Covid-19 surge pushes Mumbai to the brink
On May 10, a 35-year-old bank loan agent in Mumbai suddenly developed a temperature. With the city firmly in the grip of the coronavirus pandemic,his family was alarmed but he dismissed their concern, saying he hadn’t come in contact with any confirmed Covid-19 patient.
He ran to the local medical store in the neighbourhood in Vakola, and bought a strip of paracetamol. When he went to bed that night, he thought his body temperature would be down to normal the next day.
That didn’t happen. By morning, he was burning up and over the next two days, his condition slowly deteriorated. On May 13, his 38-year-old brother took him to VN Desai Hospital where an X-ray showed patches of pneumonia in his lungs that made the consulting doctor suspicious.
He was referred to Cooper Hospital, a designated Covid-19 hospital in the city.
“After standing in a line for two hours to take a slip to see a doctor, I was informed that the line for the fever clinic is different. By that time, my brother had already started having trouble breathing. So, I rushed him to a private nursing home,” said his brother.
The nursing home refused to admit him without a swab test. So, the doctor at the nursing home prescribed a Covid test and he was taken to Hinduja Hospital for a test.
After three days on May 16, the report confirmed that he was a Covid carrier.
Worried, his brother called the Brihanmumbai Municipal Corporation’s (BMC) helpline number (1916) for guidance. At 6pm that day, two doctors came to examine the patient.
“The doctors informed me that at around 8pm, they will send an ambulance,” said the brother. But the vehicle didn’t arrive even at 10.30pm, prompting the brother to call the helpline again. “Finally after four hours of wait, at round 12.30am, the vehicle came,” said the brother.
There was now a new problem – the ambulance didn’t have any oxygen support system, critical for a patient with severe breathing problems.
By the time they reached the Guru Nanak Hospital, four kilometres away, the patient’s oxygen levels had dipped to dangerous levels. The hospital had no intensive care unit (ICU) beds available so the doctor referred him to Seven Hills Hospitals, 12km away. They reached the hospital at 1.45am.
“Before we could enter, police stopped us at the gate and told us that there was no bed available. Despite repeated pleas, they didn’t allow us to go inside. Then they asked to go to Nair hospital [in central Mumbai],” said the brother.
By now, he had travelled across five suburbs of the city, first to get a diagnosis and then, in search of a bed. Frantic, the brother dialed Nair Hospital, one of the largest Covid-19 facilities in Mumbai with 52 ICU beds, but was told there was none available.
Four more hours were spent in the ambulance before a local politician helped the family get an ICU bed at the Jogeshwari Trauma Centre. The bed was available only after 9am.
It was already 5am, so the brothers went home to rest. “My brother’s back was paining by sitting in the ambulance for so long and there was no oxygen support, he couldn’t even breathe, so I took him home. We rested for four hours, then went to Jogeshwari Trauma Centre,” said the 38-year-old.
When they reached the hospital at 9am on May 18, they were informed that there were no vacant beds. After waiting for another three hours, at around 12pm, the patient finally was admitted to the ICU and given a bed – a week after his symptoms had worsened and two days after he was confirmed to be a Covid patient.
At night on May 18, his brother received a call that the patient’s condition was severe and that he had been put on a ventilator. “Then, at 12.35am, the hospital informed me that my brother succumbed to his infection,” the brother said.
Devastated with their loss and seething at the lax response of the authorities, the family researched his condition and found that patients develop pneumonia in the later stage of the infection.
“This means he was already serious. But because of the delay of 18 hours due to unavailability of ambulances and bed, his condition deteriorated,” said the brother. “If he got treatment on time, I could have saved him.”
The harrowing experience of the Vakola family is not isolated.
On May 1, a family from Chembur visited five hospitals to get a 62-year-old woman admitted but couldn’t. Four days later, the woman succumbed to the infection without getting any treatment. “I had never felt so helpless as I did when I could not save my mother. I was ready to put in all my savings but no hospital was ready to admit and treat her,” said the daughter.
A 38-year-old patient from Govandi could not find a bed for four days and was turned away from four government hospitals. He developed Covid symptoms on May 3; his condition is now critical but he has not even been administered a swab test.
Much like New York was in March and April, Mumbai is struggling to cope with the surge of Covid patients. Hospitals are stretched to capacity, front-line staff are struggling to deal with physical, emotional and psychological trauma and tempers are running high among patients and medical staff.
Doctors are contracting the infection by the dozen, fights are breaking out in hospital queues and bodies of deceased patients are being left behind in wards for hours on end. A worried civic body has taken over large sections of private hospitals and is looking to turn buses and school vans into makeshift ambulances.
