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Mumbai in the times of corona

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“Just as Dharavi is an inaccurate lens into Mumbai, to read Mumbai’s COVID-19 numbers merely from the lens of governance would be to miss the obvious reality that urban design and policies play their part during an epidemic. Geography, architecture, commerce, policies and decisions – that manufactured Mumbai into the high-populated and super-dense city that it is – enabled the virus to spread as it has,” writes Dr M Balasubramanian, GP and Chief Hospital Administrator at Raptakos Brett. The author has recently published a book ‘COVID 19-The New Age Pandemic’ attempting to delve into some of the contributory factors that lead to the issues the world is facing right now and some of the latest methods of treatment available

Dr M Balasubramanian

India is now among the top 10 countries worldwide in terms of total reported infections, and among the top five with respect to the number of new cases. One reason for the confusion is the lack of – or the opacity of – adequate data on the pandemic to help frame a strategic and granular response.

We are already seeing a steady surge in Covid-19 admissions and worry about a looming shortage of hospital beds, including in critical care, lack of adequate PPEs, ventilators ,lack of standardized dashboards indicating details of COVID hospitals on a particular city, number of beds available, details of critical care beds available and lack of adequately trained doctors and nurses.

When the infection peaks in July, as is expected, a spike in infections could easily lead to many avoidable deaths as hospitals run out of beds or there is delay in treatment. Most experts say a one-size-fits-all strategy to contain the pandemic and imposing and lifting lockdowns will not work in India where different states will see infection peaks at different times.

Only about 30 per cent patients require hospitalized care in a dedicated COVID hospital. But glitches in following protocol, a lag in reacting to changing patient requirements and inadequate resource-monitoring are leading to inefficient utilization of critical care beds and equipment.

To ensure ease of managing patients, the available facilities in Mumbai are segregated into layers, based on what symptoms and health conditions a particular COVID-19 patient exhibits.

Lowest in the hierarchy is a Covid Care Centre (CCC). Among CCCs, there are two categories — the first, CCC-1, is meant to only quarantine people who are high-risk suspects, example, slum-dwellers who cannot practise social distancing at home. The second category (CCC-2) is to admit asymptomatic positive cases, or cases with mild symptoms — such as those who are young with a history of fever, dry throat, etc., but who are stable at present.

Mumbai has 22,941 beds in CCC-1, and 34,329 beds in 241 CCC-2 facilities.

Next in the hierarchy are Dedicated Covid Health Centres (DCHCs), which admit moderately ill Covid patients. Patients with continued fever, cough, and cold will be admitted in these centres.

Senior citizens with slight fever will also find a place in these centres — as well as people with co-morbidities like diabetes, hypertension, heart ailments, and those with light symptoms. These categories of people will require a bed in these facilities since they remain at risk of falling severely ill.

There are roughly over 10,000 beds in DCHC.

At the top in the hierarchy are the Dedicated Covid Hospitals (DCH), which admit critically ill patients like those who require ICU or ventilator support, or patients who are gasping for breath.

The DCHs also admit some moderately ill patients — for example, a senior citizen who has low oxygen levels and a fever and remains at risk of further complications, will be kept here.

There are over 4,800 beds in DCH centres.

There is enough space to admit people in CCCs and DCHCs, but when it comes to DCHs, the beds are limited, there is a waiting period, and several patients die waiting for a bed.

The Brihanmumbai Municipal Corporation (BMC) has directed its public hospitals to strictly follow protocol — if a patient in DCH gets stable and can be monitored in DCHC, the patient has to be immediately shifted to make space for other critical patients.

This process is currently slow, a real-time updating of beds is not happening, and private hospitals are not strictly following this protocol.
BMC officials said what remains the biggest challenge is to make hospitals update information, and to ensure that they follow a strict discharge policy so that beds are available quickly for new patients.

Just as Dharavi is an inaccurate lens into Mumbai, to read Mumbai’s COVID-19 numbers merely from the lens of governance would be to miss the obvious reality that urban design and policies play their part during an epidemic. Geography, architecture, commerce, policies and decisions – that manufactured Mumbai into the high-populated and super-dense city that it is – enabled the virus to spread as it has. Mumbai’s COVID-19 numbers expose the city’s lack of public health facilities, but they also point to the structural and systemic drawbacks in urban design itself.

