Dharavi: An unlikely role model

Asia’s largest slum may offer clues to other poor, densely packed communities on how to fight COVID-19

Dharavi: An unlikely  role model

Dharavi, Mumbai was flagged as a potential “breeding ground” for COVID-19 two months ago, as the first cases of local transmission started getting reported from Mumbai.

Surprisingly, this labyrinth of one-room shacks in the heart of India’s financial capital is turning out to be quite the opposite — a role model of how a concerted and methodical effort by healthcare workers and municipal authorities can achieve the impossible by taking the common people into confidence. 

Abode of slumdogs

Dharavi, which got world-wide fame due to Slumdog Millionaire, is the largest slum in Asia, spread over 2.5 sq km, and has a population density of 2,27,136 per sq km. It is home to various small-scale enterprises dealing with leather, pottery, textiles etc, and has 5,000 GST registered enterprises, including 15,000 single room factories, and is a hub of international exports with an annual turnover of
1 billion USD.

“It was in the first week of April that the first cases of COVID-19 were reported from Dharavi,” recalls Dr Shivkumar Utture, President, Maharashtra Medical Council. “Within the next few days, the number of positive cases and the number of deaths due to COVID-19 increased exponentially due to late detection.”.

Taking into consideration Dharavi’s population density and the detrimental effect an uncontrolled spread there would have on the whole of Mumbai, a special meeting was held among local MP Rahul Shewale, the deputy municipal commissioner for ‘G North’ ward (in which Dharavi falls) and members of IMA Mumbai and MDMPA — led by Dr Shivkumar Utture, Dr Anil Pachnekar and MDMPA President Dr Shingnapurkar — to discuss modalities for tackling this pandemic.

“It was concluded that we require to take some proactive steps on a war footing to contain the disease, as Dharavi was a ticking bomb about to explode,” Utture says.

Brihanmumbai Municipal Corporation (BMC), the governing civic body of Mumbai, followed the principle of 4Ts, i.e., Tracing, Tracking, Testing and Treating, according to Kiran Dighavkar, Assistant Commissioner G/North ward of Mumbai.

Home to many diseases and epidemics like cholera, leprosy etc., the area exhibits all the problems expected from a very large population of nearly 1 million living in a space of around 3 square miles. It has extremely congested dwellings, very narrow bye-lanes with bad sanitation and common toilets with around 150-200 people sharing each toilet. 

Assistant Commissioner G/North Kiran Dighavkar too pointed out that 80% of the population in Dharavi depended on community toilets. “Around 450 community toilets are being used every day, and most of the population also depends upon outside food.”

“Around 8-10 people live in 10 by 10 hutments. Dharavi has very narrow lanes and has many 2-3 storey buildings where the ground floor is a house and the other floors are factories. Hence, there are severe limitations of social distancing, with no possibility of home quarantine.”

Door-to-door screening 

During Phase I, that is from 20th April to 30th April, some severe measures were taken. “Local general practitioners belonging to IMA and MDMPA were roped in for door to door screening. Around 25 doctors, along with BMC staff, did a door-to-door survey in the five hot-spot areas of Dharavi which had recorded the highest number of cases. Each group took details like history of travel or influenza-like illness (ILI) symptoms, [and conducted] thermal checking of all the citizens in these areas,” Dr Utture disclosed.

“Around 49,500 personnel were examined in a span of 10 days by doctors in full PPE, 4000+ people were sent to quarantine centres, 430+ were subjected to swab testing, out of which 83 tested positive, giving a positivity of around 20%. The whole endeavour was highly successful because of the full cooperation between private practitioners and BMC personnel,” he added.

After the success of Phase I, a meeting was held at the local ward office to chart out a plan for Phase II. “In the initial days of Phase II, the majority of the clinics of private practitioners were shut in Dharavi due to a fear psychosis amongst medical practitioners and the unavailability of standardised PPEs. It was decided to sensitise all local practitioners to restart their clinics and PPEs were supplied free of cost daily to every practitioner with the good offices of the BMC,” Dr Utture mentioned.

“Within the first week, around 125 clinics were restarted and by the end of May, around 250 clinics reopened in Dharavi. All the practitioners were provided with PPEs, thermal scanners and finger pulse oximeters. Special permission was taken to examine fever patients by local doctors as there was a directive from the municipal commissioner to not examine fever patients, but refer them to BMC fever clinics started in every ward by the BMC.” 

Strict measures 

“Patients were actively examined by local general practitioners and suspected cases were referred to BMC officials for PCR testing and quarantine/isolation, facilities for which were started in Dharavi itself, and where stay was free. BMC made arrangements for their daily necessities. Hence, local people were amenable and co-operative in getting quarantined and treated, as they could stay in Dharavi and were not shifted to far flung areas. It was also decided to sanitise the clinics of all general physicians on a daily basis by BMC sanitisation personnel. Also, local public toilets were sanitised at least 3 times a day and strict containment and control of movement of people was ensured. Due to all these strict measures, our hard work started bearing fruits by the end of May 2020,” Utture said.

