Pandemic second wave deepens into unprecedented crisis

The government has few constructive leads to offer as the second wave of the pandemic develops into a crisis of an unprecedented scale.

A queue to refill oxygen in cylinders in New Delhi on April 23.

The massive wave of COVID-19 infections engulfing the country is testimony to the Central government’s total ineptness in handling the crisis.

In April, nearly 42,000 deaths were officially recorded as having been caused by COVID-19. In less than a month, the count went up by more than 20 per cent of the total official COVID deaths in the 15 months since the beginning of the pandemic.

On March 28, India’s cumulative confirmed cases crossed the 12-million mark. In April, the 18-million mark was crossed. In other words, more than six million cases were added in less than a month, which is more than the total number of cases from the beginning of the pandemic until the first peak in mid September 2020.

When top scientific experts in the establishment say that this surge had not been anticipated and other experts observe that the health system has collapsed, it is evident that the country is in deep trouble. In an interview to a leading daily, the Principal Scientific Adviser to the Union government admitted in so many words that none of the scientists had predicted a wave of “such vehemence”. It is equally clear that the country is not equipped to quell the raging fire and that it will have to die down mostly on its own, leaving behind a trail of death and destruction. The tragedy has already touched an overwhelming number of families. Many have died because they could not get to hospital and many others because they could not get oxygen in time. Delhi is in the news because it is the national capital, but similar stories are coming through from everywhere across the length and breadth of the country. Even the media are overwhelmed, unable to properly depict the scale of the tragedy that is unfolding.

Statistics can only go up to a point in describing what is happening. Day after day, India is setting a new record and then breaking the world record in the number of confirmed COVID cases reported on a single day in any country. After 3.86 lakh cases on April 29, the four-lakh mark was reached in less than 24 hours the next day. Except for Maharashtra, where there are signs of a slow decline in the number of daily cases, the numbers are still growing rapidly almost everywhere else. The figures that are emerging must be seen in the context of an overstretched testing capacity and amid reported pressure from governments to slow down the process of testing. The testing numbers have gone up considerably in the last two weeks, crossing the 10-million mark for the first time in the week ending on April 18 and then increasing further to 11.4 million in the week ending on April 25.

Nevertheless, the seven-day average of the test positivity rate has also been climbing steadily and has breached the 20 per cent mark nationwide—a clear indication that the number of infected people is far higher than the numbers confirmed by tests.

Deaths, too, are probably undercounted to a great degree—but even then, the official figures are showing that not only is the daily death toll rising to levels seen only in the United States and Brazil, but that the number of deaths is actually rising faster than the number of cases. In the week ending on April 11, deaths accounted for 0.54 per cent of the cases. However, the figure has steadily risen thereafter, and in the first three days of the week starting from April 26, the ratio reached 0.91 per cent. This indicates that people are dying because they are not able to get proper medical care. The number of active cases has crossed the 30-lakh mark, three times the highest number seen at any point in 2020.

According to the figures for Delhi, which accounted for 3.35 per cent of the official tally of active cases in the country on April 28, one out of every five active cases is receiving treatment in a hospital. Yet many patients in need of treatment were unable to find hospital beds and some died after being turned away by hospital after hospital. The situation is likely to be far worse in other places.

India’s vaccination programme also increasingly seems to be losing steam even though it is notionally being opened up to a larger section of the population. In the week ending on April 11, the average number of vaccine doses administered daily was 3.66 million. In the week ending on April 18, this average dropped to 3.18 million and in the subsequent week it went down further to 2.58 million. When new vaccination rules come into effect, the process may become more chaotic and less effective. The Health Ministry clarified that covering phase one and phase two (45 plus category) was more important as these catered to more “vulnerable” categories of people. The truth was that there were just not enough vaccines to go around.

Overburdened hospital staff

While shortfalls in oxygen, vaccines and medicines have been discussed, less attention has been paid to the huge burden on medical and paramedical staff in hospitals. Government hospitals grappling with the second wave were in any case overburdened with patients even in normal times, and the public health system suffered because of poor infrastructure in rural areas. Even private sector hospitals, which have lower footfalls because of their prohibitive costs, ran short of intensive care unit (ICU) beds. A doctor working in the COVID unit of a private hospital said: “We are totally helpless. We cannot take in more patients. We have oxygen to last only a few hours, and that is something of critical importance to COVID patients. Last time it was the geriatric category that was affected by the virus. This time, small kids and young people in their late twenties and thirties are dying. Many of the young people are non-smokers.” He added that even a single-dose vaccination provided some protection. Doctors and nurses were able to treat patients because they had been vaccinated. “We are overworked. We get hypoxia [oxygen deprivation] because we are trapped in PPEs [personal protective equipment] and three-layered masks. We can work six hours, eight hours at a stretch. But it is impossible to put in more than that. As a doctor I have good contacts in the medical fraternity, but even I couldn’t get an ICU bed for the mother of a friend. Every night is torture for me,” he said, requesting anonymity.

