other areas.[3] Local guidelines were the first response and elective surgery was the first casualty. As more data came in, these strategies were modified to provide as much surgery as possible.[2,4] The authors have given a glimpse of the hit the surgical services received at the start of the pandemic with data points during the second wave an indication of the preparedness of the healthcare systems in providing essential surgery.[1]

Interestingly, the data presented show a partial rebounding of surgical care during the recovery period of the first wave and importantly reduction levels in surgery during the second wave nearing first-wave levels. This is in contrast to countries like the United States where surgical care rebounded to prepandemic levels.[1] The authors have found that the reduction was also in emergency surgery (except cesarean sections) along with elective work, similar to trends across the world.[1] The authors’ data would also help in encouraging the proven use of minimal access techniques in Low & Middle Income Countries (LMICs) which reduce the risk of infections.[5]

Entire healthcare systems across the world were overwhelmed with all types of surgical care deferred. Studies reported reductions ranging from 30% to 80% in surgical procedures during the pandemic. Modeling studies in the first wave predicted that it would take more than 45 weeks to clear backlogs. This has not taken into account new surgical cases or the effects of the subsequent waves.[6] An Indian study by the same group reported an almost 90% decrease in the elective surgery workload.[7] The reduction during the pandemic will naturally lead to long-term consequences in terms of long waiting lists as well as poorer outcomes due to delayed surgery.

Healthcare suffered around the world, with the impact felt by surgical departments who were caught unaware and unprepared to provide COVID-safe pathways for elective surgical care while scrambling to provide safe emergency surgical care for SARS-CoV-2 patients, a lesson which unfortunately healthcare systems had not learnt from previous epidemics.[7,8] Mobilization of skilled personnel, infrastructure, and equipment resources to meet the COVID response were among the factors that negatively impacted the delivery of surgical care, leading to a massive number of cancellations or postponements of surgery. The reallocation of scarce resources has also led to ethical questions on who “deserves” to be treated with the vulnerable suffering the most. We hope the world does not ever have to face those questions again.[9]

This disruption in the delivery of essential and emergency surgical care had several implications for early surgery as a public health intervention. The delay in procedures will naturally lead to the worsening of patient conditions with the risk of complications, worsened outcomes, and increased morbidity and mortality which placed further strain on an already overburdened healthcare system. It is crucial to take into account the possibility of these disruptions having a greater impact on marginalized and vulnerable groups, including those who face barriers to healthcare access, for example, those from the lower socioeconomic strata and children, thereby exacerbating existing healthcare disparities.

Developing consensus guidelines is necessary for resilient surgical systems and pandemic-free surgical pathways in countries like India. A large proportion of surgery happens in the Global South and it is essential that resilient surgical health systems are planned and put into practice to prevent the lack of care and huge backlogs in surgery that happened due to the recent pandemic. Acknowledging and addressing the issues that disrupt surgical care delivery is crucial not only to alleviate psychological stress, and enhancing overall health but also to guarantee equitable access to healthcare.

Hospitals should urgently prepare detailed context-specific preparedness plans addressing the identified domains for surgery during pandemics or other stresses.[10] The present study by Jain et al.[1] and similar studies will help policymakers identify domains that need attention as delaying elective and semi-urgent procedures is not a viable scenario.[3] The ability to meet the essential surgical procedures as noted by the authors provides insights into the robustness of the healthcare systems’ resilience, adaptability, and capacity to handle public health emergencies.[1] Data will help feed into the globally applicable surgical preparedness index which are relevant across different types of challenges to surgical healthcare allowing self-assessment and systems pandemic-ready.[10,11] To prevent disruptions in surgical care delivery in LMICs, it is important to focus on key strategies which may include training healthcare workers and promoting regional collaboration. Expanding telehealth services, ensuring supply chains, and promoting health education and community engagement are also crucial. Communities should not suffer from a lack of surgical care. This should be the objective across healthcare systems.