5 political decisions that helped Mumbai cope with Covid-19
The city reported its first two infections the same day that the World Health Organization (WHO) declared the Covid-19 outbreak a global pandemic. On March 11, 2020, Maharashtra had detected 68 patients of the coronavirus disease. A year on, more than 2.16 million people have been infected in the state, and of those, 327,619 are in Mumbai. The state authorities soon realised that Mumbai needed special measures to control the spread of the disease. Even today, the seven-day average of cases is at the worst since the end of November, though it still remains significantly below the peak of the first wave. As we stand at this juncture, a look at how we got here.
Stopping the trains
For 84 days, starting March 23, 2020 — two days before the national lockdown began —the city came to a standstill. Chief minister Uddhav Thackeray announced that local suburban train network would stop from March 22 midnight as part of the restrictions on movement due to the coronavirus pandemic. The following day, the Centre announced that local train services will be stopped in Mumbai. This was unprecedented, if anything; even after the July 11, 2006 train bombings which claimed 209 lives, local services resumed within hours.
It was only in July 2020 that trains — almost half the pre-lockdown numbers — began to ply; only essential services workers were allowed to travel by them. Railway stations also maintained a single entry and exit point, and the Railway Protection Force and Government Railway Police personnel kept a check on who arrived.
“I think it was the right decision, given how crowded local trains in Mumbai get, and how low the uptake of masks was then. There was also no background immunity and continuing the operation of trains would have the potential of being a super-spreader mechanism,” said Dr Lancelot Pinto, a Mumbai-based epidemiologist, who is a consultant pulmonologist at PD Hinduja National Hospital. Much of the rise in case numbers now is being attributed to the resumption of train services for the general public since February 1. Yet this call showed was that it was possible to implement what could have well been the toughest decision for Mumbai.
As the locals and outstations trains were suspended, the migrant population in the city started taking road transport. Most migrants also attempted to go to their home states and town on foot. By March end, Maharashtra government directed district authorities to stop the migrants, shift them to temporary shelters, and provide food and medical assistance.
Several municipal officials, irrespective of rank, realised that swift decision-making was vital to curb the spread of the disease. But, in a city of over 20 million people, how was this to be achieved? To that end, the BMC set up its first control room in June. Such control rooms, or war rooms, were opened in all the 24 wards of the city. Additional municipal commissioner Suresh Kakani, who is in charge of the civic health department, said that this decentralisation of power was key in helping the administration fight Covid-19.“Financial and administration powers were delegated to ward offices, various [hospital] deans and facility operators for the procurement of material, creation of infrastructure, etc. We provided 15 ambulances in each ward at their disposal, we gave a dedicated medical team for immediate medical intervention,” Kakani pointed out.
Each war room had a team of 10-12 civic employees and doctors who would work in shifts to help people get ambulances, offer details on hospital bed availability and help people with the next course of action in case they tested positive. “A typical day in a ward room started with receiving the Covid test results at 7.30 am. Doctors on the team would inform the patient and tell them if they needed to be treated in a hospital or if they could opt for home isolation provided certain conditions were fulfilled,” a BMC official said. “The Mumbai strategy that worked was decentralisation of power. Each ward became a mini-Mumbai and each ward officer became like a local municipal commissioner. Strategies were common and overall response improved. Whether it was public hospital or private, protocols were clear—oxygen, supportive care, and steroid, along with aggressive comorbidity care. That was the game changer for Mumbai,” said Dr Shashank Joshi, endocrinologist and member, Maharashtra’s Covid Task Force.
Bringing the experts in
The Maharashtra government constituted a nine-member panel of experts in April to advise them on how to handle the epidemic. This meant that administrative officers received continuous scientific inputs to enable them to make decisions while dealing with the crisis. The team, led by Dr Sanjay Oak, who was the dean of civic-run King Edward Memorial (KEM) Hospital, was asked to suggest ways to reduce the death toll, recommend a drug protocol in treating critically-ill Covid-19 patients, establish a management protocol for serious and critically-ill Covid-19 patients, and suggest the healthcare support needed in Covid-dedicated hospitals, among other things. Besides the Covid task force, the state government also formed similar teams in 34 districts of the state.
