Mumbai: India’s financial capital--which has more COVID-19 cases than any other Indian state or city--has detected 48% of its 35,273 cases since May 17, 2020, when the lockdown was last extended. The city has detected over 22% of the cases nationwide.
With lockdown 4.0 set to end on May 31, 2020, will Mumbai’s hospitals be able to bear the load of increasing new cases? Are hospitals being managed in terms of inflow of the right kind of patients in the right way, so as to not overload the system with patients who may not require hospitalisation? Can the logistics be managed better?
We ask Shivkumar Utture, president, Maharashtra Medical Council, and Girdhar Gyani, director general, Association of Healthcare Providers of India.
Dr Gyani, what is your sense in terms of the number of cases and how it has been rising, and the ability of the healthcare system--particularly the private healthcare system--to respond to it?
GG: In Mumbai, or in Maharashtra in general, till recently, [the] private sector was not called upon by the government. It was of their own [accord] that some premier hospitals (such as Hinduja, Hiranandani, Nanavati and a few others) offered their beds and were admitting COVID patients. On May 22, 2020, the government issued a directive that 80% of the beds in the private sector will be under the control of the government. Roughly, we have around 25,000 beds in the private sector [in Mumbai]. That means, at least 20,000 beds will now be at the disposal of the government.
Have we managed things in the right way? I am looking at Delhi very closely, because I am sitting here. Even in Delhi, where we have 30,000 beds in government [hospitals] itself--as compared to Mumbai, which I think has around 10,000--the government has taken over 20% of the beds (around 3,500 beds) from the private sector. Why is this happening in spite of so many beds in government hospitals?
Firstly, most of the initial cases were all being admitted to hospital. Ideally, they should have been put into hostels, guest houses or hotels. But because the beds were available, we went on accommodating these people, even if they really did not require hospitalisation. But the issue is, even in the quarantine centre, you need some manpower--if not a doctor, some kind of healthcare workers are required, which the government is always short of. They are all busy in the hospital, where there are people who do not require hospitalisation. So that mismatch has happened. I am sure something similar has happened in Maharashtra also. That’s why we have taken this step. My colleague from Maharashtra, of course, will be able to give the elaborate picture.
Dr Utture, your understanding of what’s happening right now in terms of the number of patients who are there, and the load capacity of the hospital system?
SU: At the outset, I will clarify one thing: The 80% beds that the government has said they are taking over in private hospitals are not for COVID patients. There is a difference, I think, between Delhi and Mumbai [in this aspect]. We were seeing that non-COVID patients were suffering more than COVID patients, because the whole concentration was on COVID only--especially in the public sector.
We have huge medical colleges in Mumbai with huge hospitals attached to them such as JJ Hospital, St George Hospital, GT Hospital, KEM Hospital, Nair Hospital and Sion Hospital. Unfortunately, as the cases went on increasing, the whole load was coming on to these government setups where the patients were getting admitted. Initially, we did not have any dedicated COVID hospitals. But over time, the government has changed some of these big hospitals such as St George Hospital, Nair Hospital and GT Hospital, which have become completely COVID hospitals. Once you convert such huge setups into COVID hospitals, where are the non-COVID patients going to go?
Further, even hospitals such as KEM and Sion initially started off with only one ward dedicated for COVID [patients]. But now, [there are] at least 100 [COVID] patients in both these hospitals. So, more of the wards are being taken up by COVID patients. Unfortunately, non-COVID patients were suffering from that, and we were finding a lot of deaths amongst non-COVID patients. They were not getting beds.
So, the government has taken over 80% of the beds in the private sector, [where they] will send patients whom they would not be able to cater to [in public hospitals]. As the expenditure in private hospitals is pretty high, they [the government] have put a cap on the charges for procedures and surgeries in private hospitals. I think that’s a good move, because ultimately, when you think about the citizens, they need to get treatment. We are not talking about COVID, [but about] the non-COVID emergencies and routine surgeries.
We are also hearing, on a daily basis now, that people are getting turned away; people are not able to get admission when they want, whether they are COVID or non-COVID--which comes back to my first question: What is the capacity-handling approach for these big hospitals?
SU: Let me talk about what is done in the government set up, because that is related to these big hospitals also. This is a new disease. We are also learning day by day how to tackle this disease. Two months back, we did not know the case scenario as far as the end of May is concerned. As the cases went on increasing, automatically the set-up in the public hospitals--because all these patients were coming to the public hospitals--was slowly revamped.
As of today, there are more than 50,000 beds dedicated for COVID patients already in place, and more of them are being taken over. For instance, we have big set-ups on playgrounds where they are converted to [contain] almost about 500-800 beds.
How many of these patients should actually be in hospital? Because that’s the question even the doctors are asking.
SU: You have to understand the uniqueness of Mumbai. The houses are small. A majority of them stay in a one-bedroom house or a one-room-kitchen house; and a majority of cases we are seeing are from the slums, where about 8-10 people stay in 10x10 rooms.
