Let’s start with the stark figures. By midnight on Wednesday, 40 people had died in Mumbai due to Covid-19 compared to nine in Delhi. The morality rate in the commercial capital was 6.2%, four times higher than the 1.6% rate in Delhi – and twice the average rate in India.
On the face of it, this is surprising. Mumbai has good medical infrastructure and an excellent array of both hospitals, both public and private, to tackle the pandemic as Stage 3 begins to unfold. This is the stage of community transmission, when a patient is infected despite not having any known contact with a person who has been confirmed with the disease or has travelled from a country affected by the pandemic.
Quality medical care is the key to achieving low mortality in Covid-19 patients. Most cities and countries with good-quality health facilities have managed a low 1%-1.5% mortality rate, until they reach the stage where the number of patients overwhelms the medical system (as seen in Wuhan, Italy, Spain, or New York City) and then the mortality rate skyrockets.
Mumbai and Delhi are both in the former category at present. And yet, while Delhi has managed to keep the mortality low, Mumbai is doing rather poorly. Why so?
As far as the preventive measures go, the city (and indeed the state and national) leadership has responded proactively to tackle the pandemic. However, in Mumbai, the urgency in enforcing these preventive steps seems to have been matched by some inefficiency in preparing for and managing the treatment side of the pandemic. Inadequate testing and the lack of personal protective equipment for frontline health workers cannot explain the differential mortality rate as these lacunae existed across the country, including Delhi. In fact, Mumbai is testing more than Delhi.
But perhaps understanding how Mumbai faltered in its planning and where it has gone wrong could help rectify the situation as soon as possible.
Mumbai has five medical colleges and hospitals: the municipal-run KEM, Sion, Nair and Cooper hospitals. Cooper is a more recent facility and is not as well equipped as the others. There is also the Maharashtra state-run JJ hospital. In addition, there are 16 peripheral general municipal hospitals and six specialty hospitals, one of which is the Kasturba infectious diseases hospital. All of this makes for an overall decent health infrastructure.
Having worked in King Edward Memorial Hospital (or KEM) for my MBBS and MD and in certain peripheral municipal hospitals for a year in 2012, I am aware of how the system functions.
The problems with Kasturba hospital
The 550-bedded Kasturba hospital is a specialty centre which focuses on infectious diseases. It is a large airy well-ventilated space, making it an ideal place for keeping infectious patient – a century ago. In the 21st century, an isolation center should ideally have advanced facilities like a negative pressure room, UV lights, high-efficiency particulate air (or HEPA) filters, and an anteroom (sort of an in-between chamber) between the patient’s area and general corridor. Kasturba has none of these, and there seems to be no plan to immediate add these.
One could still argue that it is a much better option for isolation than the other municipal hospitals. However, Kasturba was labelled as a treatment facility rather than just an isolation center. This despite the fact that it had no ICU or dialysis unit (a dialysis machine was later shifted to it to treat a Filipino patient who subsequently died), and a limited number of ventilators (four ventilators initially, which were increased later).
While doctors, nurses, and paramedical staff were mobilised from other municipal hospitals to ramp up the services, the primary staff at Kasturba are not trained to manage severe or critical cases. The transferred staff are new and may not work as efficiently at Kasturba, so the decision to make this a treatment facility was perhaps hasty.
Why leave out all Mumbai’s large public hospitals?
Mumbai’s big four – KEM, Nair, Sion and JJ hospitals – are among the best public hospitals in the country, with the most experienced faculty and top trainee doctors. They have high-class ICU facilities and a 24x7 medical staff in a multi-specialty set-up skilled at managing critical cases, which requires a coordinated team effort where subspecialists like nephrologists, cardiologists and infectious disease physicians all work together.
Even in excellent top-quality care facilities across the USA and Europe, Covid-19 is known to cause an upwards of 3%-4% mortality. Why are we not using any of our best public hospitals as Covid-19 centres to give our patients the medical support they need? In Delhi, for example, Covid-19 patients are treated at Safdarjung hospital, a large academic hospital.
Furthermore, at least some of these hospital campuses have more than one building. To earmark at least one building of these hospitals for Covid-19 treatment would have made much more sense. That would make segregation of patients feasible, ensuring that routine clinical work remained unhampered.
Equally important, it would give these institutions a chance to prepare before the dreaded peak influx occurs. (Even senior doctors will need experience in managing this new disease before hitting the right formula for patients).
These hospitals also have excellent think-tanks, which could create evidence-based and practical management guidelines and standard operating procedures for managing Covid-19 patients in the public setup.
Arbitrary private hospital lockdowns
The health authorities did make some good decisions, such as converting Seven Hills Hospital in the Andheri area into a Covid-19 quarantine facility, and roping in some private hospitals into the effort early. This makes sense. It segregates hospitals into ones that will end up managing more Covid-19 cases and those that will manage routine emergency cases (such as child birth, appendicitis, heart attacks and the like).
However, the death of an octogenarian doctor and the positive test of his son, a doctor at Saifee Hospital in the Byculla area triggered an unexpected sealing of major portions of the hospital (including the outpatient department). There was also a partial sealing of Jaslok and Hinduja hospitals. Healthcare workers across the world are known to have a much higher risk of contracting Covid-19 than the general population, for obvious reasons. The knee-jerk reaction of sealing off hospitals immediately at the instance of a few positive cases among its medical staff does not have much scientific logic. Nor do the Mumbai health authorities seem to have any standard published guidelines or standard operating procedures on this issue.
Contrast this with Singapore, where healthcare workers are quarantined only if there is a greater than 30-minute exposure to a Covid-19 positive patient at a distance of less than six feet if a surgical mask has not been worn. Otherwise, the health care worker can continue working while monitoring themselves for symptoms.
The renowned pulmonologist Dr Zarir Udwadia criticised the sealing of the Mumbai hospitals, noting that with this policy, there will not be anyone left to treat patients, as everyone will be either quarantined or have been working in a sealed off hospital.
Most Covid-19 deaths across the world occur due to health systems being burdened beyond their capacity, leading to a shortfall of ventilators, ICUs. Mumbai is nowhere close to that stage, and is still demonstrating higher mortality than Delhi (a comparable city), thanks to this artificially created shortage of high-quality ICUs and experienced medical staff in the public hospitals.
Time is still on our side though, thanks to the aggressive preventive measures undertaken in Mumbai and across the country. Utilising our best public hospitals to treat Covid-19 patients by earmarking two of the big four public hospitals as treatment centres, clearly defining quarantining criteria for health care workers, and stopping unnecessary sealing of private hospitals are among the simple steps to take.
Rampup of testing and improve health infrastructure to whatever extent possible, and there can indeed be a huge impact in preventing unnecessary deaths.
Dr Akshay Baheti is an assistant professor in the department of radiodiagnosis at Tata Memorial Hospital in Mumbai.