In January, 68-year-old Bharatkumar Desai, a general physician, sat in his clinic no bigger than a small mom-and-pop retail store, with a stethoscope around his neck, in Mumbai’s north-western suburb of Kandivali. It was no ordinary month – nearly 185 patients had come in on one day of January, most with flu-like symptoms. But the bespectacled doctor knew that for many, this was not the flu, but Covid-19.
The pandemic was raging in Mumbai – at the peak, over 20,000 new cases had been detected in a single day. And it was the family doctors, the trusted general physicians, who were at the forefront of this deluge of cases, armed with the humble and ubiquitous paracetamol. They were aided by the large scale vaccination programme, which reduced the severity of the disease and the possibly milder Omicron variant of the SARS-CoV-2 virus.
“These patients know me for years, I cannot abandon them,” Desai, who has diabetes and hypertension and has undergone a bypass surgery, would say when his family chided him for putting his patients’ health over his own. Desai said he treated an average of 130-140 patients every day between January 1 and January 8. He received his precaution dose, the third one of a Covid-19 vaccine, in the second half of January.
If India’s first Covid-19 wave was marked by the nationwide lockdown, the second wave by patients’ kin rushing to find scarce hospital beds or oxygen, the third wave has been marked by chock-a-block waiting rooms of general physicians across the country.
At its peak, on January 7, when Mumbai reported 20,971 cases, only 18% of the city’s Covid-19 beds were occupied. The number of people in home quarantine had spiked 300% in the same week to 3,30,000. Even on January 25, when IndiaSpend accessed the municipal corporation’s Covid-19 dashboard, Mumbai had 6,31,000 people under home quarantine and just 542 in institutional quarantine, even as there were only 1,815 new cases that day.
A majority of those in home quarantine consulted their family doctors, we found. The number of patients reaching out for consultation had increased in January by at least 50%, said doctors who spoke to IndiaSpend.
‘God, not again’
This was Omkar Karve’s reaction when the number of cases in Mumbai started rising in December 2021. Karve is a general physician in Thane. Usually, he is at his clinic from 5.30 pm to 9 pm, but in the first few weeks of January, he would be in the clinic, seeing patients, until 11 pm. Then “the house gets disrupted, my phone keeps ringing, a doctor’s personal life gets upended. I have a baby at home but I don’t get to spend time with him”.
The scenario in this third wave was very different from the first wave in 2020, when many private doctors had temporarily shut their clinics and the Brihanmumbai Municipal Corporation had to issue orders asking private hospitals and clinics to open.
“It has been an extremely difficult time because you feel obligated to take that additional [phone] call,” said Preeti Chhabria, director of medicine at Sir HN Reliance Foundation Hospital in Mumbai. She manages virtual as well as a physical outpatient department, while also caring for hospitalised patients, she said. It is even more taxing as she has to take every precaution to prevent taking the infection back to her 89-year-old mother at home.
Despite wearing personal protective equipment while seeing patients, Chaitanya Kulkarni, a consultant at Reliance hospital in Navi Mumbai, tested positive for Covid-19 in January.
“That is the risk we take every single time,” said Kulkarni, who spoke to IndiaSpend, whilst in isolation at home. “I did not consult on the phone because I believe seeing the patient is important.” In the second wave, he lived in a rented home to keep his family safe, said Kulkarni, who has a four-month-old son.
India lost 747 doctors to Covid-19 in the first wave and 776 in the second wave, according to data from the Indian Medical Association.
Home testing
Many doctors IndiaSpend spoke to did not recommend a test for Covid-19 immediately, especially for healthy patients. Patients with very mild symptoms too preferred either no tests or testing at home using Rapid Antigen Test kits, rather than through the “gold standard” RT-PCR.
India reported a surge in the use of home testing kits with 2,00,000 home tests used in the first 20 days of January 2022 as against 3,000 in all of 2021, the director-general of the Indian Council of Medical Research, Balram Bhargava said on January 20.