According to the new guidelines, positive patients who are asymptomatic or [have] mild symptoms can be kept in their homes if they have the facilities [to self-isolate]. But once you put this positive patient [in home isolation], imagine what is going to happen to the other people in the family or their neighbours. It is impossible for a majority of these patients in Mumbai to be home-quarantined; and therefore you need to take them into centres.
Accordingly, we have put into place four different types of centres--COVID Care Centre 1 (CCC1), to house contacts of positive cases and high-risk patients who have not yet tested positive; CCC2, for patients who test positive; dedicated COVID hospitals (DCH); and dedicated COVID centres (DCC). In DCCs, there are now arrangements for oxygen, because now the whole concept [of care] is changing: We are seeing more patients going in for high-flow oxygen instead of being put on ventilators. The DCH is an ICU set up with ventilators, with continuous doctors.
Once we have made this [classification], there has been a little bit easing off. I would not say that we are on very safe or firm ground. But definitely, a little bit of easing has taken place compared to what we were experiencing about 15 days or three weeks back, because these huge centres (CCC2s) have come up, huge tents that they have put up on playgrounds, where they have made arrangements for oxygen supply also. Eighty percent of these patients are either mildly symptomatic or non-symptomatic. So, these patients don’t require active treatment as such.
So, the problem is not in the medical/hospital capacity, but in where the people or the patients live and the environment in which they stay. Is that right?
SU: Yeah, that is the case. Even if you see the number of people staying in Mumbai; [the density is very high]. And you have to understand that the number of tests that are done in Mumbai is pretty high as compared to any other place in the whole of India. It is natural that if you have a dense population and you are doing a lot of testing, the number of positive cases is automatically going to increase. So, today we are not bothered about how many positive cases we are seeing; what we are more bothered about is how many of them do require ICU admissions and ventilators. And that is what we require to ramp up, and that is where our concentration should be.
Dr Gyani, the ICMR was on record a few days ago saying that there were barely 100 cases of ventilator and ICU patients who went into ventilators across the country. And so, the use of critical care is not as much, at least at this point. So, should we be reorienting the way we are investing or planning ahead?
GG: I support what Dr Utture said, that in Mumbai, the behaviour of the population is a little different. In Maharashtra, we have done, as of May 25, 2020, 379,000 tests. Only Tamil Nadu (around 421,000) has done more tests than Maharashtra. But the problem is, in Maharashtra, the percentage of the positive cases is 13.9%--the highest--while Tamil Nadu, which has done more tests, has a percentage of just 4%. A third state, for comparison, would be Rajasthan: They have done 325,000 tests, but the percentage of the positive cases is just 2.23%.
This is the question we are still struggling to understand. Maybe in Maharashtra, we have done more testing in hotspots and that’s why the percentage is more. And in Rajasthan, maybe we have spread out. But still, I think the Maharashtra population presents to us a peculiar structure--crowded places, staying in smaller huts and all that. So I think that way, Maharashtra has to be treated a little differently, as a special case, and it has to be handled with more sensitivity.
When we say Maharashtra, we really mean Mumbai, right? Because after all, 20% of the cases nationwide are here.
GG: Mumbai, yeah; because the bulk of the cases from Maharashtra are in Mumbai, but I was giving you these data for Maharashtra.
Dr Utture, would you have a sense of how many patients who are in hospitals at this point come from an environment where they are not able to stay in their own homes or do not live in large enough homes where they could be self-quarantined?
SU: If you take across the board, amongst all these four types of centres, I would say almost 75% of these patients come from regions where they do not have the facilities to either home-quarantine or home-isolate themselves. That is why, as you said, we are even today finding it a little difficult to get a bed when someone tests positive and becomes a little serious. They have to run from one hospital to another.
But just a day back, the Corporation has started a dedicated online process--a dashboard has been made which is continuously updated. Using this, you can make out which hospital has how many beds empty, so that the patients don’t have to be [turned away].
But definitely, the number of cases is increasing. So we are required to ramp up the bed strength and the ICU strength. Down the line, we are expecting the graph to go up in the first and second week of June--at least that is what the mathematical calculation is. And that is the time when we are going to require a lot of ICU set-ups, because the rains are going to hit Mumbai at that time, leading to a lot of other diseases: It is going to be a big burden to differentiate between COVID and the simple flu or malaria or dengue. Those people will also require ICU set-ups.
But Dr Utture, are you getting a sense--going by data so far or your own experience--that we need so much critical care capacity, such as intensive care units, ventilators and so on?
SU: [More] ventilators may or may not [be needed], but critical care, that is ICU beds, should definitely [be ramped up]. Why not ventilators? Because our whole outlook towards how to treat a patient is changing. In the initial phase, about two months back when all this started, as soon as we saw oxygen levels below 92% or 90%, the [patients] used to be put on a ventilator. That is not the case now.
Now, they start with nasal oxygen. Then, they go for high-flow oxygen. Then, they may or may not go for CPAPs [continuous positive airway pressure], which gives you oxygen at a high pressure. And, they keep them in the prone position. We have found the results are much better than putting them on early ventilation. That is why, as compared to western countries, we are using ventilators less.