At least three factors intersect each other. The first is the density of the population. Cities are synonymous with density where large crowds of people live, work and play in close proximity. Data from UN Habitat in the last two years placed Mumbai second in the list of the world’s most dense cities – with a jaw-dropping 31,700 persons per square kilometre.

Within this are clusters with ultra-high densities such as Dharavi, with an average of 2,00,000 persons per square kilometre (2,70,000 according to data from World Economic Forum). Such unimaginable densities mean epidemics like COVID-19 turn disastrous.

The second is its weird housing matrix in which two facts stand out. Informal settlements or slums house nearly 45 percent of the city’s population, or a staggering nine million Mumbaikars. However, they occupy less than ten percent of the city’s land – a fact that is often overlooked when more land is released from no-development zones for the housing sector.

Easing of lockdown in Mumbai and allowing the city to resume even half of its economic rhythm calls for putting its trains and buses back on track. But the super-crush load they carry every trip would make a mockery of the one preventive tactic against COVID-19 used so far – physical distancing. If only there was a larger fleet of BEST buses on Mumbai’s streets, and a denser or parallel network of trains, some of this load may have spread out.

COVID-19 should make Mumbai’s planners and politicians review not only the city’s health facilities but also its housing and transport policies. These are, of course, idealistic expectations.

Since the practice of Telemedicine has been formally approved by the government, the model implemented by Apollo Tele-Health under the Leadership of Vikram Thaploo gives us a good prototype for the whole country to follow:

  • This model has been tried tested in Andhra Pradesh and Madhya Pradesh.
  • We could think of a Private Public Partnership with the Government of India and all state govts.
  • This could be very useful and practical, especially in rural areas where they do not have adequate healthcare facilities
  • This should be tried during the Covid 19 Pandemic.
  • It could also help create a uniform dashboard and centralization of data across the states
  • Since Apollo Hospital is a pioneer in this field, they could run the project as a primary partner in a PPP arrangement with the governments
  • A project proposal could be generated and submitted to the central government
  • If implemented it could become an innovative step to help treat and contain Covid which other countries could follow

This new age pandemic has shown us that all of us have to bow towards Mother Nature. Like our Honorable PM said, “This virus sees no race, religion, caste, creed or sex”: it has affected the world globally irrespective of whether we are rich or poor. Global warming, rapid industrialization, deforestation, loss of natural habitat, increased stress of new age living have all contributed to what we are facing now.

At a media briefing on 25 March, the World Health Organization’s Director General Tedros Adhanom Ghebreyesus indirectly expressed similar concerns. He called the “unprecedented measures” introduced around the world in the context of the novel coronavirus outbreak, “buying time,” and urged all the countries “to attack the virus,” enabling “the more precise and targeted measures that are needed to stop transmission and save lives.”

In this context, WHO recommends six key actions:

  • Expanding, training and deploying healthcare and public health workforce.
  • Implementing a system to find every suspected case at community level.
  • Ramping up the production, capacity and availability of testing.
  • Identifying, adapting and equipping facilities to treat and isolate patients.
  • Developing a clear plan and process to quarantine contacts.
  • Refocusing on suppressing and controlling COVID-19.

According to the Director General, these will help to suppress and stop transmission, “so that when restrictions are lifted, the virus doesn’t resurge.”

At the same time, Matthew Jackson, the William D. Eberle Professor of Economics in Stanford’s School of Humanities of Sciences, said in an interview that the current efforts, both on national and global levels, lack coordination, which “may end up being very costly for the world.” He noted that while one area was slowing the virus down and getting it under control, it was growing somewhere else. “Once it is under control in the first area, it can return from another area.

References:
https://healthmanagement.org/c/hospital/news/where-are-the-most-effective-anti-covid-19-strategies
https://www.thequint.com/voices/opinion/mumbai-maharashtra-uddhav-thackeray-covid-crisis-urban-housing-population-density-public-transport
https://indianexpress.com/article/explained/mumbai-coronavirus-covid-19-cases-hospital-beds-deaths-6413025/
https://www.expresshealthcare.in/interviews/telemedicine-during-covid-19-a-nationwide-pilot-in-a-real-time-situation/421050/

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