“Mumbai is on the verge of a health crisis,” said Dr Deepak Baid, president of Association of Medical Consultants. “The corporation should have made the arrangements earlier considering the huge population of Mumbai. Now, the helpline number has started giving a token number for the waiting list. They don’t even consider the patients who are critical,” he added.
Mumbai reported its first infection on March 11, when two passengers from Dubai tested positive. But the city’s crisis grabbed national attention on April 1, when the first case was reported from the slum cluster of Dharavi, where more than a million people jostle in cheek-by-jowl shanties and tin-roofed rooms are often shared by eight or 10 people.
Since then, the virus has raced through almost every neighbourhood of the coastal city, from the upmarket localities of Marine Drive and Malabar Hill to the working-class neighbourhoods of Worli and Sion. As of Sunday, Mumbai had 30, 542 cases with 988 fatalities.
On average, the city has reported around 1,500 cases every day this week, with experts warning that the peak of the disease will come in the middle of June. On Sunday, the city crossed 30,000 cases with 1,725 new infections – its highest daily jump yet.
This trajectory of the virus is well chronicled. When the disease pummeled New York in early March, the daily tally of cases suddenly jumped from the hundreds into several thousands. A week later, hospitals were overflowing and exhausted health care staff struggled to treat the patients who were being wheeled in almost every minute, as as depicted in unforgettable photos from that time of tired nurses with garbage bags for protective equipment.
The Maharashtra government’s data says roughly 29% of the state’s patients need hospitalization. Daksha Shah, deputy health officer of the BMC, further added that 20% of the patients require ICU care and 5% need ventilators.
In Mumbai, which has 21,297 active cases, Shah’s calculation translates to roughly 6,100 patients needing hospitalization, 4,200 patients needing ICU beds and 1,060 requiring ventilators.
A separate calculation by the daily report of state medical education and drugs department pegged the percentage of patients requiring critical care at 5%. If this figure is extrapolated for Mumbai, it translates to around 1,000 patients.
But the BMC controls just 530 ICU beds, though the capacity has now gone up to 1,165 after the government on Friday took over 80% of beds in private hospitals in the city.
Additionally, the city has 589 ventilators, and 2,255 beds with oxygen support systems.
“This will be inadequate,” said a top state health department officer on condition of anonymity.
He said according to the government’s calculations, almost 0.5% of Mumbai will be infected by the end of June, which translated to at least 100,000 infections. At the 5% ICU requirement calculation mentioned earlier, this translates to 5,000 ICU beds.
One big advantage Mumbai has over New York is that India has a much lower fatality rate than the US – 2.9% compared to 5.9%.
But the city is grappling with rising panic and outdated technology.
Government procedure dictates that a patient is supposed to call the BMC helpline and get themselves registered for a hospital bed, which is then allotted to the patient as soon as it is available. This may take between a few minutes to several hours.
The BMC helpline is fielding 4,000 calls daily – out of which 1,800 are for bed requests -- but the lack of live dashboards means that helpline coordinators cannot guide patients on time, causing further delays.Volunteers of the number say unavailability of live updates from hospitals cripple their ability to help patients.
“By the time we assign a bed to a caller, the bed gets booked by another critical patient. There are waiting lists in all tertiary care hospitals. So, we need to distribute the crowd to peripheral hospitals where beds are available. For that, we need a live dashboard to inform patients,” said a volunteer on condition of anonymity because he is not allowed to talk to the media.
In response, BMC officials said they have put in place a foolproof system.
“We have appointed a doctor in the 1916 control room, who is supposed to gauge the need to allot an ICU bed, on call with the patient, after asking a set number of simple questions. These questions can help the doctor determine for the time being if the patient primarily needs an ICU bed. Every co-morbid patient does not need an ICU bed,” said Suresh Kakani, additional commissioner (health), BMC.
Officials also said they are developing a live dashboard in coordination with a private company that will be installed soon.
“Only BMC officers will have access to the dashboard. It will get updated every 30 seconds. It will have the list both from private and civic-run hospitals. We can’t keep it open as people will unnecessarily start flocking to the centres,” added Kakani.
Beds in Mumbai are divided into three categories:
One, Covid Care Centres 1 and 2 (CCCs 1 and 2), the first for high-risk contacts of positive persons and the second for asymtomatic and mild symptomatic patients.
Two, Dedicated Covid Health Centres (DCHC) for symptomatic patients and moderately ill patients and some patients with co-morbidity; and, three, Dedicated Covid Hospitals (DCH) for patients showing prolonged symptoms of fever, cough, and breathlessness, patients with co-morbidity, Covid positive senior citizens, severely ill and critical patients who need ICUs.
