How Dharavi flattened the curve, and showed Mumbai the way

BMC credits extensive screenings, contact tracing and stringent quarantine for the drop in cases

On May 8, Dharavi-based labour contractor and community volunteer Avirath Shinde, 36, was carrying a large package of food to distribute to families in India’s worst-affected Covid-19 slum cluster. He was in a hurry that day, and on the unevenly paved inner lanes of Dharavi, Shinde slipped and fell, breaking his hand. He walked to the nearest private hospital to get his bones fixed, and it was here that he began to complain of fever.

In May, Dharavi reported an average of 48 cases per day, with May 3 recording 94 cases, its highest single-day spike. In April, while the average was 18 cases per day, the second half of the month saw intermittent spikes. (Satyabrata Tripathy/HT file photo)

The doctors immediately tested him for Sars-CoV-2, the virus that causes Covid-19. When the reports came in later that day, Shinde was found to be positive.

Dharavi is India’s largest slum, with over 8.5 lakh people living in around 55,000 dwelling units spread across approximately 2.5 sqkm. The population density here is 3.4 lakh per sqkm, more than 10 times the average population density of Mumbai (32,303 per sqkm) according to a July 2019 United Nations Population Review. On average, in Dharavi, around 10 people live in every housing unit that averages 100 sqft in size.

Shinde’s household is no different. There are at least 14 people in his joint-family house that measures approximately 1,200 sqft, a large unit by Dharavi standards. As soon as Shinde tested positive, his family was classified as ‘high-risk contacts’, and every member was tested the same day.

Between May 11 and May 12, Shinde’s wife, his 56-year-old mother and his 88-year-old grandmother also tested positive.

The Shinde family was one of scores from Dharavi that tested positive in April and May, the months when Covid-19 peaked in this region, making it one of the country’s worst-affected Covid hotspots, along with Worli Koliwada in Mumbai’s G-South ward.

In May, Dharavi reported an average of 48 cases per day, with May 3 recording 94 cases, its highest single-day spike. In April, while the average was 18 cases per day, the second half of the month saw intermittent spikes. For instance, on April 28, Dharavi reported 42 cases, and on April 20, 30 cases. But in June, Dharavi seems to have turned the corner; cases are rising only by 18 per day. In fact, on June 23, it recorded only five cases, the lowest since April 5, prompting the Brihanmumbai Municipal Corporation (BMC) to shutter two Covid care centres (CCC), a Covid facility at the Rajiv Gandhi Sports Complex, and a quarantine centre at a local municipal school.

Noted epidemiologist and the state’s Covid-19 surveillance officer Dr Pradeep Awate, said, “Dharavi’s cases plateaued in early June, and the curve has now flattened. We are seeing signs of further reduction, and soon the curve will begin to dip. The challenge is to maintain this momentum.”

The dip in cases led to recognition by the Union ministry of health and family welfare. On June 21, it issued a release touting the Dharavi model.

Dharavi’s current daily growth rate is just 0.47%, compared to the May average of 4.3%.

While 34 new cases were recorded on June 1 (the month’s highest number), June 2 saw 25 cases. The downward trend continued with 19 cases on June 3, 23 on June 4; 17 on June 5; 10 on June 6; 13 on June 7; 12 on June 8; 26 on June 9; and 11 on June 10. Since then, the highest number was reported on June 12 (29, with two deaths). On June 24, Dharavi saw only 10 cases, while eight cases were recorded on June 26.

Overall, Dharavi – which is part of the 9.07 sq km G-North ward – has recorded 2,218 Covid-19 cases and 81 deaths as of June 26. The same day, Mumbai had a total of 72,175 cases and 4,179 deaths. While it was one of the country’s worst hotspots in April and May, Dharavi’s doubling rate on Friday rose to 140 days, compared to Mumbai’s average of 41 days (June 24) and the national average of 19.1 days (June 26, source: covid19india.org). “It seems (that Dharavi has flattened its curve). Even in my hospital, there used to be a waiting list of patients, but for the last four or five days we have some vacant beds. ICU beds are still full, so the critical patients are still recovering, but overall it seems that cases per day are decreasing,” said Dr Behram Pardiwala, head, department of medicine, Wockhardt Hospital.