The sale of self-testing kits rose in Mumbai too, but a majority of those purchasing the kit would not report the result to the municipal corporation by scanning the QR code on the test kit. Because of this, the civic body made it compulsory to provide the Aadhaar number while purchasing self-testing kits.
“If people had come in contact with a positive individual, they would just stay at home assuming it is the mild variant, but we must not forget that the [more serious] Delta variant is also present,” said Rahul Pandit, the director of critical care at Fortis Hospital in Mumbai and a member of Maharashtra’s Covid-19 task force.
Most of the patients who would consult doctors would do so because either they had symptoms, had gotten tested for work or travel and the test was positive. Or, they knew they had been exposed to someone who was detected with Covid-19, doctors said.
“We assume suspected flu patients as Covid-19 patients and take precautions,” said Karve. “Not everyone tests, which is alright, especially when there is community transmission.” About 95% of his patients recovered at home and the few who had to be referred to a hospital did not require intensive care.
Desai’s approach to treating patients with Covid-19-like symptoms was to observe on medication such as paracetamol, cough syrup and the antibiotic azithromycin (if required) for two days and do a test only if the symptoms persisted.
Kaushik Joshi, 65, a general physician in Mumbai’s Malad area, would ask all young adults with symptoms to take precautions for five days, irrespective of whether they had been tested by RT-PCR or not. “I had to be more watchful towards those above 60, and with comorbidities, because tomorrow if their health deteriorates and they need to be rushed to the hospital, how will they get admission without an RT-PCR? In Covid-19, every case is different, you cannot be complacent for anybody.”
“When people have Covid-19 symptoms, follow-up for 10-12 days is needed but after two days, if the patient is out of touch, I do not know if GPs follow up,” said Pandit. “At least if the patient has done an RT-PCR, the civic body is in touch with him or her.”
Home care
Some doctors, like SP Mathew, from Borivali’s Ashok One Hospital, have a home isolation programme for patients.
“We have a five-day and seven-day home monitoring programme where we monitor patients through video calling,” he said, adding that the patient or a relative fills a form and a doctor is assigned to the patient, and they get medicines delivered and test samples taken from home. His programme gives guidelines to the patient, so that they know signs to watch out for, to know if the disease is becoming severe.
Doctors would prescribe paracetamol, cough syrup and an antibiotic if needed, they said. “No other treatment is required. Some doctors are giving Fabiflu or Molnupiravir,” said Kulkarni, adding that some patients demand that their doctor prescribe these medicines and if they do not, patients go to another doctor. “Very few doctors stand their ground in such a case.”
Maharashtra’s State Surveillance Officer Pradip Awate said that Favipiravir, Remdesivir and Molnupiravir have been used in lower quantities in the state in this Covid-19 wave.
Chhabria of HN Reliance hospital warned against the indiscriminate use of antibiotics for a viral infection. “It is okay to not give anything to the patient. You do not have to give an antibiotic unless the patient has a superadded [secondary] bacterial infection,” said Chabbria. “For a viral infection, antibiotics do not work. They have to be used judiciously, otherwise, we will deal with another problem of antibiotic-resistant bacteria in a year.”
Too few doctors
Along with the surge in Covid-19 cases, doctors were also burdened because India has too few doctors for its population. Compared to the World Health Organization’s ideal ratio of one doctor for every 1,000 people, India has one doctor for every 1,308.
“It is not an issue if general practitioners are treating Covid-19, as long as all of them are referring patients to hospitals when required,” said Pandit of Fortis and the Covid-19 task force.
“The immunity we have right now is also because of large-scale previous infections, as we saw in the serosurvey results,” said Awate.
Vaccinations also help keep cases mild, said Suhas Pingle, a general practitioner and the president of the Maharashtra unit of the Indian Medical Association. “Waves like these will keep coming but we will get used to it.”
This article first appeared on IndiaSpend, a data-driven and public-interest journalism non-profit.
