Amid a rising spate of Covid-19 cases, Goa, as part of Unlock 2.0, officially reopened for tourism on July 2. Approximately 250 hotels registered with the state tourism department have been allowed to open following guidelines set by the state. While the state has received a mixed response to this decision, the number of Covid-19 cases continues to rise.

Goa witnessed its highest single-day rise of 198 cases on July 15. By July 22, the state had confirmed 4,167 cases – of which 1,607 were active – and 28 deaths. These cases have been reported from over 50 areas in the state, the state’s Covid-19 bulletin shows. At least 10 neighbourhoods, none in popular tourist spots, were declared containment and micro-containment zones – see here and here. On July 15, at a press briefing, Chief Minister Pramod Sawant announced a three-day statewide lockdown and a “janata curfew” everyday from 8 pm to 6 am until August 10 – three hours longer than the night curfew nationwide.

How did a state that was declared a green zone in early May clock in nearly 4,000 new cases in two months?

The answer is complicated, and comprises of an array of reasons. Interviews with recovered patients, a local councillor and health officials suggest administrative glitches that allowed Covid-19 to spread its tentacles from one hotspot to all across Goa. Mismanagement of containment zones, lack of timely ambulance services, fear among and shortage of healthcare staff, social stigma against the disease, blurry details around contact tracing and the monsoon season all played a role.

Three waves

Goa is currently witnessing its third wave of Covid-19 spread, state health officials told IndiaSpend. The first wave in the week of March 25 had consisted of the state’s first seven Covid-19 cases. All seven had had a travel history, and had recovered fully at the Employees’ State Insurance Hospital, the state’s designated Covid hospital at Margao in South Goa.

By April 20, Goa had been declared Covid-free. By ramping up its health infrastructure and restricting interstate movement, Goa had managed to push back the disease, the state’s health minister had told IndiaSpend in an interview.

Goa had been fairly “lucky in the beginning”, said Oscar Rebelo, a consultant-physician from Panjim, explaining that despite being an international tourist destination and its borders kept open, Goa had avoided an initial surge, unlike other states. The state “used its time well”, setting up the Covid hospital, training health staff and restricting inter-state movement, he added. In fact, the first week of the lockdown in Goa was so severe that a food crisis had ensued.

For 23 days, the state was officially Covid-free. The second wave started on May 14, soon after movement of stranded persons by trains was allowed and seafarers started returning. This was expected, health officials said. “We had been prepping our staff for the second wave,” said Ira Almeida, medical superintendent of Hospicio Hospital in Margao and in-charge of ESI Hospital. By May 30, there were 70 confirmed cases, 28 of them active as of that date – all from outside, and all controlled.

With June came a spike. “The third wave started with Mangor Hill,” said Almeida. Mangor Hill is a township covering six wards near Vasco, a port town in Mormugao sub-district in central Goa. “The total area would have a population of around 9,000-10,000 people,” explained one of the local councillors of Mormugao from the ruling party, requesting anonymity.

Some time towards the end of May, Stan*, an elderly resident of Chhota Mangor Hill, fell ill. Feeling feverish and coughing, he visited his local doctor. According to the version of events provided by the councillor, the doctor took Stan to the sub-district hospital, one of Goa’s five Covid-testing centres. By June 1, two Covid-positive cases were reported in Mangor Hill. These were the first two cases of Covid-19 in Goa that seemingly came from within the state.

Containment conundrum

Contact tracing revealed that Stan, a trader of scrap fish – he collected scrap fish and sold it as chicken feed – was, perhaps, in touch with truck drivers transporting fish from other states. Truck drivers’ services are considered “essential”, so they are not required to undergo testing. “We are still not completely sure where it came from, but it had to [have] come from outside. It is possible that he was in touch with one of the truck drivers who could have been positive,” said Utkarsh Betodkar, the state epidemiologist and nodal officer for Covid-19 at Goa’s Directorate of Health Services.

After testing residents, ward numbers 11 and 17 within Mangor Hill were declared as containment zones on June 1. When an area is declared a containment zone, no one is allowed to enter or exit without permission, and movement within is restricted.

