Critical COVID-19 Care In Chennai’s Hospitals ‘Maximally Stretched’

Mumbai: The city of Chennai has gone back into lockdown from June 19-30, the first major city in India to do so. The number of cases continues to rise and that continues to be worrying for everyone--including in government, public policy, public health and the doctors who are fighting this battle at the frontlines.

We speak with Raymond Dominic Savio, critical care consultant at Apollo Hospitals, and chairperson, Indian Society of Critical Care Medicine, Chennai, and N Kumarasamy, chief and director, Infectious Diseases Medical Centre at the Voluntary Health Services Hospital, Chennai, who is part of the Clinical Research Group of the Indian Council of Medical Research’s National Task Force on COVID-19. We discuss where things are today, and get a sense of what has been happening in the last 60 or 70 days, and more importantly, what lies ahead from their vantage point as well as their ringside view.

Edited excerpts:

Dr Savio, in the last 60-70 days, how has the disease--and our ability to better understand and treat it--progressed?

RDS: It is not that the disease has progressed. Maybe the spread has progressed, [but] the disease has been the same. 

In the initial part of the lockdown, we did feel like we were doing great. We thought we were never going to face what the West was facing at that time, and that we may not be the epicentre. But that was all only until the lockdown was in place, and obviously, the lockdown was not the answer for this.

Of course, probably it helped flatten the so-called growth curve. But ultimately, a steady increase in the rate of transmission--which we are seeing right now--was anticipated to happen.

For whatever reason, we have been fortunate, in the sense [that] our death rate--or the case fatality--has not been as bad as it is elsewhere. You can attribute [it] to various reasons--maybe the size of the elderly population etc. But our case fatality has been less. We still seem to be growing on the so-called flat part of the curve, but yes, our numbers are anticipated to rise. This is not something that we are surprised about--what we are seeing in the last one or two weeks especially.

The way forward, various mathematical models have predicted numbers. We may not be as bad as that, but we are still going to [see an] increase [in] our numbers. We are going to see a few more fatalities, but I believe that we are reasonably equipped to handle it. But again, it is more of a prediction. You don’t know which way the things would go.

You mentioned that you are not seeing as high a fatality. Why is that? You mentioned age is one reason. Could there be any other reasons?

RDS: The number of co-morbidities, or the coexisting illness, that also tends to increase with an increase in age. And there is a significantly large population in the West that was above the age group of 60 to 70 years, which is not the case in our situation. 

It is not peculiar to COVID. It's like with any other infection. Any other infection is expected to tilt the balance in people who are elderly, in people who have more coexisting disease. So, that’s just what we’ve been seeing.

Dr Kumarsamy, how are you viewing this--the manner in which the transmission has happened, our response to it, and why it is flaring up in the way it is right now?

NKS: I will only stick to Tamil Nadu and Chennai where we live and practise. We have almost 53,000-54,000 infected confirmed cases in the state. Of those, almost 38,000 are in Chennai. In the last two weeks, every day, roughly more than 1,500 people are testing positive in the state, and nearly 1,200 are from Chennai. This is an area of concern, and is going to cause a grave situation on the healthcare system in future. 

If you look into the infectivity rate, it varies from district to district. In Chennai, which is very densely populated and people live very close, a lot of transmission might happen. If you extrapolate the data from Tamil Nadu, I would say our positivity rate--which was 1% a couple of months back--is nearly 10%. In our own hospitals, around 25-30% of the people who have suspected symptoms, or who have been admitted for various indications are testing positive. That is an area of concern.

How are these people doing well? In Tamil Nadu, the mortality is only around 1%--up from 0.6% in the last two weeks or so. But if you look into the mortality in the hospitals, where the patients who are really sick come and get tested, it is still high because they present to our hospitals very late, when they are moderate or severe, or they are being turned away from different hospitals in the final stages, and they come and die in one of the COVID treatment facilities. But, the mortality is much lower in Tamil Nadu as compared to Maharashtra, Delhi and Gujarat. 

This could be [due to] a variety of reasons. When we started [tackling] this pandemic in our state, a significant number of people who tested were middle-aged. But now, the infection has moved from age-group to the younger ones as well as the elderly (over 60-65 years). That means, the middle-aged people have brought the infection home and [it is] being transmitted to the elderly population. 