But yes, when a patient does not improve in spite of all these, then he has to be put on ventilation. So, we will require, in future, much more ventilators. But more of ICU beds than ventilators.
Dr Gyani, what’s your sense in the days ahead? We know the data now, and we can see how things are not slowing down. What’s your sense of the demand-supply for hospital beds, particularly given the demographics of the people who are now being admitted.
GG: We have to admit, as a medical fraternity, that we are learning every day. We thought two months back that we know everything, and after lockdown, this [will be] the situation, and peak will come at the end of May--that was the earlier prediction. But now, we are learning that the peak is going to be in June, we are still not sure. So, it is very difficult to understand the behaviour of the virus spread. You see Brazil now; Brazil was nowhere, but suddenly it has come up and is occupying the position number 2 [in number of cases detected]. So, we have to be extremely careful, but I think, by and large, we have understood what we will need, and now we will be carefully utilising the hospital beds.
As Dr Utture was saying, I know in Maharashtra they have put up huge facilities in temporary sheds. They have created thousands of beds for quarantining. So, we will be putting the patients there, maybe even transferring existing patients from hospitals to these facilities. And, as he was saying, with the rainy season when more patients will come with other diseases, they will actually require ICU, while the COVID patients may not require as many ICU beds. So, we have to reposition ourselves.
The other challenge the system is facing is that many hospitals--particularly, smaller hospitals and clinics--have shut down across the country. Do you see some of them opening again?
GG: The simple reason is fear. Even small clinics are very afraid. They do not have the paraphernalia to handle a COVID patient if he comes to an out-patient department. The same fear is there in the mind of the population--they are also trying to postpone [consultations for] all kinds of things. So, as we go on overcoming that fear, I am finding that in-patient occupancy in non-COVID hospitals, which was at 30%, is now around 35-40% in different places. So, patient footfall is now gradually increasing. We are trying to bring in tele-consultation--although the Indian Medical Association is still not in favour of that, the government of India has brought out tele-consultation guidelines and an authorised platform. So, maybe some element of fear obviously will be overcome and some simple things [will be tackled] through tele-consultation.
But do you see many of these smaller hospitals and clinics opening up in the coming weeks and months?
GG: Yes, because we have no option. We cannot allow them to [remain] shut. We will need [these smaller hospitals]. In any case, we are short of beds. Overall, in India, we have 1.3 beds per 1,000 [population]. Bombay and Delhi still have a huge number of beds. We require 3.5 beds per 1,000. So, we cannot allow them to shut down. I think the government has to offer a special incentive. They must see to it that these continue to operate.
Any sense of how many such hospitals or clinics are shut across the country?
GG: We have really no number. But we know when the footfall goes below 20%, the EBITDA [earnings before interest, taxes, depreciation and amortisation] will go negative. And if the EBITDA is negative, you cannot sustain the cash-flow for more than two months. This is across India. We have done the survey.
Dr Utture, as numbers rise and as we go into June 2020. what’s your sense on how we are going to manage this? Are you confident that the capacity that we are creating, as a quarantine capacity as you described it, is going to be sufficient? And all the other steps that we are taking, will that be enough?
SU: To be very frank, I think as of now, the disease is galloping much more ahead than the capacity we can create. We are trying. The government is trying its best to increase the capacity. Maybe we may catch up with them [the cases]. But to add to what Dr Gyani has said--that the clinics were shut, which you were seeing even in Mumbai--you have to understand that doctors are also human beings. Doctors also get scared. This was a new disease, which we never knew anything about. We were hearing the horrific things that were happening in the western countries; we thought that the same thing would happen here.
And the worst part was that, in the beginning when this disease came in, we never had any protection. We did not have an industry of manufacturing PPEs [personal protective equipment] or masks. And then, you found suddenly that in the medical colleges and the government hospitals, a lot of doctors or health workers were falling sick. So, this put a scare in all the doctors.
In a place like Dharavi, which was the worst [affected] place up till now (I was involved in that whole Dharavi project from day 1), there were hardly two or three clinics that were open. Then, we tied up with the Corporation and then, from the Corporation’s side, we promised to give all the doctors PPEs every day. Once we started supplying them with PPEs--you won't believe it--as of now, around 125-130 clinics have already started in Dharavi. So, if you are going to give proper protection to the doctors, I don’t think a doctor likes to stay at home.
This happens only when you can put that confidence in the doctor that he works there because he is being protected enough. Not only that, we also assured all the doctors that if they contract the infection, they would be given full treatment by the government. And because of that, slowly, the clinics are starting.
You have to understand that in India today, almost 70% of the health requirement is provided by the private sector. So, the private sector cannot remain shut for a very long time. Otherwise, it is going to have a domino effect and the whole health system will collapse. So, the private sector has to start. I am a surgeon, I have my own hospital, and right from day one, my hospital was never shut. So, once they understand what the problem is, I think a majority of the health workers will come back into the field.
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