The requirement of oxygen per patient had gone up from six litres per hour to 50 litres per hour, he said. “No one anticipated this level of requirement. Normally we administer oxygen in the ICU to asthmatic patients. But the virus is replicating so fast within the body that all of us have been compelled to resort to blind treatment depending on the severity of the case,” he said. The Central government, he added, was coordinating COVID treatment and should have prepared for the second wave.

According to the latest annual Rural Health Statistics (2019-20) report released in April, the shortfalls in manpower in health care continued to be stark. While the number of allopathic doctors had increased in primary health centres from 20,308 in 2005 to 28,516 in 2020, there was a shortfall of 6.8 per cent at PHCs at the all-India level. In the same 15-year period, the number of specialist doctors had increased from 3,550 to just 4,997. Community health centres had a shortfall of 78.9 per cent surgeons, 69.7 per cent obstetricians and gynaecologists and 78.2 per cent physicians and paediatricians. Overall, there was a 76.1 per cent of shortfall of specialist doctors at CHCs at an all-India level. The average rural population covered by sub-centres, PHCs and CHCs far exceeded the norm. For example, as of July 2020, the norm for the average population coverage at a sub-centre was 300 to 5,000 people. The rural population covered was 5,729. Similarly, a PHC on an average was supposed to serve a population of 20,000 to 30,000; it was attending to 35,000 on an average. A CHC was supposed to cater to a population of 80,000-1,20,000; instead, 1,71,779 persons were being catered to by a single CHC on an average. The average rural population covered per sub-centre was over 3,000 in the entire country, barring Kerala, Mizoram, Tripura and Ladakh where it ranged between zero to 3,000. Over 7,000 people on an average were catered to by a single sub-centre in Bihar, Uttar Pradesh and Jharkhand, whereas in 11 States, including Gujarat, the population covered in a sub-centre was between 3,000 and 5,000 people.

The average population coverage in PHCs and CHCs was on the lower side in the southern and north-eastern States, indicating a better spread of such centres. The numbers were much higher in the northern, central and western parts of India. There are 810 district hospitals in the country equipped with 22,827 doctors and 80,920 paramedical staff. There was an observed decline in the number of doctors and paramedical staff over the last three years, from 2018 to 2020. With the virus spreading fast in the interiors as well, the state of preparedness of the rural health infrastructure is anybody’s guess.

The Bharatiya Janata Party (BJP), which holds power at the Centre, was busy with election rallies when there were the first signs of an imminent second wave. When the crisis could no longer be ignored, the worst impact was felt in the National Capital Region that included parts of Haryana and western Uttar Pradesh. “Needed, an oxygen cylinder, Please help”; “Need an ambulance, please give some leads”; “Need an ICU bed for a 40 year old whose Oxygen saturation level is less than 80, please help”; “Need some food delivery service”; All four in family down with COVID-19, please help”—these were some of the SOS calls that were circulating on the social media platforms in the NCR from April 20 onwards. The frequency increased manifold with each passing day. People were dying at home, even people who could afford it could not get a hospital bed or ICU care. There were people ready to shell out lakhs for a single injection of Toculizumab, but the medicine was nowhere in sight. Online consultations with doctors had a limited impact as oxygen levels dipped drastically in thousands of cases. Private hospitals that resembled five-star hotels had never seen such a crisis before. Tocilizumab, Remdesivir and Fabiflu tablets all disappeared from the stores, including hospital pharmacies, even though the efficacy of all three in reducing mortality was still unclear.

Profit over public health

The World Health Organisation’s multi-solidarity study on repurposed antivirals had ruled out Remdesivir’s efficacy in COVID treatment. Yet the medical community recommended it and put pressure on patients and their attenders to look for it, sometimes at huge cost. The medicines were also sold on the black market at astronomical prices. Rentals of ambulance services, especially when fitted with supportive equipment like oxygen cylinders and ventilators, went up drastically. Everyone seemed to be cashing in on the opportunity offered by the crisis. The rates of home care services also shot up four-fold. One such provider in Gurugram, Haryana, told this correspondent that had it not been for COVID, the rates would not have been inflated thus. “I am sending my fully trained staff nurse at great risk. The compensation should also be more. Everyone is into dukaandari [making profit] and so am I,” he said.

At the end of the day, people who themselves were either infected or had entire families infected were clueless about what to do. If someone had managed to get an ICU bed in a hospital, the attendants of the patient were scrambling to organise Remdesivir or the anti-inflammatory injection Tocilizumab. But it was oxygen that the capital was gasping for. No one knew why the cytokine storm (an aggressive inflammatory response) was so severe in some cases. Doctors involved in COVID treatment told Frontline that many young people were succumbing to it by the tenth or eleventh day of the onset of the disease and some even earlier. “They are not poor people. They are rich people who can afford to pay, pull strings to get admission, but even for them there aren’t any beds,” one of the doctors in a COVID ward said. All that those people needed was oxygen and that was in short supply. None of the hospitals in Delhi had their own oxygen plant. There were less than a hundred pulmonologists in Delhi, said a doctor. With little research happening on why the disease was progressing so fast in people of all ages, most people were caught completely unawares. The Central government was equally clueless. In his Mann Ki Baat on April 25, Prime Minister Narendra Modi said that the second wave had shaken the nation, a fact that he need not have stated as people were directly experiencing it.