In India, particularly in southern India, we have a high [prevalence of] comorbidities--particularly diabetes, hypertension, renal disease and obesity. All these add to mortality from COVID. We saw young people in the beginning with less co-morbidities. But in the last two weeks, more and more elderly people with comorbidities [are] getting infected, and the mortality is increasing.

You mentioned that almost 30% of the people in the hospitals are testing positive. This is something we have been hearing from the specialists in other parts of the country as well. In Mumbai, there are doctors who have told me that almost anyone who walks into a hospital for anything is testing positive. What does that tell you, Dr Kumarasamy?

NKS: I won’t use the word “everyone” who is walking into the hospital is being tested positive.

I think it’s more a figurative rather than literal.

NKS: We don’t test everyone. We test people with the typical suspected symptoms, or anyone who has had contact with confirmed cases, or if they are hospitalised for any other indications where procedures are going to be conducted. The positivity among this group has climbed from 10% earlier, to around 30% and above.

But that does not mean 30% of all the people tested in Tamil Nadu are positive; this is among the hospitalised population, people who are sick or [have] symptoms, [or] want to be tested. 

But again, in our state as well as in the whole of India, we have a very large number of people who don’t have any symptoms (asymptomatics) who are already positive, but they do not know their status because they have not been tested. If you test them, we will know the true prevalence in the whole population, and also the true incidence rate, i.e. occurrence of new infections among the whole population. 

You are saying that we definitely have far greater transmission than we know or are able to record.

NKS: Absolutely. The numbers have been rising. In India now, [the number of cases is] almost crossing 400,000. In Tamil Nadu, [there are] almost 54,000-55,000 [cases]. Every day, we have been adding almost 1,500 [new cases in the state]. And more and more testing is happening, more testing labs are being identified every day. So, more testing will happen. 

Dr Savio, among the critical cases that you are seeing, apart from the age factor that you have already mentioned, are there any other similarities or differences in the way it’s progressing in your hospitals versus what you are hearing of in either the rest of India or the rest of the world?

RDS: I presume you want to know whether the percentage of people infected who turn out to be critically ill is any different between India and the West and whether it is different between the states?

That’s one thing, and also the nature of progression--is it the same? In the last 60 days, doctors seem to be seeing new signs, which were perhaps not there in the early days but are now quite evident.

RDS: I would say less than 30% of the overall infected people are probably getting sick--the real sick requiring ICU admissions or a high-dependency unit. Of course, if you want to know the real figures on this, the national figures, I am not sure if the ICMR has actually released anything about that--the percentage of people who need high-dependency units, who need critical care admission. That would be a worthwhile information if it does come from ICMR. 

My rough estimation from the institutes I take care of will be less than 30% of the overall infected people. That means, the vast majority of them are mildly sick or they can be managed in the ward. A majority of them can even be home quarantined. Coming to the sickest of the people who land up in the ICU, again in that, I would say roughly 10% of them land up requiring mechanical ventilation. Those are the people who really account for the mortality. The mortality in this small subset of people who actually land up requiring mechanical ventilation is extremely high.

The ones who do not progress up to mechanical ventilation do fairly well. And again, this obviously needs to be stratified according to their age, and the number of comorbid illnesses. We really need to dissect this and get to know these data. I would say, still, the vast majority of them are asymptomatic. Some of them require ward admissions. A small percentage need ICU. Of that, a very small percentage are the ones who land up requiring organ supports. Those people have an extremely high mortality.

Is there anything that tells you that the virus is behaving differently in your part of the country versus other parts of the country or other parts of the world?

RDS: No, there is nothing that we actually see of that kind.

NKS: I do not think we have any evidence at this time to show that our viral strain is different from the others. Initially, there was speculation that the strain circulating in Asia is not that virulent, [and that] that is why people are not dying [in the numbers seen in] Italy and Spain. We do not have any evidence to show that.

Dr Savio, what is your sense in terms of the capacity to respond? Unlike Mumbai or Delhi, Chennai is obviously still in control. You have gone into lockdown once again, so I am assuming that should help. But what is your sense of response--bed capacity for COVID, the number of doctors and nurses available at call?