In all, there are 73,000 beds in Mumbai -- 5,500 DCH, 10,000 DCHC, 23,000 CCC1 (not for Covid patients), and 34,500 CCC2 beds.
Currently, a total of 5,392 patients are admitted in the first and second categories of beds – the most critical. Out of this, 4,056 are in government and civic-run hospitals while 1,336 are in private hospitals.
Kakani said the body has sufficient CCC, DCHC and DCH beds for Covid-19 patients. “It is true however, that there are limited number of ICU beds and these need to be used judiciously,” he admitted.
According to the government, there are four main reasons for the shortage in critical care.
One, many patients and their relatives prefer major hospitals to peripheral hospitals. “While we have beds available in peripheral hospitals, we cannot force a patient to go there if he doesn’t want to. The hospitals everyone chooses are the ones that are over burdened,” said a senior civic body official on condition of anonymity.
Two, the stigma and panic around the infection prompt many families to not seek treatment on time. “They wait and watch for the symptoms to subside, but it only gets worse. Many patients come to hospitals at a much later stage of the infection, and then need critical healthcare,” said a second civic body official on condition of anonymity.
Three, many patients insist that doctors put them on oxygen support even if their levels are normal. “Due to the anxiety and fear, they become breathless. Then they assume that their oxygen saturation is low. The recovery rate among patients between 20-40 years is high. We need to save the beds for senior citizens with co-morbid issues,” said Dr Om Srivastava, a city epidemiologist who is also part of the Covid task force.
Four, many government officials feel private non-covid hospitals should not discharge a Covid-19 patient until a bed is found in a Covid hospital. “We coaxed private hospitals, offered them incentives, but it did not work. Hence we came up with the guidelines for 80% reservation of beds in all private hospitals, managed and distributed centrally by BMC,” said a third civic body official.
The BMC says it is aware the city is yet to hit the caseload peak and is preparing for an even bigger surge in cases. So-called Jumbo facilities for asymptomatic patients in six locations are being converted into critical care units, with at least 10,000 beds added. At least 50% of these will have oxygen points as well and 10% beds will be reserved for virus patients who need dialysis.
The BMC is also revamping mini buses and school buses to make ambulances and hopes this will add 350 vehicles to its 250-strong fleet. “The preparations we are making now will complete by May end. These are being made keeping June’s cases in mind,” said additional municipal commissioner Sanjeev Jaiswal.
The surge of the pandemic has hit hard thousands of medical staff at the forefront of the fight against the virus in isolation wards.
Interns, resident doctors, senior doctors, and nurses, all working in three shifts of eight hours each with personal protective equipment (PPE) as their only shield, are fighting a steep battle against not just the disease but also associated mental health concerns.
In Mumbai alone, 300 medical staff have contracted the infection.
“We can’t start the air conditioning due to possible transmission of the virus. In this heat, we have to work in PPE for 6-8 hours without even drinking water. With precipitation and dehydration, our body starts aching. We feel dizzy,” said a doctor stationed in the isolation ward of St George Hospital which has over 100 covid-19 patients.
Many woman nurses and doctors complain of urinary tract infection (UTI) due to the dehydration. The problem gets worse during menstruation. “During the monthly cycle, women generally feel nauseous and weak. With the PPE on, we can’t even go to the washroom, to get refreshed,” said a nurse from Kasturba Gandhi Hospital.
All the medical staff on Covid duty are given alternative accommodation in hotels or lodges. Many haven’t seen their family for over two months.
“I have a 3-year-old daughter whom I have seen last in March. We do video chats everyday but I miss hugging her,” said Mahalaxmi Iyer, a nurse at Seven Hills Hospital, a resident of Vasai.
At the Kasturba Gandhi Hospital, a 48-year-old midwife developed loose motions. So, she used an adult diaper for two days to avoid going to the washroom while on PPE.
“I can’t take leave as we are already short staffed and I couldn’t afford going to the washroom repeatedly. So, I used an adult diaper. It felt uncomfortable in the beginning but later, I got used to it,” she said.
The fear of contracting the infection is ever present. So far, over 75 resident doctors have contracted the infection on duty. Many of them are as young as 20 years.
“We weren’t ready to face the situation. Even after the duty hours, we discuss the reports of patients. Many of us have developed anxiety. Then parents keep forcing us to come back home which adds on to the mental trauma,” said a nursing student from Sion hospital who contracted the infection.