Twin challenges that are complicating Mumbai's covid battle

Ram Manohar Singh was a fruit vendor at the Vakola vegetable market in Mumbai’s Santacruz East. The 67-year-old was a well-regarded elder in the market close to St Anthony’s Church. Singh had had a history of heart disease and opened his stall only sporadically through the lockdown.On May 5, feeling unwell, Singh called up his son Sanjay, who lived in a northern Mumbai suburb, in Nalasopara, and asked him to come over. Singh wanted to rest for a few days. The next day, late evening, Singh started feeling breathless. What followed was a night of despair the family can never forget.When they reached the nearest hospital in Santacruz East, the oxygen saturation level in Singh’s blood had fallen to 76%. That metric measures the share of oxygencarrying haemoglobin in the blood. The normal at sealevel is 95-100%. Singh was in clear danger of developing hypoxia, a condition in which the tissues are starved of oxygen, leading to organ failure. The doctor’s advice was clear: shift him to a hospital with better facilities.By the time they reached Holy Family Hospital in Bandra West, Singh’s oxygen levels had fallen to 72%. At 12:30 am on May 7, the hospital said they did not have a free bed and the symptom looked like a Covid-19 infection (Holy Family has only six isolation beds and two ICUs for Covid-19 patients).While Singh was administered oxygen in the hospital’s OPD, Sanjay took off into the night to try and find a hospital bed with oxygen facility for his father. By 4 am he was back, having visited five top private hospitals without any success. Sanjay now decided to try Mumbai’s government hospitals.There was no ambulance available and, in the car, Singh’s oxygen level kept dropping. By 5:30 am, when they checked at Kasturba Hospital, it was down to 67%. Kasturba did not have beds. Neither did Nair Hospital nor Sion Hospital. 75922606In desperation, Sanjay called up his doctor in Nalasopara, almost 50 kilometres away, and secured a bed at the Riddhi Vinayak Hospital there. By the time Singh was admitted, his oxygen saturation level was down to 64%. The damage was probably already done. Next day, tests confirmed Singh had Covid-19.A day later, Singh suffered a heart attack and passed away. 75922748Migrant labourers arrive to board the Shramik special train at Lokmanya Tilak TerminusSuch horror stories are becoming rampant in Mumbai as India’s financial capital reels from the spread of the Covid-19 pandemic, with the number of positive patients crossing the 25,000 mark. That’s more than 20% of India’s total Covid-19 burden. The processes needed to coordinate such a large number of patients in a single crowded metropolitan area are not yet in place. There are several examples of distress, of patients dying on the street while waiting for an ambulance, or reaching a hospital to see the allotted bed having been given away to someone else.Cap on CostsThe Maharashtra govt has put a price cap on 80% of all hospital beds. Here is the per day price for Covid-19 patients:Ra 4,000 Isolation in routine wardRs 7,500 Isolation in ICU without ventilatorRs 9,000 Isolation in ICU with ventilatorPrices include regular treatment and tests; exclude PPE, high-end treatment and drugs for Covid-19 casesCommonly used medicines and drugs in hospitals for Covid-19: Hydroxychloroquine, lopinavir/ritonavir, oseltamivir, paracetamol, azithromycin, tocilizumab.According to a Mumbai Mirror report, on May 14, bone cancer patient Shivaji Sawant died after being turned away by eight hospitals. Samir Chavan, 35, who passed away on May 16, had to visit multiple hospitals with a fever, over a few days, before finally getting admission. While patients suffer, doctors themselves are no better off. Malvika Neeraj, 29, a junior doctor at St George’s Hospital, told ET Magazine how after testing positive for Covid-19, she was allowed only a few days at the hospital’s isolation ward, before being asked to move back to her hostel room. 75922624“An app-based allotment of beds is being launched. We will also take action against private clinics that are not functioning” Kishori Pednekar, Mayor of MumbaiWhere did Mumbai go wrong? After all, the state government had clamped down a few days before the nationwide lockdown was announced on March 25, precisely to avoid such a situation. Very early, it had also involved Mc-Kinsey, an international management consultancy, to advise it. It also set up a task force of doctors to recommend action. With patient numbers predicted to touch 35,000 by June and peak at 45,000 during the monsoon, the bigger question is whether enough is being done to avoid an unmitigated disaster in the city, home to nearly 20 million people.Maximum Distress Epidemiologist Giridhara Rao says that with 340 cases per million, Mumbai is seeing a “widespread outbreak” of Covid-19 that can still be contained. “With nearly 60-70% of Mumbai’s population in overcrowded areas, managing its Covid-19 situation is the toughest in the world,” he says. Meanwhile, BJP Lok Sabha MP from Mumbai’s North Central constituency, Poonam Mahajan, who has seen party workers die in the pandemic, says there is a lack of coordinated approach in every level in the manner the pandemic is being handled, from allotment of beds to availability of ambulances. “There is no way to sugarcoat this. There is a clear lack of leadership” says Mahajan. In the middle of all this, a change of guard was effected at the Municipal Corporation of Greater Mumbai (MCGM). Municipal commissioner for MCGM, Pravin Pardeshi, was transferred and replaced by IS Chahal, on May 9.Mahajan says: “Till now we do not have a dashboard for Mumbai, even though the city is home to the richest people and top companies and there is dearth of neither money nor technology.” 