As India’s Covid-19 growth rate becomes the world’s fastest, vital lessons from its deadliest hotspot: Involve private healthcare, make testing liberal, don’t forget the needs of non-Covid patients and plan, plan, plan. Last of a three-part series
Mumbai: Over the last four months, as hospitals and nursing homes were fighting the spread of the coronavirus here in India’s worst-hit city, there was a silent, dangerous side-story playing out.
With medical facilities overwhelmed with a deluge of coronavirus infections, those with non-Covid illnesses struggled to get any medical care. Many, including those needing emergency care, were left stranded or abandoned. Others spent hours looking for a hospital bed, and some died searching for a hospital that would admit them.
After more than four months of such hardship, many hospitals are now cautiously opening up to non-Covid treatment, easing some of these woes. The Brihanmumbai Municipal Corporation (BMC) has asked private hospitals to attend to patients with monsoon illnesses, such as malaria and dengue.
Mumbai is the country’s worst-hit coronavirus hotspot, with 127,571 infections adding over 1,000 cases every day, on an average. As on 13 August, the city had more than 5.30% of India’s caseload of 23,96,637 cases. But Mumbai has a disproportionate 14.8% share in Covid-19 deaths nationally, with 6,988 of 47,033, more than any other city and state in India. Delhi is a distant second with 4,153 dead.
Mumbai’s death rate for coronavirus infections is 6% for detected coronavirus cases, three times the national average. It now has over 19,300 active detected infections, almost double the number of active cases in Delhi.
This is the concluding part of the three-part series (read the first part here and second here) chronicling the response of India’s richest and supposedly most-prepared city, as it developed into India’s coronavirus capital.
This piece will look at the struggles faced by those looking for non-Covid medical care over the last four months—from heart patients dying while waiting for a bed to those who died as a result of poor care in hospitals overwhelmed by coronavirus infections to those who had been stabbed.
Stabbed To Death, Then Lost
On 3 June, my uncle, Dilip Purohit, 59, died on the way to the Brihanmumbai Municipal Corporation (BMC)-run Rajawadi Hospital after having suffered through acute breathlessness for days without getting any medical care, as the first part of this series reported.
As we waited for his body to be handed over to us, my life intersected with the last moments of 29-year-old Meraj Shaikh.
Shaikh, the victim of a stabbing caused by a family feud, was rushed into Rajawadi hospital the same night that my uncle died. He arrived in an autorickshaw accompanied by several young men on motorcycles.
As nervous minutes went by, the men who had accompanied him were joined by more men and women. Less than 30 minutes after he was wheeled in, a doctor in a blue surgical suit came out and told the anxious crowd that Shaikh was dead.
Shaikh’s family and my family grieved alongside each other for the next few hours without exchanging a word. We waited together for the hospital to hand over the remains of our loved ones. Post-midnight we left the hospital after receiving my uncle’s body wrapped in double body bags. When we left, Shaikh’s family was still waiting to receive his body.
It would be a long wait.
That night, his family was sent back home by the hospital. Shaikh’s brother, Bhola told me that the hospital had told them that an autopsy was required. But the doctors insisted on a Covid test before such an autopsy.
“They promised us that we would get his body the next day,” said Bhola. But the next day when the family returned to the hospital, they were told his Covid test results were still awaited, said Bhola. So, they waited for another day. “When we went there on Friday again, they told us we will have to wait till Sunday,” said Bhola.
On Sunday the test report had not arrived, hospital authorities told the family.
On Monday when the family returned and demanded answers, the hospital finally said they could not find Shaikh’s body. He had tested for Covid-19, the doctors told the family.
Bhola said his family was shocked. How could a body go missing from the hospital’s morgue? The hospital did not respond and instead asked the family to go and check the morgue for themselves.
Heartbroken at not being able to even bury Shaikh’s body four days after his death, Bhola said the family had no option but to take the offer. “We went multiple times (to the morgue), but we could not spot him; we even checked the labels on the bodies because many bodies had decomposed,” said Bhola. “But my brother was not there.”
The hospital finally found Shaikh’s body nearly two weeks after his death and asked Bhola to return to the morgue. When he did, his heart sank at the sight—the body that the hospital claimed was his brother’s had decomposed beyond recognition.
“There was little skin left—it was all bones,” Bhola said, adding that the family could not even look for birthmarks. Looking at the body, Bhola said, the family suspected that Shaikh’s body had been exhumed.