RDS: There is a difference between the public sector and the private sector, and between the number of critical care beds versus the number of beds in wards. Both sectors have been increasing the number of beds available for the less sicker patients who do not need ICU care. So, I have a feeling that we will be able to manage through with those patients. And those are typically the patients who also have a shorter duration of illness: Their turnaround time, or the length of stay at the hospital, is going to be around a week. So, for the patients who are not critically ill, we probably can still get away with it, if this is the rate of increase, and hopefully with this lockdown also helping to reduce the rate of transmission. 

Now, coming to critical care beds, that is where we are maximally stretched. Between the public and the private sector, we are facing something different [scenarios]. The public sector seems to have increased the number of beds. They claimed to have got a good number of equipment such as ventilators and high-flow nasal cannula. There are several things they seem to have invested in--beds and equipment. But I am not sure whether we are equipped in terms of the specialist personnel.

The vast majority of the specialist personnel are probably concentrated in the private sector where the bed strength cannot be expanded beyond what is available right now. So, we are in a catch situation. As of today, we are stretched. The critical care beds are maximally stretched. 

Also, critically ill patients tend to stay longer in the ICU. They probably have [ICU stays lasting] anywhere between 2-3 weeks; I have had patients who were in the ICU for six weeks and then got discharged. So, if that is going to be the average length of stay, then naturally you can imagine the compounding use of beds. So, we are likely to be in a crisis, but each one of us has been trying to improve on our bed strength. There are more newer hospitals contributing to a greater number of beds. And again, if I am not wrong, the government is also on a spree in increasing the number of beds available in the private sector. 

The third problem that is compounding this issue is people’s preference between the private and the public. Even in the public sector, if everyone is going to be choosing one centre and that is going to always be full, the false sense of unavailability of beds is also out in the air.

You said that there are patients who have been in the ICU for six weeks and then got discharged. But if that is the case, then it seems to be quite encouraging, in terms of pulling through.

RDS: It all depends. [For] a typical critically ill patient with multiple organ failure, who also pulls through additional hospital-acquired infections and problems inherent to staying in an ICU for four to five weeks, this is a typical course of illness. 

And it is not that somebody who has been sick for four weeks or six weeks will eventually die. There is nothing like that. It all depends on the kind of support and infrastructure available, and sadly I have to say, the kind of financial backup as well. Many of these people either do not have insurance backup, or even if they do, you do not expect them to cover this big a period. So, there are people who are able to sail through this and they do well.

Dr Kumaraswamy, what are your projections in terms of capacity of beds and the ability to manage pressures hereon?

NKS: Tamil Nadu has better healthcare facilities than many other states… we have both good public and private hospitals. In fact, the public hospitals in Tamil Nadu are far better than many other states in terms of their infrastructure, the facilities available, and the expertise. So, that is something of an added boon for Tami Nadu. Of course, we also have good private hospitals with excellent infrastructure. Some of them are world-class, international standards with excellent expertise. 

If you see this [case detection] curve, our numbers are going up: 1,500 people are testing positive every day in Tamil Nadu, and of those, 1,200 are in Chennai. It will depend on how many of them are getting really sick with moderate and severe symptoms and require beds. 

For example, in my hospital, when someone comes to the outpatient clinic and tests positive, if they are mildly symptomatic or if they can be managed at home, we do not admit them. We just treat their symptoms, and counsel them and make sure that they self-quarantine. We also counsel the caregivers. This is something that will really help our healthcare system. We need to right now protect our healthcare system, and not just admit everyone who tests positive.

Also, the government is now developing COVID-care homes, where people who do not need acute patient management by the doctors and nurses can be housed in quarantine facilities. I think that is right and the hospitals should focus on moderate and severe cases. 

Right now, we have a large number of hospitals in the city but we should not forget that we have a large number of non-COVID patients also requiring admission--because diabetes is a major problem in our city, we have hypertension, elderly people, cancer patients, patients with HIV, TB. We also need places for patients to go for dialysis, maternity centres need to continue to do deliveries. We cannot completely take away the entire hospitals for COVID care. 

For this reason, now the government has requested almost 30-40% of the total bed strength to be allotted to COVID. This is something that the hospitals should be prepared for, and raise their standards, infection-control practices, train appropriate staff, and procure all protectors and PPEs.

Again, to your question as to whether we really prepared to take care of everybody, I really do not know, with the way the numbers are going up. The way it is going up and if it goes beyond July, we will definitely run out of hospital beds in Chennai.

We welcome feedback. Please write to respond@indiaspend.org. We reserve the right to edit responses for language and grammar.