“BMC decided to proactively screen high-risk zones and organized fever camps for the identification of suspects. As manpower was a key issue, BMC mobilised all available private practitioners. Through this drive conducted in mission mode, 24 private doctors came forward and BMC provided them with PPE Kits, thermal scanners, pulse oximeters, masks, gloves and started door-to-door screening in high-risk zones and all suspects were identified. Later, all practitioners were asked to open their clinics and attend the patients and communicate all suspects to BMC. Also, BMC sanitised the clinics of all these private practitioners and provided them all other support as well,” shared Assistant Commissioner G/North Kiran Dighavkar. 

According to statistical data, out of the 2,013 cases as on June 15, 1,040 cases were discharged, 941 remained active and 77 deaths were recorded. “The recovery rate was more than 51% of the total cases. The growth rate fell steadily from 12% in April to 4.3% in May and 1.05% in June. Mortality rate dipped from more than 5% in April to 4% in May and around 3.7% in June. The doubling rate plunged from 18 days in April to 43 days in May and 80 days in June,” mentioned Dr Utture.

The total positive cases diagnosed in April were 491, 1261 in May and in June (upto 15th), it was 274. “We believe that well begun is half done, and we require to be extremely vigilant as the cases may increase due to partial lifting of the lockdown and the arrival of monsoons, which will also increase vector-borne diseases and influenza cases. Dharavi has been a success story purely because of the cooperation between BMC and private practitioners and is being hailed and appreciated by chief minister Uddhav Thakeray, the health minister and authorities. Our fight against COVID-19 will continue and we shall do our utmost to contain this disease,” said Dr Utture.

The Dharavi model is being activated in many other hot zone slum pockets across Mumbai. “Unfortunately, the launch of these projects was delayed, leading to an increase in cases. The basic concept of medical entities and sanitation departments being given a free hand was not followed across the board. Local citizens and political parties need to be actively involved and the basic needs of the citizens regarding daily necessities, nutrition, sanitisation and medical needs require to be rigorously pursued,” he further added.

Local physicians turn the tide 

The reasons behind the success in Dharavi were the involvement of local family physicians who knew the pulse of Dharavi residents, the confidence of Dharavi citizens as they were examined by familiar doctors who were practicing for 15-20 years in local areas and the education of the citizens about this dreaded disease and the need to be diagnosed and treated at an early stage. Along with the examination, the doctors were also engaged in sensitising the patients.

“Early intervention i.e. launching of Project I immediately after a few active cases were reported, well-coordinated efforts of all sections of government, municipal corporation, private medical practitioners, NGOs and local political parties, letting the medical team and sanitation department take precedence and allowing them to take the lead on the front line, a proactive municipal corporation department, full cooperation between private medical practitioners and MCGM departments, active testing, contact tracing and compulsory quarantine/isolation, door to door screening of high-risk population, sensitisation and holding regular public awareness meetings for gaining confidence and cooperation of local citizens controlled the spread of coronavirus disease.

“The basic mantra should be testing, contact tracing and early quarantine/isolation if we want to succeed in containing the spread of COVID-19,” Dr Utture concluded.

Kiran Dighavkar said 90% of Dharavi patients were treated inside Dharavi itself and only critical patients were moved outside Dharavi for admission to hospitals. The high-risk zone was sealed from all sides and community leaders were appointed as part of ‘Covid Yoddha’ plan to address all the issues of the community. BMC also distributed 25,000+ grocery kits and 21,000+ food packets for lunch and dinner separately within the containment zones. So people stayed inside Dharavi and did not have the need to move out, thereby curbing the spread of the virus. Apart from this, food and grocery were also supplied and distributed free of cost by the local MLA, MPs and corporators.”

Sharing information regarding setting up of health infrastructure, he further added “All private hospitals were onboarded and acquired for treatment, including Sai Hospital, Prabhat Nursing Home, and Family Care.

Since home quarantine was never an option in the area, the focus was always on setting up of institutional quarantine facilities covering all available schools, marriage halls, sports complexes etc. In all institutional quarantine facilities, all the below facilities were provided:

1. Community Kitchen: Breakfast /lunch /dinner

2. 24*7 Doctors/ nurses / medical staff

3. Medicines/ Multivitamins

4. All medical equipment

Under the guidance of Municipal Commissioner Iqbal Singh Chahal, a 200-bed hospital with oxygen supply was set up in 14 days.

From being a hotspot, Dharavi has now become a role model and has given several lessons to other similar areas in the city. However, all is not over yet as Maharashtra still remains the worst affected state in the country. With the arrival of the monsoons that brings with it several water-borne diseases, and the relaxation of restrictions by the government, the situation might prove fatal to the people residing in the state. However, hopes remain that armed with strong actions, Maharashtra might be successful in containing the virus. 

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