Interview: Dr Mathew Varghese

Dr Mathew Varghese: ‘Why didn’t China fail?’

Print edition : June 04, 2021

Dr Mathew Varghese. Photo: Ramesh Sharma

Interview with Dr Mathew Varghese, public health expert and former director, St. Stephen’s Hospital, New Delhi.

There are very few people who work in a private hospital setting but strongly advocate greater investment in public health. Mathew Varghese, former director of St Stephens Hospital, New Delhi and an orthopaedic surgeon by training, is one of them. He said that the surge experienced by the second wave that overwhelmed hospitals in the National Capital Region and elsewhere could have been managed if there had been a policy in place. He spoke to Frontline on some of his own experiences and the flaws in policy. Excerpts:

Why and how did the situation get out of control? The government had time to work on this since the last peak was reached in mid September.

What happens is that if anyone tries to fault any policymaker or any government, they go on the defensive. Some also go on the offensive and then the critic becomes persona non grata. True democracy should have none of these. There should be a transparent, candid and honest exchange of ideas. In our kind of democracy particularly, the defence and offence mode is often resorted to against critics. Getting things done in such a diverse country as ours is difficult. Given these foundational issues, we have to think how to make people comfortable and reduce suffering. I look at it from this perspective.

At 1.30 am in the morning, I get a call from a young boy asking me to save his mother. I don’t know how he got my number. He was telling his mother to prone and take deep breaths. It is suffering of the worst kind. Imagine a child watching his mother die. As a healthcare professional trained to save lives, what can one do? The caregiver feels helpless. The situation is too heartrending, overwhelming. So whatever be the ideology of any government, we should ensure this doesn’t happen. Systems have to be in place. Access to facilities that mitigate suffering should be there for everyone. Let us assume that all that happened was an act of omission. So now we need to find out what we need to do and address the weak links in the system.

As a doctor with years of experience, why do you think this was unprecedented?

We have never faced such situations before. I get a call from a patient whose wife tells me his oxygen saturation level is falling. They have an oxygen concentrator, she says, and the saturation is 83. I tell her he has to be taken to a hospital. But there are no ambulances. It is midnight. I think of innovative ways of having an ambulance with oxygen. But that’s not workable. A relative then takes the patient in their own car, drives at breakneck speed and reaches hospital but there is no ICU bed there. There are a number of such heartrending incidents I can narrate.

Also read: Government's all round failure to manage pandemic exposed

A 30-year-old lady who is 32 weeks pregnant has a saturation point of 80. She needs admission. She has been turned away by many hospitals as there are no ICU beds. The family then waits in the ambulance and the oxygen is running out. But there’s no bed. She’s given a replacement ambulance. The new ambulance takes them to Panipat as someone has told them there is an ICU bed there. Her saturation point has dipped to 70 now and she’s put on a high-flow nasal catheter and then put on a ventilator. But she dies, along with the baby. I have been living with these stories day after day.

Why did things come to such a pass? One would have assumed that Delhi would not face such a situation.

This particular wave was caused by a super contagious virus. In the older strain, one member of the family used to be infected. Now entire families are getting infected, including the household help. That doesn’t happen if the virus is not super contagious. Eighty per cent were symptomatic with mild symptoms. But the 20 per cent had serious symptoms, requiring oxygen. The numbers of the asymptomatic were also very high. So in a family, if everyone was positive, one person would get critical. As a percentage of the population, it comes to quite a bit. It was the virus and the strain. Symptoms got fast forwarded.

In the first wave, it took seven days for somebody’s condition to deteriorate; in this one, people’s conditions were getting worse in four to five days. Within a short span of time, we had a huge number of cases. In the previous epidemic, the bed capacity didn’t get overwhelmed. This time, people realised that even if they had money, they couldn’t get beds. So there was a genuine deficiency. The numbers were really huge. The surge could not have been anticipated but what could have been anticipated was that if there was a surge, then was the system prepared for it?

What would be the normal ICU occupancy in a typical hospital setting as compared to the requirement in the event of a surge?

When I was director [of St. Stephen’s Hospital] several years ago, one of the most difficult things for me was to tell a sick patient that we don’t have a ventilator. There has always been a short supply. In any hospital, 10-15 per cent of the beds are reserved for the ICU, of which some are ventilator beds and some are non-ventilator beds. The most limiting factor in a ventilator bed is the availability of the operator and the technical staff. A normal doctor cannot do all that. I am a reasonably dedicated and trained doctor but I don’t know how to run a ventilator. So one may buy ventilators but one won’t have the staff to run it.