“There is no other way to explain the state of the body,” said Bhola. “They must have given it to someone else and that family must have buried my brother thinking it was their own.”
Finally, they decided to scan his left leg. Shaikh’s left leg had a steel rod inserted after an accident a few years ago. The x-ray confirmed the presence of the rod. By then, the family was so emotionally exhausted that they did not ask for any other proof.
“We just wanted to bury him with dignity,” said Bhola.
The BMC has since ordered an inquiry into the episode. The local police filed a first information report against hospital attendants. Sources at the Rajawadi Hospital told me that the hospital was overburdened.
“We are low on staff and our patient intake is at an all-time high. We are trying to manage our best,” is all a doctor would say when I asked in early July.
‘If You Fall Ill Right Now, You Are In Serious Trouble’
The Shaikh family’s experiences point to a larger trend: The inability of Mumbai’s health systems, overwhelmed by the pandemic, to service the needs of those who need medical care for non-Covid illnesses.
As the second part of this series pointed out, government hospitals were overflowing with Covid patients while, initially at least, the private sector was unable to share the load because many shut or were shut down by the BMC.
The result was fatal for many. A 44-year-old woman with a brain haemorrhage shuttled between three hospitals before finally getting a bed. She died within hours.
A 26-year-old experiencing labour pains died in an auto-rickshaw after three hospitals denied her a bed.
A 50-year-old struggled to find a bed after a heart attack and drove over 520 km to Ahmedabad in the neighbouring state of Gujarat to be operated on for blocks in his arteries.
In some cases, hospitals insisted patients get tested for Covid before admission, a contravention of a 30 April Maharashtra government order that said no hospital could turn patients away in an emergency. There are few signs the order exists.
Harmik Singh, 31, knows this first-hand, which is why he now warns people: “If you fall ill right now, you are in serious trouble.”
When asthma flared in his 59-year-old mother, Prabjyot (name changed on request) on 18 June, Singh checked her oxygen saturation levels with an oximeter the family had recently bought. “It was 70% (the normal range is 95-100, according to the World Health Organisation), so I decided to call up my doctor and get her checked,” said Harmik.
Singh called at least four doctors, “all of them well known to the family for decades”, but they all said their clinics were shut or that they were not in town. He said he also called at least seven hospitals. “They would ask what was wrong with her and then refuse to admit her,” he said.
On 19 June at 5am, Prabjyot’s blood oxygen level had dropped to 40%. “I was scared, so I just decided to rush her to Hiranandani hospital, even though they had refused a bed the previous day,” he told me.
The hospital did not immediately admit her, but Singh refused to leave. Their car was stopped at the gate while doctors came out to check her. A few minutes later, she was finally admitted.
After nearly a week in hospital, she was healthy enough to be discharged. But, Singh said, he now knows that getting treated for a non-Covid illness right now involves jugaad. “You need to know the right people to call and the right things to do,” he said.
Routine But Critical Procedures Badly Hit
Even routine but critical procedures, such as dialysis, were badly hit, said Brijesh Gadhia, coordinator at Kidney Warriors, a nationwide voluntary support group for patients with chronic kidney disease.
The early days after Prime Minister Narendra Modi announced a national lockdown on 24 March with a four-hour notice, were “absolute chaos” said Gadhia.
“Most dialysis centres shut down because even if one patient tested positive for Covid, the centre would be sealed by the BMC,” said Gadhia. “Other centres voluntarily shut down either out of fear or because of staff shortages.”
Patients who needed regular dialysis were stranded. “One patient had to wait for over 12 days. He stopped having all liquids because, he told us, that was the only way he would make it alive without dialysis,” said Gadhia.
BMC chief I S Chahal acknowledged that dialysis care was disrupted till May. “By the end of May, we asked a group of eminent doctors to help us develop a web page on which all dialysis centres were registered and doctors could select time slots for their patients who needed dialysis,” Chahal told Article14, adding that the process was streamlined after the system was in place.
Kidney transplants were as badly hit. “Ordinarily, Mumbai sees about 10-15 transplants each month,” Gadhia said, in mid-July. “But since March, Mumbai has not seen a single transplant as far as we know.”
Things got complicated when patients with chronic illnesses contracted the coronavirus, as Robin D’souza (name changed) explained. D’souza’s 62-year-old father, who requires dialysis three times a week, tested positive for Covid-19 in mid-June.
“We had to look for a hospital for him because he was high-risk due to his complications,” said D’souza. “I called up seven different private hospitals, the biggest, the best in the city. All of them said they had no bed for a dialysis Covid patient.”