Mumbai: The city of Chennai has gone back into lockdown from June 19-30, the first major city in India to do so. The number of cases continues to rise and that continues to be worrying for everyone--including in government, public policy, public health and the doctors who are fighting this battle at the frontlines.

We speak with Raymond Dominic Savio, critical care consultant at Apollo Hospitals, and chairperson, Indian Society of Critical Care Medicine, Chennai, and N Kumarasamy, chief and director, Infectious Diseases Medical Centre at the Voluntary Health Services Hospital, Chennai, who is part of the Clinical Research Group of the Indian Council of Medical Research’s National Task Force on COVID-19. We discuss where things are today, and get a sense of what has been happening in the last 60 or 70 days, and more importantly, what lies ahead from their vantage point as well as their ringside view.

Edited excerpts:

Dr Savio, in the last 60-70 days, how has the disease--and our ability to better understand and treat it--progressed?

RDS: It is not that the disease has progressed. Maybe the spread has progressed, [but] the disease has been the same. 

In the initial part of the lockdown, we did feel like we were doing great. We thought we were never going to face what the West was facing at that time, and that we may not be the epicentre. But that was all only until the lockdown was in place, and obviously, the lockdown was not the answer for this.

Of course, probably it helped flatten the so-called growth curve. But ultimately, a steady increase in the rate of transmission--which we are seeing right now--was anticipated to happen.

For whatever reason, we have been fortunate, in the sense [that] our death rate--or the case fatality--has not been as bad as it is elsewhere. You can attribute [it] to various reasons--maybe the size of the elderly population etc. But our case fatality has been less. We still seem to be growing on the so-called flat part of the curve, but yes, our numbers are anticipated to rise. This is not something that we are surprised about--what we are seeing in the last one or two weeks especially.

The way forward, various mathematical models have predicted numbers. We may not be as bad as that, but we are still going to [see an] increase [in] our numbers. We are going to see a few more fatalities, but I believe that we are reasonably equipped to handle it. But again, it is more of a prediction. You don’t know which way the things would go.

You mentioned that you are not seeing as high a fatality. Why is that? You mentioned age is one reason. Could there be any other reasons?

RDS: The number of co-morbidities, or the coexisting illness, that also tends to increase with an increase in age. And there is a significantly large population in the West that was above the age group of 60 to 70 years, which is not the case in our situation. 

It is not peculiar to COVID. It's like with any other infection. Any other infection is expected to tilt the balance in people who are elderly, in people who have more coexisting disease. So, that’s just what we’ve been seeing.

Dr Kumarsamy, how are you viewing this--the manner in which the transmission has happened, our response to it, and why it is flaring up in the way it is right now?

NKS: I will only stick to Tamil Nadu and Chennai where we live and practise. We have almost 53,000-54,000 infected confirmed cases in the state. Of those, almost 38,000 are in Chennai. In the last two weeks, every day, roughly more than 1,500 people are testing positive in the state, and nearly 1,200 are from Chennai. This is an area of concern, and is going to cause a grave situation on the healthcare system in future. 

If you look into the infectivity rate, it varies from district to district. In Chennai, which is very densely populated and people live very close, a lot of transmission might happen. If you extrapolate the data from Tamil Nadu, I would say our positivity rate--which was 1% a couple of months back--is nearly 10%. In our own hospitals, around 25-30% of the people who have suspected symptoms, or who have been admitted for various indications are testing positive. That is an area of concern.

How are these people doing well? In Tamil Nadu, the mortality is only around 1%--up from 0.6% in the last two weeks or so. But if you look into the mortality in the hospitals, where the patients who are really sick come and get tested, it is still high because they present to our hospitals very late, when they are moderate or severe, or they are being turned away from different hospitals in the final stages, and they come and die in one of the COVID treatment facilities. But, the mortality is much lower in Tamil Nadu as compared to Maharashtra, Delhi and Gujarat. 

This could be [due to] a variety of reasons. When we started [tackling] this pandemic in our state, a significant number of people who tested were middle-aged. But now, the infection has moved from age-group to the younger ones as well as the elderly (over 60-65 years). That means, the middle-aged people have brought the infection home and [it is] being transmitted to the elderly population. 

