India’s health systems buckle as case counts explode

July 11, 2020 0 By FM

Even as India negotiates with weapon-rich-countries like Russia and France to bolster its firepower in view of the escalating border tensions, inside the country, the COVID-19 virus continues to batter its citizens of the country with a new-found rage.

“The sacrifice of Indian soldiers will not go in vain. India is capable of giving a befitting reply,” vowed India’s Prime Minister Narendra Modi on June 17, confirming deaths of 20 Indian soldiers during a scuffle with China’s People’s Liberation Army in the latest flare-up along the long-disputed Indo-China border in the Himalayas. 

Away from the border, around 500 people die every day of COVID-19 and another 20,000 fall within its grasp as the pandemic continues to ravage the length and breadth of the world’s second-most populous nation.

However, in this war with the ‘unseen enemy’, India has few weapons to fight with and stands largely exposed and defenceless, not unlike most other countries in the world.

India surpassed China, where the virus is believed to have originated, both in terms of infections and deaths, long back. Today, the country is reporting more infections per day than any other nation except the US and Brazil. Going by the current trend, it could even emerge as the No.1 in days to come. 

In fact, India is yet to control the initial wave of the outbreak while countries such as China and South Korea are testing newer approaches to tackle repeated outbreaks after declaring victory over the first wave of infections.

India embarked on the process of lifting its 10-week-old lockdown restrictions in early June, at a time when the infection was starting to gather steam instead of showing signs of abating.

The government seemed to have stopped listening to health experts after the shutdown cost the country more than 100 million jobs, while failing to bring the infection under control like it did in other parts of the world. The sputtering economy could not withstand the impact of such a long shutdown and was starting to show signs of crashing, sending alarm bells ringing in the government corridors.

However, with the loosening of the restrictions, the number of infections also started exploding. From a few hundred per day at the time the lock-down was imposed in March, the number of new infections soon crossed the 20,000 per day mark.

As the uncontrolled spike in new cases leaves health authorities in India’s big cities scrambling for a solution, some states have even started demanding the imposition of another full-fledged pan-India lockdown to gain a hold over the rapidly worsening scenario.

Creaking under the heavy load

The huge rise in the number of new cases have put tremendous pressure on the country’s already overburdened healthcare system. 

Hospitals in most of the country’s major cities are crammed and over-crowded with corona patients. 

Delhi, where the virus spread is one of the highest in the country, has been reported to be facing an acute shortage of beds, even though the state government maintains that things are well under control. Many public hospitals have already hit their surge capacity. 

Even patients in need of emergency care are being turned away by many hospitals in the country’s capital.

Currently, chances of admission to hospitals are very little, not only for COVID-19 patients but also for people who require intensive care in Delhi, reports say.

The situation is getting out of hand by the day as the number of people catching the infection grows exponentially.

The local government has now proposed to commandeer some of New Delhi’s fanciest hotels to turn them into hospitals. The banquet halls of some hotels have already been converted to COVID-19 care homes and more such hotels are being enlisted amid protests from the hotel industry.

An expert committee of doctors constituted as per a Delhi High Court directive to examine the feasibility of the proposal found that “banquet halls can be appropriately equipped and converted into dedicated COVID health centres if the need arises on account of acute shortage of hospital beds” provided these “COVID Care Centres” ensure training of the hotel staff in infection control practices, including donning/doffing processes. 

The central government has already repurposed hundreds of railway coaches to be used as sick bays, though their utility is currently limited by hot weather conditions. 

Meanwhile, the media is filled with heartbreaking stories of deaths due to utter neglect and disregard by hospitals in India’s capital city.

Taking cognisance of the media reports, the Supreme Court made an intervention, reprimanding the Delhi government over its mismanagement of dead bodies and described the treatment provided to the COVID-19 patients as “worse than [that of] animals”.

“[There is a] very sorry state of affairs in Delhi and inside its hospitals. Look at the treatment meted out to patients. The patients are crying and no one is looking after them. Relatives are not even informed, as reported by the media, after the death of patients…,” it added.

The top court directed the centre and states to set up an expert panel for effective monitoring, supervision, and guidance of the government, as well as COVID-19 hospitals for providing proper healthcare to the patients.

Further, National Human Rights Commission (NHRC), the country’s human rights watchdog, has also reportedly served notices to the state and central governments on complaints alleging mismanagement and gross human rights violations resulting in the deaths of a large number of people. Residents of Delhi are made to run from pillar to post for securing a hospital bed at this time of crisis even as 70% of dedicated beds for COVID-19 patients are lying vacant in various hospitals of the national capital region, a complaint alleged. 

Meanwhile private hospitals in Delhi are terrified about the prospect of an institutional shutdown, as happened to some clinics, in case of the detection of COVID-19 among their regular patients.

The home ministry has issued a directive to all hospitals to remain open for “all patients, COVID and non-COVID emergencies.”

