Covid-19 pandemic forces hospitals to scale up

“Somebody help me. I need a corona bed for my father,” said Ajai Kumar, carrying his sick father who was gasping for breath into the emergency ward of Lok Nayak Jai Prakash Narayan Hospital in the Walled City of Delhi after being turned away by two private hospitals.

That was last Friday (June 5).

Sudama Kumar, a 63-year-old retired official of the Central Public Works Department had developed fever the week before, but when it progressed to breathlessness, his son took him to Max hospital, Patparganj on June 3, fearing it might be the coronavirus disease (Covid-19).

“He was so sick that he fell off the chair and collapsed in a heap on the floor [but] the hospital turned us away without testing him because they had no free beds for Covid or suspected Covid patients,” said Kumar, whose father is a beneficiary of the Central Government Health Scheme, a health care facility scheme for current and former employees of the central government.

When asked to verify Kumar’s account, Max Hospitals declined to comment.

“I next took him to a small nursing home, which got the test done but asked us to leave after he tested positive because the clinic did not treat Covid patients,” said Kumar. Finally, Sudama Kumar received a bed in the Delhi government-run LNJP.

With the number of cases rising every day, the strain on the health care infrastructure of metropolises like Delhi and Mumbai has begun to show. In the past two months, several people took to social media to express their dismay at being unable to find hospital beds or proper treatment for their family members and friends.

During a recent press conference, Delhi deputy chief minister Manish Sisodia said that Delhi will require 80,000 hospital beds by the end of July; based on the infection’s current doubling rate of 12.6 days, by July 31, the number of cases in Delhi will reach 550,000.

Mumbai was only testing 4000 samples daily at the beginning of this month; its testing capacity is 7000 tests a day.

Hospitals, particularly those designated in various states as Covid-19 treatment hospitals, have been forced to adapt using limited infrastructure, space and human resources. Early in the pandemic itself, healthy patients were segregated from suspected and Covid-positive patients; the focus shifted to critical care treatment; hospitals staggered timings of staff to decongest the wards, and scaled up e-consultations and remote management of chronic conditions like diabetes and heart disease. As early as March, hospitals like the All India Institute of Medical Sciences in New Delhi began to postpone elective surgeries to free up hospital staff for Covid care.

Experts said that managing a pandemic will leave hospitals with some important lessons.

“Measures taken now will help reduce the overload on the tertiary and secondary hospitals and improve documentation, data-collection, diagnosis and care without risking the safety of the patients or the health workers. For patients already under treatment, reports can be viewed online and prescriptions made accordingly. Patients will need to come to tertiary care hospitals outpatient clinics only if the treatment needs an overhaul or if they need surgery or invasive treatments, like radiation,” said Dr Nikhil Tandon, professor and head of the department of endocrinology and metabolism, AIIMS, Delhi. He is a member of the board of governors in supersession of the Medical Council of India that drafted the brand new Telemedicine Practice Guidelines notified in May.

Telemedicine has already helped decongest AIIMS Delhi, which moved its out-patient department services online from April 8 to follow up with the around 60,000 patients registered for treatment during the lockdown.

This is continuing post the lockdown at AIIMS, which is arguably one of the world’s busiest hospitals with a daily footfall of 15,000 (3.5 million patients in the outpatient clinics, 200,000 in the in-patient department) and 170,000 surgeries in pre-pandemic times. Around half of these patients are from other states. Telemedicine may well emerge as the most transformative change to provide health care.

“Leveraging India’s IT strength and increasing investment in telemedicine to shift from human resource-intensive care to meet shortfall to a great extent, especially of super-specialists. Start-ups are doing it already, we have e-ICUs and home-isolation support remote-managed from hundreds of kilometres away,” said C K Mishra, former health secretary and mission director of National Health Mission.

Do more with less

With Covid-19 spreading , India was forced to rapidly scale up its critical care infrastructure after seven decades during which much of public health budgets went to programmes on maternal and child health. It did that, and with some measure of success.

Several thousands with severe disease were treated, which would not have been possible a couple of months ago. As of June 11, 141,028 people are reportedly cured of Covid-19 in India, which translates into a recovery rate of 49.21%. For the first time since the pandemic began, the number of those recovered has overtaken the number of those who are currently infected.

On March 30, four weeks after the first two Covid-19 cases in Delhi and Hyderabad (on March 2), there were just 32,000 ventilators for all diseases across all states in public and private hospitals, according to an internal assessment report of the ministry of health.

According to the Association of Indian Medical Device Industry, a private industry body, the manufacturing capacity for ventilators alone has increased from 3,000 a month in February to 33,000 a month in May.

By June 9, centre and states have designated 958 Covid hospitals across the country, as well as 2,313 Covid Health Centres (for those who don’t need too much medical support) and 7,525 Covid Care Centres (for those with mild infections who can’t isolate themselves at home).

That’s only a start.

“A few thousand ventilator beds are not enough for India’s 1.35 billion population. It’s certainly not enough for when cases peak in July and August. It’s a jump-start, but we need to sustain it and [have] a lot more testing, a lot more beds, far more hospitals to make up for decades of neglect of public health,” said Dr Jacob John, former head of the department of virology, Christian Medical College, Vellore, Tamil Nadu.

In two short months, India has had to upgrade its flailing infrastructure and create a contingency plan for large-scale medical emergencies. This, despite public health expenditure hovering at just around 1.28% of its Gross Domestic Product.

“Many countries are learning that you cannot build health care capacity during a crisis. It takes time and investment to build a good public health system. India has failed to invest in health for decades and this must change post-Covid19. Health spend must at least increase to 2.5% of GDP, at a minimum,” said Prof Madhukar Pai, director, McGill Global Health Programs, McGill University, Montreal, Canada.

As part of the stimulus package finance minister Nirmala Sitharaman announced in May, Rs 15,000 crore has been earmarked to strengthen public health infrastructure, down to the block level. India has 7,096 of them.

“Each city and district has to develop its own programme because there is a difference between metros and other cities, and between towns and rural India,” said Dr Randeep Guleria, professor and head of pulmonology and director, AIIMS Delhi.

Made in India

With roughly 10% of all Covid-19 infections in India found in hospital employees – in March and April, hospitals around the country became hot spots and were shut down – the focus shifted early on to procuring protective personal equipment kits (PPEs). After an early consignment of 1.7 lakh imported kits from China were found to be faulty, domestic production was ramped up. By mid-April, the Bureau of Indian Standards came up with stringent measures.

Now, domestic manufacturers provide medical devices, protective gear, diagnostics, hospital equipment, and telemedicine services. As of Tuesday, the Centre had provided 12.84 million N-95 masks and 10.47 million PPE kits to states.