In India, particularly in southern India, we have a high [prevalence of] comorbidities--particularly diabetes, hypertension, renal disease and obesity. All these add to mortality from COVID. We saw young people in the beginning with less co-morbidities. But in the last two weeks, more and more elderly people with comorbidities [are] getting infected, and the mortality is increasing.

You mentioned that almost 30% of the people in the hospitals are testing positive. This is something we have been hearing from the specialists in other parts of the country as well. In Mumbai, there are doctors who have told me that almost anyone who walks into a hospital for anything is testing positive. What does that tell you, Dr Kumarasamy?

NKS: I won’t use the word “everyone” who is walking into the hospital is being tested positive.

I think it’s more a figurative rather than literal.

NKS: We don’t test everyone. We test people with the typical suspected symptoms, or anyone who has had contact with confirmed cases, or if they are hospitalised for any other indications where procedures are going to be conducted. The positivity among this group has climbed from 10% earlier, to around 30% and above.

But that does not mean 30% of all the people tested in Tamil Nadu are positive; this is among the hospitalised population, people who are sick or [have] symptoms, [or] want to be tested. 

But again, in our state as well as in the whole of India, we have a very large number of people who don’t have any symptoms (asymptomatics) who are already positive, but they do not know their status because they have not been tested. If you test them, we will know the true prevalence in the whole population, and also the true incidence rate, i.e. occurrence of new infections among the whole population. 

You are saying that we definitely have far greater transmission than we know or are able to record.

NKS: Absolutely. The numbers have been rising. In India now, [the number of cases is] almost crossing 400,000. In Tamil Nadu, [there are] almost 54,000-55,000 [cases]. Every day, we have been adding almost 1,500 [new cases in the state]. And more and more testing is happening, more testing labs are being identified every day. So, more testing will happen. 

Dr Savio, among the critical cases that you are seeing, apart from the age factor that you have already mentioned, are there any other similarities or differences in the way it’s progressing in your hospitals versus what you are hearing of in either the rest of India or the rest of the world?

RDS: I presume you want to know whether the percentage of people infected who turn out to be critically ill is any different between India and the West and whether it is different between the states?

That’s one thing, and also the nature of progression--is it the same? In the last 60 days, doctors seem to be seeing new signs, which were perhaps not there in the early days but are now quite evident.

RDS: I would say less than 30% of the overall infected people are probably getting sick--the real sick requiring ICU admissions or a high-dependency unit. Of course, if you want to know the real figures on this, the national figures, I am not sure if the ICMR has actually released anything about that--the percentage of people who need high-dependency units, who need critical care admission. That would be a worthwhile information if it does come from ICMR. 

My rough estimation from the institutes I take care of will be less than 30% of the overall infected people. That means, the vast majority of them are mildly sick or they can be managed in the ward. A majority of them can even be home quarantined. Coming to the sickest of the people who land up in the ICU, again in that, I would say roughly 10% of them land up requiring mechanical ventilation. Those are the people who really account for the mortality. The mortality in this small subset of people who actually land up requiring mechanical ventilation is extremely high.

The ones who do not progress up to mechanical ventilation do fairly well. And again, this obviously needs to be stratified according to their age, and the number of comorbid illnesses. We really need to dissect this and get to know these data. I would say, still, the vast majority of them are asymptomatic. Some of them require ward admissions. A small percentage need ICU. Of that, a very small percentage are the ones who land up requiring organ supports. Those people have an extremely high mortality.

Is there anything that tells you that the virus is behaving differently in your part of the country versus other parts of the country or other parts of the world?

RDS: No, there is nothing that we actually see of that kind.

NKS: I do not think we have any evidence at this time to show that our viral strain is different from the others. Initially, there was speculation that the strain circulating in Asia is not that virulent, [and that] that is why people are not dying [in the numbers seen in] Italy and Spain. We do not have any evidence to show that.

Dr Savio, what is your sense in terms of the capacity to respond? Unlike Mumbai or Delhi, Chennai is obviously still in control. You have gone into lockdown once again, so I am assuming that should help. But what is your sense of response--bed capacity for COVID, the number of doctors and nurses available at call?

RDS: There is a difference between the public sector and the private sector, and between the number of critical care beds versus the number of beds in wards. Both sectors have been increasing the number of beds available for the less sicker patients who do not need ICU care. So, I have a feeling that we will be able to manage through with those patients. And those are typically the patients who also have a shorter duration of illness: Their turnaround time, or the length of stay at the hospital, is going to be around a week. So, for the patients who are not critically ill, we probably can still get away with it, if this is the rate of increase, and hopefully with this lockdown also helping to reduce the rate of transmission. 