Former Additional Chief Secretary of Maharashtra Chandra Iyengar, who also handled the health department during her service in 2009, lauded the government’s move on setting up such a group and giving them a free hand to chalk out the road ahead. “The priority that was laid down and the approach was good [to set up a treatment protocol]. Given the largeness of the problem, there was no confusion. They have been clear in the approach. The government respected the task force that it set up and almost gave this group of experts full freedom to work... The direction has been correct. Even today, there are cases but the death rate is in check. What is critical that lives should not be lost. Because there was clarity right down the line, with no two people giving two differing ideas that helped [the city],” Iyengar said.
Easing strain on hospitals
Mumbai faced a severe shortage of beds in the initial months of the pandemic, and as the caseload began to increase, patients began to be turned away from hospitals and many couldn’t receive adequate care on time. In the second week of April, the BMC came out with a standard operating procedure for treatment.
It opened Covid Care Centres (CCC-1 and 2) — the first for high-risk contacts of positive persons and the second for asymptomatic and mildly symptomatic patients — in makeshift facilities; Dedicated Covid Health Centres (DCHC) for symptomatic patients, moderately-ill patients and some patients with co-morbidities; and Dedicated Covid Hospitals (DCH) for patients showing prolonged symptoms of fever, cough, and breathlessness, senior citizens, as well as severely ill and critical patients who needed ICUs. In April, the National Sports Club of India’s (NSCI) stadium dome in Worli was made into a 500-bed isolation facility and later upgraded to Mumbai’s first jumbo Covid facility. In all, the BMC created seven such jumbo facilities across the city, including Mulund, BKC and Goregaon. In July, when Mumbai hit its peak, it had a total of 16,859 beds all dedicated Covid hospitals, and by October, the city had nearly 70,000 beds across all CCC1 and 2 facilities, which also included seven jumbo Covid centres that could cumulatively handle 5,000 patients.
“Initially beds [jumbo centres] were only for patients who tested positive. Then gradually beds were available for walk-ins, or for someone who was a suspected case. We ensured that all critical facilities were available such as ICU units, ventilators, and oxygen. Initially oxygen supply was cylinder-based. We turned to a pipeline system by connecting it to a turbo cylinder with capacity of 13,000 litres. It provided a major support as most patients did not require ventilators, and oxygen supply beds did the work. This helped us reduce the mortality rate,” said Kakani.
Test, test, test
The one parameter that Mumbai has consistently scored the best on, compared to other Indian cities, has been testing: With a testing rate of 19,015 samples tested a day on average for the week ending February 25, 2020, it is the highest the city has ever done. In March last year, Maharashtra had only two reverse transcription polymerase chain reaction (RT-PCR) testing facilities: the National Institute of Virology, Pune and Kasturba Hospital, Byculla. Soon, the civic body added testing facilities at other civic and state-run hospitals.
By mid-April, 10 private laboratories and diagnostic centres were added to the list of testing centres. “Our testing capacity was scaled up every few months. Today we have a capacity to test about 25,000 samples in a day, including RT-PCR and antigen test,” said Dr Daksha Shah, health officer, BMC. According to Kakani, Mumbai was the first to liberalise testing in the country. Initially, only people who have a prescription from a doctor could get tested for coronavirus, which changed after July 7. “We liberalised testing against the guidelines of ICMR as we wanted more people to get tested. From July 7, self-declaration by people was more than sufficient to get tested,” he said. Currently, there are 37 private laboratories and hospitals that are authorised to carry out RT-PCR and antigen tests. According to a civic health department official, the private laboratories alone boost Mumbai’s daily testing capacity by 90%.