Left with no choice, his father was admitted to the municipal Nair hospital, where he was admitted and discharged after more than a week.
Poor Hit The Hardest
As with the rest of India, the inaccessibility of private and public healthcare particularly affected some of Mumbai’s poorest communities.
This was evident in the eastern suburb of Govandi, one of the city’s poorest areas, with the city’s lowest human development index citywide, where 78% of people living in slums , according to a 2009 BMC 2009 report.
With most families living off daily wage work, the lockdown in Govandi caused severe financial hardship. Many could not afford private healthcare, with dangerous consequences.
“Since the lockdown most have lost their incomes, so they can barely afford private hospitals,” said 52-year-old Mohammed Umar Shaikh, a Govandi activist. Instead, he said, most lie low and hope for the best.
Maternal care too was severely disrupted, said Apnalaya, a Mumbai nonprofit that works on health issues. A survey by Apnalaya conducted between 20 March and 25 June, found that 6% of 534 women who gave birth over this period delivered at home —many no larger than 10 feet by 12 feet.
Local municipal hospitals where women had been scheduled to deliver had been turned into Covid-only health centres, and some maternal clinics remained shut through the lockdown.
“With antenatal care clinics disrupted, iron and folic acid tablets for expectant mothers were either not available or families were forced to buy it,” said Poornima Nair, director, health and disability, at Apnalaya. The immunisation of young children, she said, ground to a halt over the last three months.
Many disruptions in routine healthcare procedures carry a more long-term risk to patients. One of the most crippling effects of the lockdown and the pandemic has been on surgeries.
Mumbai’s unabated rise in Covid-19 infections meant that hospitals are so overwhelmed with treating patients with the virus that surgeries, in some hospitals have gone down by as much as 90%, said Satish Dharap Ph.D, secretary, Association of Surgeons in India and head of surgery at Mumbai’s municipal B Y L Nair Hospital.
“If some of them are not performed in time, say a heart surgery or a cancer surgery, a person’s health deteriorates gradually,” said Dharap. “Some others, like a bone replacement surgery, if not performed, leads to a poorer quality of life.”
With Mumbai’s monsoon washing over the city, diseases like malaria and dengue grow. In 2018, according to data gathered by Praja, a Mumbai-based NGO, Mumbaireported 11,799 cases of malaria and 19,516 cases of dengue.
The most common symptom for both is fever, as it is for Covid-19.
“Now, our immediate response to symptoms like fever is to get the person tested for Covid-19,” said a senior doctor at Mumbai’s privately-run Kohinoor Hospital. “In trying to chase the virus, there is a tendency to not investigate patients for illnesses like malaria and dengue and this could be dangerous.”
Prescriptions For Other Cities
While Mumbai continues to report the highest number of Covid deaths, the infection is spreading fast elsewhere.
On July 31, states like Maharashtra, Tamil Nadu, Jharkhand, Nagaland and Bihar, extended their lockdowns. In Maharashtra, Pune and Thane have more active coronavirus infections than Mumbai at 40,225 and and 19,589 cases respectively, in comparison to the 19,314 active cases in Mumbai, according to the daily bulletin issued by the Maharashtra government’s Public Health Department on August 13.
Other cities report stories similar to Mumbai’s: inadequate testing, unavailability of beds and poor use of private healthcare facilities.
Chahal, the BMC chief, said that Mumbai’s experience demonstrated that “four pillars” were needed to beat the pandemic.
“Cities need to basically work on testing, ambulance, hospital beds and doctors,” he said, adding that this needed to be done in time. “When the pandemic hit, we had only 80 ambulances and we gradually increased them to 700,” he said. “Similarly, we had just 271 Intensive Care Unit beds in March but now have 2000.”
Chahal also said that authorities need to make a distinction between isolation beds and hospital beds. “A hospital bed needs to have oxygen, ICU facilities and constant supervision, whereas an isolation bed needs none of that,” he said, Such a distinction was necessary because many governments were passing isolation beds off as hospital beds in order to ward off criticism about shortage in beds.
“The thing they must remember is, isolation beds won’t save lives,” said Chahal.
However, all this was useful only when patients knew what needed to be done, if they were detected with Covid said Vinayak Kamath, vice-president of the Bharatiya Janata Party’s Mumbai wing.
Kamath said between March to the end of June, he got tens of calls each day from families of Covid patients, unable to seek healthcare. “They just did not know what was to be done from testing to beds, they were left to their own,” he said, citing the example of his cousin, who after testing positive was admitted to a quarantine centre after her family could not find a hospital bed. She was discharged a week later.