Now, coming to critical care beds, that is where we are maximally stretched. Between the public and the private sector, we are facing something different [scenarios]. The public sector seems to have increased the number of beds. They claimed to have got a good number of equipment such as ventilators and high-flow nasal cannula. There are several things they seem to have invested in--beds and equipment. But I am not sure whether we are equipped in terms of the specialist personnel.

The vast majority of the specialist personnel are probably concentrated in the private sector where the bed strength cannot be expanded beyond what is available right now. So, we are in a catch situation. As of today, we are stretched. The critical care beds are maximally stretched. 

Also, critically ill patients tend to stay longer in the ICU. They probably have [ICU stays lasting] anywhere between 2-3 weeks; I have had patients who were in the ICU for six weeks and then got discharged. So, if that is going to be the average length of stay, then naturally you can imagine the compounding use of beds. So, we are likely to be in a crisis, but each one of us has been trying to improve on our bed strength. There are more newer hospitals contributing to a greater number of beds. And again, if I am not wrong, the government is also on a spree in increasing the number of beds available in the private sector. 

The third problem that is compounding this issue is people’s preference between the private and the public. Even in the public sector, if everyone is going to be choosing one centre and that is going to always be full, the false sense of unavailability of beds is also out in the air.

You said that there are patients who have been in the ICU for six weeks and then got discharged. But if that is the case, then it seems to be quite encouraging, in terms of pulling through.

RDS: It all depends. [For] a typical critically ill patient with multiple organ failure, who also pulls through additional hospital-acquired infections and problems inherent to staying in an ICU for four to five weeks, this is a typical course of illness. 

And it is not that somebody who has been sick for four weeks or six weeks will eventually die. There is nothing like that. It all depends on the kind of support and infrastructure available, and sadly I have to say, the kind of financial backup as well. Many of these people either do not have insurance backup, or even if they do, you do not expect them to cover this big a period. So, there are people who are able to sail through this and they do well.

Dr Kumaraswamy, what are your projections in terms of capacity of beds and the ability to manage pressures hereon?

NKS: Tamil Nadu has better healthcare facilities than many other states… we have both good public and private hospitals. In fact, the public hospitals in Tamil Nadu are far better than many other states in terms of their infrastructure, the facilities available, and the expertise. So, that is something of an added boon for Tami Nadu. Of course, we also have good private hospitals with excellent infrastructure. Some of them are world-class, international standards with excellent expertise. 

If you see this [case detection] curve, our numbers are going up: 1,500 people are testing positive every day in Tamil Nadu, and of those, 1,200 are in Chennai. It will depend on how many of them are getting really sick with moderate and severe symptoms and require beds. 

For example, in my hospital, when someone comes to the outpatient clinic and tests positive, if they are mildly symptomatic or if they can be managed at home, we do not admit them. We just treat their symptoms, and counsel them and make sure that they self-quarantine. We also counsel the caregivers. This is something that will really help our healthcare system. We need to right now protect our healthcare system, and not just admit everyone who tests positive.

Also, the government is now developing COVID-care homes, where people who do not need acute patient management by the doctors and nurses can be housed in quarantine facilities. I think that is right and the hospitals should focus on moderate and severe cases. 

Right now, we have a large number of hospitals in the city but we should not forget that we have a large number of non-COVID patients also requiring admission--because diabetes is a major problem in our city, we have hypertension, elderly people, cancer patients, patients with HIV, TB. We also need places for patients to go for dialysis, maternity centres need to continue to do deliveries. We cannot completely take away the entire hospitals for COVID care. 

For this reason, now the government has requested almost 30-40% of the total bed strength to be allotted to COVID. This is something that the hospitals should be prepared for, and raise their standards, infection-control practices, train appropriate staff, and procure all protectors and PPEs.

Again, to your question as to whether we really prepared to take care of everybody, I really do not know, with the way the numbers are going up. The way it is going up and if it goes beyond July, we will definitely run out of hospital beds in Chennai.

We welcome feedback. Please write to respond@indiaspend.org. We reserve the right to edit responses for language and grammar.


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