Also read: Pandemic second wave deepens into unprecedented crisis

The virus was responsible for the surge. The numbers are overwhelming. But the lack of ventilators and oxygen could have been anticipated and planned for. Already, there was a deficiency. But there is a greater shortage of staff, nurses, doctors and trained staff. Ventilators are high-tech equipment that cost aboutRs.15 to 20 lakh. One may get a basic ventilator for Rs.7 lakh but in this situation only a high-end ventilator would have been of use. All these special ventilators being touted are of little use. There is a perennial deficiency in every city for ventilators and a greater deficiency of staff. We had trouble with ventilators even in the first wave. ICU beds and ventilators were a big issue even then. People were waiting for others to die on the ventilators so the others could get on.

There may be something else tomorrow but the job of the government and administrators is to plan for all that. For this, technical training, technical manuals, protocols had to be prepared. Even then the existing hospital infrastructure would not have been enough. How do we deal with isolation cases, mild cases, severe cases? Now if a patient gets serious and there is no ventilator, we tell the relatives to go find a ventilator. The poor relatives just run around.

The treatment protocol itself is a disaster. It talks about how to deal with mild, moderate and severe cases. One of the criteria for deciding whether a case is moderate or severe is the oxygen saturation level. What did we see? The policy decisions were not dynamic. As an example, the government hospitals were declared as COVID hospitals. So to enter it, one had to have COVID. There were false negatives. One-third of COVID victims went around spreading infection as they were negative. Then there were no support mechanisms. I knew of one family in Uttarakhand where all family members were positive. They got themselves admitted to a local nursing home and were finally taken to AIIMS, Rishikesh. But as all were positive, and had no one to attend to them, the brother based in Delhi rushed there along with his son. Both tested positive. Finally, both the brothers died, one in Delhi, the other in Rishikesh. Doctors themselves are scared of getting infected. They are in PPE [personal protective equipment]. They talk minimally to the patient and don’t touch the patients as much as they should.

You have disagreed with the protocol for COVID treatment.

Have you seen what Ivermectin is for? Just do a Wikipedia search. It is a drug for parasites, roundworms and other parasitic infestations. There is no evidence that it has any effect on COVID-19. The medicines themselves are suspect. On plasma therapy, ICMR has its own multi-centre, double-blind placebo control study published in the British Medical Journal. It says there is no evidence that plasma therapy is more effective than placebo therapy. Why don’t they stop people from running around for these medicines? The problem is that as long as it is in the protocol, doctors will recommend it. There is a disease which is new and people do not have sufficient understanding of the disease. We need people to do research as well.

Also read: Ramanan Laxminarayan: ‘Vaccination the only way out of the pandemic’

In institutions like Harvard and Stanford, if they have 30 people in the department of orthopaedics, not all of them would be clinical orthopaedicians. Fifteen would be research assistant professors. We don’t have a concurrent research team in medical colleges. It is considered superfluous. Earlier, jobs were secure. A UPSC [Union Public Service Commission] appointment was a permanent appointment. Today, all the new appointments are on contract; there is no provision for pension. These doctors join these medical colleges for five years. Everyone knows who is good. Then they get poached by a private hospital. So by policy, the corporatisation of health is encouraged. If one doesn’t have pension, one ends up joining the corporate sector and rakes in as much as long as the sun is shining.

The government claims that the health systems of the developed world were also overwhelmed and that India was no exception.

Yes, that’s what happens in a pandemic. Systems get overwhelmed. But did they run out of oxygen? They didn’t. Large hospitals have their own oxygen manufacturing plants. They ran out of PPEs because they had shifted out all their polluting manufacturing industries to the developing world. On Najafgarh road in Delhi there used to be a huge Indian Oxygen Limited Plant which was shut down as all polluting industries had to be removed. Hospitals with more than 500 beds should have an oxygen plant. Oxygen plants should have been set up as a matter of policy. A captive oxygen plant would have worked. Why didn’t China fail? They didn’t run short of ventilators or PPEs. There wasn’t any mass migration. They didn’t turn away any patient. The West had criteria for admission but once they fulfilled the criteria, they admitted them. Patients have died on trolleys and ambulances in India. Health care should never be privatised.

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