On April 29, the Union Health Ministry issued a set of revised guidelines for home quarantine. In the section on the line of treatment in home isolation for mild and asymptomatic cases, it was recommended that the patient and caregivers should seek “immediate medical attention” if they developed serious signs and symptoms like difficulty in breathing, dip in saturation (SP02 less than 94 on room air), persistent pressure and pain in chest or mental confusion. The government had basically placed the onus of seeking medical attention on the people themselves. There were families where the elderly, young and even pregnant women were down with COVID, unable to even organise medicines for themselves. How were they supposed to seek medical treatment or any other kind of care in the absence of either government or a resourceful family network?

“Patients must be in communication with a treating physician and promptly report in case of deterioration,” stated the revised guidelines. People in India do not have the luxury of a private physician on call. Doctors attached to private hospitals were unable to take calls from their own patients and unable to give the kind of counsel the government expected them to give. A single one-time online consultation with a private physician was chargeable at rates that most Indians were certainly not able to afford, especially if entire families were infected.

The guidelines also cautioned against the use of Remdesivir in a household setting. It was to be taken only in a hospital setting. The problem was that the drug was not available in the hospital setting as well. The guidelines recommended Ivermectin, an anti-parasitic drug, and the inhaler Budesonide, both of which were unavailable for days altogether in the NCR.

In one of the biggest ironies, the guidelines stated that “people whose oxygen saturation levels were falling and suffered shortness of breath should seek hospital admission”. The only hitch was there were not any hospitals to go to.

‘Only logistical issues’

On April 30, at the Health Ministry’s press briefing officials were at pains to convince the media that a lot of panic had been created over shortages and that oxygen and medicines were available. There was no supply side crunch, government spokespersons said. If there was a shortage, they said, it would be looked into. There were only logistical issues, the media was told. Oxygen supplies had been ramped up, 162 pressure swing adbsorption (PSA) plants for in situ generation of oxygen had been sanctioned, transportation of oxygen in cryogenic containers by road, rail and air had been organised and even imports from Singapore and Abu Dhabi were on their way. Of the 162 plants, only 52 had been installed while 87 had been delivered. Earlier, on April 25, when the daily number of cases had crossed 3.5 lakhs, the Prime Minister announced that 551 plants would be set up in public health facilities, for which funds would be provided from the PM Cares Fund. An industry insider told Frontline that it would cost Rs.30 lakh to set up a medical PSA plant in a hospital of a capacity of 25 cylinders a day and take eight to ten weeks for a “typical delivery”.

As April ended, close to four lakh infections were reported in the country, and SOS messages abounded in the social media from even outside the NCR, from places in Madhya Pradesh, Bihar and Rajasthan. April 30 was the eighth consecutive day since April 22 when the number of daily infections touched and crossed the three-lakh figure. In the second half of April, Maharashtra, Uttar Pradesh and Delhi accounted for 40 per cent of all cases.

There was an attempt by the Health Ministry spokesperson to show that non-BJP ruled States like Maharashtra, Kerala, Delhi, Punjab or Chhattisgarh were contributing more to the daily caseload and the overall caseload. Among all the high-surge States, Kerala has been consistently recording the lowest daily death rate, even though it scarcely received a mention in the Centre’s communication. The categorisation itself was meaningless. All States were reporting a surge, and comparisons between States do not have much meaning because population sizes are varied. Maharashtra’s population size is double that of Karnataka’s. On April 30, the positivity rate in Karnataka was 26 per cent as more than 48,000 cases were recorded in the last 24 hours with Bengaluru accounting for the bulk of cases. Even though Maharashtra had the highest number of daily and cumulative cases among all States, a slight decline and plateauing was observed over the last three days in April, which the Health Ministry did not mention.

At the Ministry’s briefing, Randeep Guleria, Director, All India Institute of Medical Sciences (AIIMS), said that the virus had reached Tier 2 and Tier 3 cities. The Centre now planned to train doctors on COVID management through “regional excellence centres”. There was no reference in the briefing to the unavailability of ICU beds and shortage of trained medical personnel and paramedical staff. No figures of the proportion of people on oxygen support, ventilators and in ICUs was shared; neither were figures of agewise mortality given.

It was evident that had people not posted images of queues in front of hospitals, weeping relatives, mass cremations, patients waiting in ambulances, people carting oxygen cylinders in their hands or posted messages asking for help with details of CT scan reports and oxygen levels, the government would not have budged. Appeals by private hospitals requesting oxygen supplies caught the attention of one and all, including the courts. By the time the supplies arrive, many more lives will be lost.