The order re-emphasised that all private clinics, nursing homes and labs, with all their medical professionals and staff, need to stay open to relieve the burden on other hospitals.

Chronic to acute 

For long, India’s healthcare system has been lacking in many respects and the pandemic has now pushed the system to the edge of collapse.

India spends too little on healthcare, even by the standards of many developing countries. The total outlay by both the centre and state governments for the financial year 2020 was ₹2.6 trillion, which accounts for 1.29% of GDP. The amount spent per individual on healthcare can be translated to an average of less than Rs 2,000 a year.

Organisation for Economic Co-operation and Development (OECD) estimates that India’s total out-of-pocket and public combined healthcare spending is only 3.6% of GDP, while the average for OECD countries in 2018 was 8.8%.

The doctor-patient ratio is below recommended levels. The country has only an average of 8 physicians to cater to 10,000 people, whereas WHO recommended doctor to population ratio is 1:1,000 (10:10,000). When it comes to the supply of hospital beds, the ratio is 8.5 to 10,000 people. 

Inevitably, hospitals are facing an acute shortfall of beds, clinicians and equipment even as the rapid spread of the virus is driving more patient admissions across the country. 

Critical care beds constitute 5-8% of total hospital beds at large medical facilities in India, according to a Center for Disease Dynamics, Economics & Policy report.

India has only 10,000 critical care specialists in the country, as per the Indian Society of Critical Care Medicine.

Ventilators can save 95% of hospitalised COVID-19 patients, experts say. The country is currently reported to have ordered 50,000 ventilators with funds from PM CARES. 

The real cause of concern, even more than the shortage of ventilators, is the dearth of well trained and skilled intensivists to run ICUs, which are getting overwhelmed in the country’s hospitals.

Recently, the Maharashtra state cabinet approved a resolution to make use of the services of postgraduate final year medicos to man ICU wards across the state hospitals to handle the increasing number of COVID-19 cases. 

Rajesh Tope, Maharashtra’s health minister, said the step was taken after considering the fact that the number of COVID-19 cases might increase in the coming months.

Cases in Maharashtra have already exceeded 1.8 lakh, with more than 8,000 deaths as of 1 July. 

Many hospitals in the country still have no department of critical care. These facilities are not mandated by Medical Council of India, the apex body which regulates medical education, as a prerequisite. Hence many medical colleges do not have exclusively trained ICU specialists. It is not rare to find ICUs in India managed by doctors of surgery or those from anaesthesia departments, doctors say.

Ramping up infra—A missed opportunity?

When imposing the lockdown, the government obviously hoped that it would, while slowing the spread of the virus, also provide time to ramp up the required healthcare infrastructure to meet the emergent situation arising out of the pandemic.

Of course, the country did make some attempts in this direction. However, it is still woefully inadequate in a country with a 1.3 billion population.

No country, for that matter, would be able to cope up with an epidemic of this scale and rapidity at any time, analysts say. 

India could have over 10 lakh active cases by July end or even sooner, considering the current reproductive factor of 1.22 for SARS-CoV-2, shows a statistical analysis by the Institute of Mathematical Sciences in Chennai.

If one goes by the numbers provided by the government that only 3-4 percent of active cases need ICU care in hospitals, it is estimated that there would be 30,000-40,000 COVID-19 patients who require ICUs by the end of July.

Presently, there are 32,362 ICU beds dedicated to COVID-19 patients in the country, apart from 1,20,104 oxygen supported beds and 8,91,828 isolation beds, according to the health ministry figures.

More than 958 dedicated COVID hospitals, 2,313 dedicated COVID Health Centres and 7,525 Care Centres have also been set up.

The government also provided a boost to domestic drug manufacturers by enlisting them to manufacture active pharmaceutical ingredients (APIs) as well as personal protection kits (PPEs).

On COVID-19 testing infrastructure front, the government now has over 1,000 labs equipped to run RT PCR testing to detect SARS-CoV-2 infection.

The number has gone up from one on 23 January to 160 on 23 March and 1,000 on 23 June. 

Various government and private labs can cumulatively test around 2.5 lakh samples in 24 hours as of late June, according to Indian Council of Medical Research (ICMR).

“The government did a splendid job of establishing RT-PCR labs in all medical colleges and tertiary care public hospitals but didn’t show the same enthusiasm for doing the same in private medical colleges and labs,” averred a leading expert on clinical microbiology from South India, who didn’t want to be quoted. 

According to him, molecular testing by RT-PCR is unavailable in all public and most private sector hospitals.

The biggest hurdle for the private sector was to get NABL accreditation, which is expensive, time-consuming and difficult. Many private labs that were doing molecular biology tests did not even make that attempt to apply for it due to the complexities involved. A government medical college just needed to find two rooms, borrow the equipment, transfer a few staff and start testing. 

The same flexibility was not shown toward the private sector. Without easy access to diagnostics, how we are going to contain the spread, he asked. 

There is no way the government could have built all the ICUs required to treat a highly infectious disease like COVID-19. The key challenge is that the highest risk of transmission is also in these ICUs, added the expert.

The expert rued that policies related to quarantine, testing, treatment and discharge differ drastically from state to state. 

Somewhere in the narrative, everybody, including the health care professionals, thought that flattening the curve by lockdown would take care of everything, without realising that the area under the curve (population getting infected) will ultimately remain the same, he said.

What is more astonishing, he further commented, is the stoic silence of authorities when it comes to community transmission.  “Community transmission is considered a banned word by the government and everyone behaves like an ostrich, denying its existence.” 

With 2,000 plus cases being reported every day in Delhi, the central government still believes there is no community transmission, which defies logic.

Experts agree that there is reluctance on the part of the government to say that community transmission is driving the outbreak in most parts of the country. The authorities, they say, feel that accepting community transmission amounts to agreeing that the lockdown has failed. But the spread of the virus in the community is not the government’s fault. It is the nature of the virus. It is the way the contagions work and it is very difficult to stop it. 

At the same time, these experts admit that, compared to the untold misery and hardships people suffered during the two-and-a-half-month-long country-wide lockdown, the achievements are little. 

“By imposing the lockdown, the government bought time, but it was not enough to undo the decades of neglect to healthcare that all state and central governments have shown,” commented the clinical microbiologist.

Another lockdown — the unfolding narrative

Some countries have been compelled to go back to a lockdown if repeated outbreaks occur as no other measure has been found to be as effective to control the spread of the pathogen.

Independently conducted studies underscore that lockdowns and other distancing measures have succeeded significantly at thwarting viral spread. While stay-at-home orders and policies that restrict face-to-face contact were found effective to cut down the spread by 81% in 11 European countries, the combination of policies aimed at slowing the virus transmission stalled more than 3 million deaths from the epidemic’s start to early May. 

China was forced to reimpose a lockdown in Beijing after a fresh flare-up of coronavirus infections just after two months of celebrating victory over the virus, albeit with much-criticised “heavy-handed’ country-wide restrictions.

The virus did come back to haunt the Chinese capital city after a period of nearly two months with “zero new cases” following the lockdown. The fresh bout of infections left the city in jitters even though the scale of the outbreak is far smaller than that seen in Wuhan, the central Chinese city where the virus first emerged late last year. According to Chinese authorities, the mainland saw more than 89,000 cases of COVID-19 and more than 4,600 deaths during the first wave.

Maybe, China provides a template to other economies in this regard.

A second wave of outbreak has also been reported in other places as well. New Zealand, a country which declared they have eradicated the epidemic, has been the latest in this list, reporting two new cases just days after the announcement. South Korea, Singapore, Japan, Germany and Rome are among others who claimed to have contained the virus successfully, only to see the contagion return in second and third waves. Hence, it is more or less certain that the virus is bound to come back, either from lack of compliance with the social distancing norms or from migrant workers and travelers.

Several states in the US, including Florida, Texas, Oklahoma, South Carolina and Arizona, which went ahead reopening the economies, have been witnessing some of the largest spikes in the day-to-day infections in recent days, signalling a broader spread of the virus in the months to come. 

The WHO has also warned that the infection is readying for a new peak globally. Countries are understandably eager to open up their societies and their economies. But the virus is still spreading fast, noted WHO, highlighting the stark tension between tumbling economies and a relentless pandemic.

People are fed up with being at home and are tired of hearing the same warnings and of taking the same daily precautions.

Leaders of some of the developing world have already aired their concern that they couldn’t sustain the punishing lockdowns without risking an economic catastrophe, especially for their poorest citizens.

Even as new infections soar to dizzying highs, it still remains unclear whether India will go for another lockdown. Experts are sceptical of the political and social will of Indians needed to sustain another round of community lockdown, especially at a time when the country’s economy is nosediving. The prevailing political unrest following the fresh eruption of tensions on the Indo-China border and escalating Indo-Pak conflicts aggravate the problem.

“It is not possible to continuously impose lockdown and it has to be relaxed. But we should give enough attention to personal care at home, and individual responsibility is very important in fighting COVID-19. COVID cannot be totally eradicated and it will remain with us,” said Dr Arun Gadre, Member, Alliance of Doctors for Ethical Healthcare (ADEH), a nation-wide group of 300 doctors.

Official figures pertinent to the impact of lockdown in India is yet to be available. But the long lockdown, above all, has helped reach word of the pandemic to every nook and cranny of the country. This is despite the fact that it is not easy to communicate with people who live in the rural heartlands of India, which are often mired in dogmas and superstitions. 

Unfortunately, despite this, a large majority of Indians still take it lightly and can often be seen flouting safe-distance norms. 

What is most dangerous, according to experts, is that many people take the lifting of the lockdown to mean that the threat of the pandemic has passed, and have started lowering their guard!