It was not easy achieving this plateau, though. Kiran Dighavkar, BMC assistant commissioner and the G-North ward officer said Dharavi’s population density was the biggest challenge “right from the beginning”.

Four-fifths of its population still relies on the 450 community toilets, and an average dwelling unit is not more than 250 sqft big with at least 10 persons living in each. “Social distancing is impossible here,” said Dighavkar.

The Dharavi model, therefore, had to be different, and more aggressive. The BMC used what it called the ‘4Ts’ approach – Tracing, Tracking, Testing, and Treating.

According to Dighavkar, strict containment measures have been in place since the beginning, and BMC even delivered cooked food, or grocery packets to residents to ensure they do not need to break containment zone rules for essentials. “We proactively screened residents through fever camps, and that helped us identify those with Covid-19 risk from the community randomly. With early detection, the suspected cases and high-risk contacts of Covid-19 patients were identified and placed at quarantine centres,” said Dighavkar. “Over 90% of Dharavi’s cases were treated within Dharavi, and only critical patients were moved out for treatment.”

While the government and civic institutions such as sports complexes and schools were converted into isolation and treatment centres, BMC acquired three private hospitals in Dharavi, in addition to erecting 22 Covid care centres with 4,447 beds and four dedicated Covid health centres with 266 beds. BMC staffers and volunteers even organised laughter therapy and music sessions at these centres to keep up the spirits of Covid-19 patients.

The tracing and tracking programme included a massive door-to-door screening exercise using mobile dispensaries, which was run by hundreds of BMC staffers and healthcare volunteers.

While mobile dispensaries screened 14,970 people in Dharavi, over 3.6 lakh people were screened by private doctors working with BMC, and municipal staff in door-to-door visits to 47,500 homes. Senior citizens and comorbid patients, considered as vulnerable groups for Covid-19 were screened for oxygen concentration in the body, and simultaneously treated. A Union health and family welfare ministry statement issued on June 21 said that “8,246 senior citizens were surveyed and as part of its policy of ‘Timely Separation’, they were separated from the other community to effectively limit the transmission of the disease”.

In addition, over 25,000 grocery packets and 21,000 food packets have been distributed in Dharavi so that people stay indoors and do not leave the containment zones.

This programme was so successful that BMC Commissioner Iqbal Singh Chahal announced on June 22 that it will be replicated across Mumbai’s western and central suburbs as part of BMC’s Mission Zero project. Across the city, 879 municipal dispensaries are operational and 5.8 lakh people have been screened so far.

In Dharavi, the Shinde household was among the hundreds that were isolated. “We did not interact with anyone and were locked up in our house at all times for 14 days,” said Avirath Shinde, who had tested positive in May.

“We had home quarantine stamps on our hand. All food, including vegetables and milk, were brought to us by volunteers or BMC staff. Because my grandmother is old and had cough in her chest after she tested positive, the kind of hospital bed needed for her was not easily available. We had to look for an entire day for a bed, moreover, I was already quarantined and could not contribute to the hunt.” Shinde beat the virus in May itself, and is back to being a food distribution volunteer.

Despite the victory, the challenges of maintaining the downward curve remain, as Dharavi’s economy largely depends on small enterprises run from single rooms or homes within the slum. As businesses open as part of the state government’s Mission Begin Again, migrant labourers who had returned to their hometowns are gradually returning, and physical distancing may once again pose a huge challenge, say activists and healthcare professionals.

“Migrant workers left Dharavi throughout the lockdown months. But they will all eventually return and we will kickstart the local economy,” said Dighavkar. “We will then continue with tight containment measures to ensure cases are in check.”

Dharavi has over 15,000 single-room factories, and over 5,000 GST-registered enterprises. During the lockdown, according to BMC estimates, over 1.45 lakh workers left Dharavi to go to their hometowns. Dr Awate said, “Such infections [Covid-19] are known to bounce back. The future trend in cases will depend on the quality of interventions and their efficacy. Strong containment measures have proved successful in Dharavi, so we will have to maintain them.”