75922639“There is no way to sugar-coat this. There is a clear lack of leadership” Poonam Mahajan, BJP Lok Sabha MP from Mumbai North Central constituencyIn fact, in a late push, the MCGM announced the launch of a dashboard on May 22. The state government also empowered MCGM to take control of the allotment of 80% beds in private hospitals. It also capped bed charges for Covid-19 patients at private hospitals at `9,000 per day. Senior chest physician Pralhad Prabhudesai, who is associated with Lilavati Hospital, says Mumbai started off on the wrong foot with the lockdown by creating a sense of panic, forcing many people to not come out and seek treatment. “Patients may be mildly unwell for a fortnight. Then some will get better, but older patients or those with other illnesses will feel sudden, severe breathlessness,” he says.He says the policy of cordoning off buildings, entire areas and even hospitals created a stigma around the disease that became counter-productive. “Now they are reversing all that, but without increasing testing,” says Prabhudesai, stressing that the government should spend as much as it can on testing for Covid-19 and at the same time treat non-Covid-19 diseases aggressively, too. He says most health workers may be already carrying the virus or have become immune to it without ever displaying any symptoms, indicating that a community spread might already be happening in the city and instead of panic it might be worthwhile to protect the vulnerable by testing and isolating them early. 75922652On May 22, KEM even arranged to provide oxygen to patients on stretcher beds outside the buildingA look at the number of beds available in the city may hold some clues to what might have gone haywire. As per the dashboard for Maharashtra, Mumbai city today has less than 2,800 oxygen-supported beds, around 1,200 ICU beds and around 600 ventilators. Although the number of isolation beds has crossed 56,000, many doctors are indicating that home isolation is good enough. Of course, capacity building happened with some lopsided priorities and needs to be corrected with haste.The state government’s task force of physicians, led by Dr Sanjay Oak, sent out an SOS last week, asking the government to be ready with 20,000-odd critical care beds and urgent clearance for a couple of medicines — remdesivir and favipiravir— cutting through bureaucratic hassles. 75922416Scale Up and Speed UpMeanwhile Mumbai’s Mayor Kishori Pednekar told ET Magazine that actions initiated by the MCGM and the state government are likely to help ease the situation. “An app-based allotment of beds is very important and is being launched. Action is also likely against private ambulances and doctor clinics that are not operating,” she said.The situation has not been helped by many senior consultant physicians staying away from their practice while some others employed by private players are resigning from their positions. Sujit Chatterjee, CEO, Hiranandani Hospital, acknowledges the problem: “I think doctors in private practice are used to certain comforts and they feel that ‘others’ can manage. But they don’t understand that they are the ‘others’. We have refused to accept resignations of doctors, forcing them to stay.”Mumbai’s 94-year-old King Edward Memorial Hospital (KEM) treats Covid-19 and other patients, and is a favoured destination for patients with Covid-19-like symptoms but no confirmed test reports. If they are ready to wait, a bed will ultimately free up. On Friday, the MCGM-managed hospital had also arranged to provide oxygen to patients on stretcher beds outside the building. 75922696Hemant Deshmukh, dean of KEM, says the same treatment protocol is being applied to whoever comes to the hospital with symptoms of severe acute respiratory infection (SARI) while their Covid-19 results are pending. Later, beds are allotted as per the test results.He admits that a lot of time is wasted in the process of a patient seeking admission to a hospital of her choice or landing up at a hospital that is earmarked for Covid-19 or otherwise without confirmed test results.Deshmukh says patients should call the 1916 helpline and wait at home till an ambulance arrives. Much of the healthcare horror stories of Mumbai in May 2020 would not have happened if that system had worked, and beds had simply not run out.Deshmukh says that the four jumbo corona care centres coming up in the city (at Goregaon, Bandra, Worli and the Racecourse in Mahalaxmi) will take on much of the increased load, boosting capacity to 5,000 immediately. But more needs to be done.“At first we thought ventilators were critical. But what we need to increase is the number of critical care oxygen beds. There can be non-invasive ventilation, mask ventilation and the high-flow nasal cannula (HFNC) that can deliver oxygen to patients and help them recover,” he says.To streamline processes, the state government has deputed IAS officers to set up dedicated war rooms at government hospitals, with a system for live-tracking every ICU and critical bed, allotting them unique IDs and uploading data to the newly created bed-allotment dashboard, so that allotment can happen soon after a patient calls the helpline. Implemented a month back, these measures could have saved the lives of Singh, Chavan, Sawant and many others.Singh had come to Mumbai as a teenager in 1970 from Jaunpur, made his life as a fruit vendor and saw his son Sanjay land a job at Axis Bank. Singh lived the Mumbai dream, but was let down in death. For Mumbai, a city that rarely sleeps, an unprecedented nightmare is unfolding

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