Asif Zakaria, a three-term Congress corporator from Mumbai’s Bandra West area. Zakaria said that a clear “standard operating procedure” or SOP was vital.
“The SOP must have clearly specified roles for all—patients, families, hospitals, ambulances, private doctors,” said Zakaria. “So, let’s say, whenever there is a new patient testing positive for Covid, the SOP must be able to guide the patient to get the care that he or she needs.”
Consider access to ambulances. Of more than 230,799 calls that the BMC’s helplines received from 24 April to 12 August, over 13%, or 30,224 calls, were for ambulances.
“I know cases where patients died at home because there were no ambulances to take them to the hospital,” said Zakaria. “This is one area where authorities need to plan better.”
Such an SOP seemed to have been in place for areas like Dharavi and Worli Koliwada, where municipal officials systematically followed a plan to establish fever clinics to screen, test and isolate those with Covid symptoms.
A Unifying Authority And The Use Of Experts
Cities also need to use available healthcare resources in the most effective manner, as the sprawling Mumbai slum of Dharavi did. Private nursing homes were turned into dedicated Covid facilities, and private doctors worked alongside municipal officials to run surveillance for the virus (see part 2 of this series for more on the Dharavi model).
“Authorities must realise that private healthcare resources will outweigh public resources,” said Amar Jesani, a Mumbai public-health researcher and editor of the Indian Journal of Medical Ethics. They must create a central plan to rope in private and public facilities and use them to fight Covid.”
Such a plan, Jesani said, would require a unifying authority that would manage resources—from beds to ambulances. “These resources should be employed in a coordinated manner rather than leaving patients to fend for themselves by calling up multiple hospitals and ambulance providers,” said Jesani.
The planning should involve medical and health experts, said a senior bureaucrat not wishing to be named. He pointed to a Maharashtra government’s announcement in April, forming a nine-member task force of senior doctors from private and public hospitals.
“This allowed us to have the best in business advising us on the steps the bureaucracy must take,” said the bureaucrat. “It also allowed us feedback from the ground through these doctors.” The government also set up a Covid control room headed by four bureaucrats, who crunched extensive data that indicated pandemic trends.
One of the four IAS officers, on condition of anonymity, told Article 14 that the control room also helped data-driven decisions. “We would look at various kinds of data, from the demography of those succumbing to the disease to the contact tracing measures,” he said. “Often, the agencies tackling Covid on the ground were too overwhelmed, so the control room would use data and ask them to shape their responses accordingly.”
Perhaps the biggest lesson that Mumbai has for the rest of India is the need for
better testing protocols and more accessible testing, as a sero-surveillance survey, conducted across three administrative wards by the BMC in collaboration with the Niti Aayog, Duke University and others, indicated.
The survey revealed that 40% of the city, or 4.8 million people, had antibodies to Covid-19, which means they were likely exposed to the virus. But Mumbai had tested only 629,899 until 13 August, according to municipal data.
Large cities, such as Mumbai, must avoid the “trap of targeted testing”, said Manoj Mohanan, an associate professor of public policy at Duke University and part of the team that conducted the sero-surveillance study.
“Many policy-makers in India have said that they want to ensure that their testing yields a higher ‘strike rate’ in the belief that it might be beneficial,” he said, referring to the rate of tests yielding positive results.
However, such a policy allows asymptomatic carriers to spread the virus, said Mohanan. “What happens is that you end up targeting only symptomatic cases which is just 5% of all the infected cases in India,” said Mohanan. “In an epidemic, it is the remaining 95% who show no symptoms at all that should be the worry.”
The BMC’s has changed protocols nine times so far, confusing patients and healthcare workers.
“If you make people run around to get tested, they will infect others if they are infected,” said Anant Bhan, a researcher in global health, bioethics and health policy. “If they aren’t, the running around in hospitals makes them susceptible to catching an infection from someone else.”
Communication by public authorities, such as safety measures, the nature of the disease, arrangements made by the government, are critical to combat the pandemic, said Bhan.
“However, all this [communication] is good only if you have actually created the infrastructure for fighting Covid in the first place,” said Bhan. “This is what cities need to remember.”
This reportage was supported by the Thakur Family Foundation. The Thakur Family Foundation has not exercised any editorial control over the contents of this reportage
(Kunal Purohit is an independent journalist based in Mumbai.)
Previously on Article 14: