Break Inertia to Tackle Second Wave of Pandemic on War-Footing

The COVID situation and its management in India have been worsening by the day. Thousands are dying and lakhs are getting infected every day. Heart-breaking stories and scary pictures are being posted on social media, where relatives and friends of patients have been pleading and crying for oxygen or a bed at the gates of hospitals. Even dignity of death is being denied, with bodies lined up, waiting for space at cremation and burial grounds.

This is definitely a war-like situation in India where nearly 300,000 people (officially) have died so far from COVID.

The approach of governments -- Central and states-- barring a few, is ‘not to break the inertia’ in the system and rather allow the ‘business as usual' practice. This will not help. Of course, such an approach seems to have been imbibed from the country’s ‘supreme leader’, who had claimed “finish COVID in 21 days”,  and went on to declare that “we have attained victory over COVID.” Nevertheless, this approach must be checked and alternatives need to be developed, if not from the top, then from bottom up.

Take, for example, Delhi, a metropolis with a population of over 20 million, and Shimla, a small hilly town in Himachal Pradesh, with nearly two lakh population.

Delhi, which boasts a massive health infrastructure, has crumbled so badly, unable to ensure oxygen supply to patients. SOS calls by individuals and hospitals continue to be a regular feature even after a month of the second wave rearing its head. Even hospital beds are not available for patients.

In Shimla, however, such a situation has not arisen, yet. But going by the rise in numbers, the day is not too far when similar stories may be witnessed in this hill town. There is immense pressure on the medical fraternity, right from the sanitation staff to doctors who have not taken any leave since March 2020, and many of them, despite two shots of vaccine, are getting infected by the virus.

But, that is not the point. What is needed is complete revamp of the existing structure and operations on war footing. Recently, in a single ward of medicine unit in the Indira Gandhi Medical College and Hospital (IGMC), Shimla, 25 indoor patients tested positive for COVID. Likewise, in the intensive care unit of the Heart Centre, all the patients tested positive. All of them had tested negative in their RTPCR report while getting admitted to the hospital.

This is an alarming situation and is not limited to one hospital, but almost all the hospitals across the region. The virus is spreading fast and the situation requires some radical steps. It is very important to ensure that adequate testing, isolation, and treating facilities are created at the community level. The pandemic cannot be tackled by building new hospitals because the time lag will be huge.

The only way the situation can be handled is by re-designating the already existing facilities into COVID facilities in a time-bound manner.

All hospitals and healthcare facilities need to become treating facilities the moment the positivity rate crosses the threshold. That is the only way out of this pandemic because multiple waves cannot be ruled out.

Some of the measures that can be taken are listed below.

POOL THE RESOURCES

Let me cite two hospitals, Hindu Rao Hospital in Delhi and IGMC in Shimla. Hindu Rao Hospital is a large hospital run by the Delhi Municipal Corporation, with a capacity of 1,000 beds. However, effectively, only 832 beds are shown on its website. Out of these 832 beds, only 250 are allotted for COVID patients (though in a recent notification this has been augmented to 350, howeve,r at the moment only 250 are available). The rest i.e., 582 are kept aside for elective, routine work which has now become redundant due to the lockdown and closure of outpatient departments.

Likewise, IGMC has a bed capacity of 850, of which 150 are reserved for COVID patients. However, with some proactive intervention from the hospital administration and the need of the situation, this hospital now has 350 beds for COVID patients.

This is a situation in almost all the large hospitals in bigger cities, where a small percentage of beds have been kept for COVID patients and the rest of the hospital staff is working tirelessly treating other patients. As the virus is spreading super-fast, other departments are also getting infected and the response has been more spontaneous than planned.

What needs to be done is this. Let’s take the example of Hindu Rao Hospital. In any given hospital, if outdoor patients are stopped and the hospital is allowed only to deal with trauma patients, not more than 5% of beds are required for medical and surgical emergencies. This, in simple terms, means that in Hindu Rao Hospital. Delhi, out of 852 beds, just 85 beds are required to deal with trauma cases. The other 752 beds can be optimally utilised for COVID patients. This means a jump of over 300% in the existing capacity of the hospital. Imagine the kind of difference this would make in meeting the demands of the people of Delhi if such interventions are done in most city hospitals. Likewise in Shimla, IGMC, the COVID bed capacity can jump to almost 200% totaling a figure of nearly 750 beds.

Now, one may ask that where is the medical staff and other health infrastructure going to come from? The simple answer is that those departments that were dealing with their respective wards along with the paraphernalia should be allowed to manage their wards on a rotation basis. And since for COVID management, the requirement of human resource intervention is far less compared with other surgery or indoor patients’ requirement, the situation can be easily managed. Even oxygen supply is available at most of these beds, and if at all additional augmentation is required, it can be done promptly in most cases.

In this way, the augmentation of capacity in large towns can be increased by 300% to 400%, and this can be done just for a few weeks or months.

Another question that may be raised is why are so many beds required when on paper there are surplus beds in Delhi. According to Delhi government’s website, there are 21,561 COVID beds, and out of these, nearly 18,000 are óxygen’ beds (at least on paper). On any day, if the total number of COVID patients is 100,000, then a near 10% require hospitalisation. This means only 10,000 COVID beds are required. Whereas the availability is nearly double the requirement.

Then why is there this mismatch? If bed availability is almost double the requirement, why are we witnessing patients dying on the streets, in front of hospitals unable to get oxygen beds. Some of them are even migrating out of Delhi for treatment. Actually, the fallacy is both in numbers and practice.

In Delhi, it is not the numbers of those who have tested positive that should be taken as a consideration, rather the positivity rate, as the numbers of tests has been reduced over a period of time. Let us consider the population of Delhi to be 2.3 crore (considering population of adjoining areas as well) and if the positivity rate is 30%, then actually those who are infected is a startling nearly 69 lakh. In any given situation, if 10% of these require hospitalization, then nearly 69,000 beds are required, and we are nowhere near that in Delhi. Hence, a large number of people are dying at home and we find long queues at cremation and burial grounds.

So, what will happen if the formula suggested above is implemented and the bed strength is augmented in the available hospitals?

It will definitely be easier for the existing medical staff to handle patients in the given infrastructure rather than to create new ones,which may be deemed fit, but require time. RML Hospital Delhi is already converting a large section of the medical ward into COVID ward.

The second question that will arise is where will the extra oxygen come from? That is where the Central and the state governments will have to work together and ensure regular supply to hospitals. Once done, the infrastructure is already available to cater to these patients, as in most of these hospitals even for indoor patients (medicine, surgery etc.) there is an existing oxygen line that supports these beds. The only bottom line is that oxygen will have to be supplied regularly by the government. Even if there is no central line, oxygen cylinders can be provided at the bedside more promptly than relying on social networks.

This is the least that governments’ must do to protect the lives of citizens.

The government must consider such proposals, some of which are emanating from the medical fraternity itself, like the IGMC spontaneous intervention (though the OPD still functions) that could augment its capacity by almost 150%.

The OPDs can also be managed through telemedicine and other forms of interaction with patients. As this is a war-like situation, hospitals cannot and should not turn away patients just because their capacity is exhausted.

The writer is former Deputy Mayor of Shimla, Himachal Pradesh. The views are personal.