“This was a mistake,” said the Mormugao councillor. “Ward numbers 11 and 17 represent Chhota Mangor Hill and Bada Mangor Hill. Both wards are separated by a building. The first positive cases were in Chhota Mangor Hill. Why did they have to seal off Bada Mangor Hill?” he asked. Bada Mangor Hill houses a number of daily-wage workers and their families, he said, adding, “They need to step out and earn everyday. Once this area was declared a containment zone, they were entirely dependent on rations provided by the administration. But food rations were not coming in on time. They were also not testing everyone.”

Simultaneously, at least 20 healthcare workers in Vasco also tested positive in the first week of June. “This is the monsoon season and the areas of Mangor Hill are highly susceptible to dengue and malaria,” said Almeida. “The healthcare workers had gone on a regular round to spray disinfectant in the area. Someone must have come in contact with a Covid-positive family.” The urban healthcare centre in Vasco that the workers came from has a single door and no windows, a “perfect incubation room for the virus”.

Soon after, cases began sprouting up in remote parts of Goa. From June 11, the Directorate of Health Services, in its daily media bulletin, began to add more locations in Goa where cases were being reported. From urban townships to remote villages and border districts, Covid-19 was being detected everywhere. All cases were being traced back to the healthcare workers of Vasco. “They just work in Vasco, their homes are across Goa,” said Almeida.

On June 22, Goa recorded its first death, a 85-year-old with co-morbidities. “We were able to trace almost all cases,” said Betodkar, the Covid-19 nodal officer. “We have a team of people. Whoever is tested positive, we call their family and ask them for everyone they had been in touch with.” However, one cannot always be exactly sure of where exactly the virus came from. Isolated cases that could not be traced back to Mangor Hill also began showing up.

Contact-tracing glitches

Contact tracing involves identifying people who are Covid-positive and the people that they had come in contact with in order to map and thereby contain the spread of the disease.

For example, Father Tomas*, a parishioner at a church in Vasco, had body ache, fever and a dry throat. He decided to get himself tested and was declared positive on June 11. “I meet so many people everyday. I don’t know whom I got it from, it is impossible to tell,” he said. He was sent to Goa’s designated Covid hospital, where he recovered in 17 days. “The Directorate of Health Services tried to contact people I had been in touch with in the last two weeks,” he said. “Three of my colleagues also tested positive while 15 were negative.”

But the officials had missed others who had been in touch with Father Tomas – one such person was Steven*. “[Three of us] were volunteering with him for relief work and no health official contacted us,” he told IndiaSpend. On hearing about the priest’s diagnosis, he and his colleagues voluntarily got themselves tested. All three turned out to be positive, though asymptomatic. “Honestly, I think this contact tracing is a joke,” he said. “When I tested positive, no one bothered to contact my family either.”

When he went to the ESI Hospital in Margao, he met a man whose 10-year-old daughter was positive. “He was telling me how surprised he was that his daughter got the virus as she had not ventured out at all,” said Steven. “But he also said how strange it was that no one had got in touch with the family to test the rest of them [his wife and a 10-month-old child].”

“I do not agree with this,” said Betodkar, refuting the claim, adding that they were “working very hard to ensure contact tracing is done thoroughly. You can ask the concerned person to get in touch with us for any clarification. We have been consistent with this.”

Covid-care nightmares

The current protocol in Goa requires asymptomatic patients to be admitted to a Covid care centre, of which there are 14, as per a health official in charge. Five are Goa Tourism Development Corporation residencies.

When Steven and his colleagues tested positive on June 10 at 3 pm, they were told that an ambulance would pick them up at 5 pm and take them to ESI Hospital. “The ambulance arrived 10 hours later at 2.30 am the next morning,” said Steven. “We reached the hospital at 4 am,” he said. At ESI Hospital, they were made to wait inside the ambulance for an hour. “We were told that we would be allowed in once the doctors were available.”

When they were finally let in, even the doctors were surprised why asymptomatic cases had been brought to the hospital instead of being sent directly to the Covid care centre. Eventually, only Steven’s 72-year-old colleague was admitted and the other two were sent to a Covid care centre in Shiroda village in South Goa.

The Shiroda primary health centre was set up as Goa’s first Covid care centre to accommodate the rising number of Covid-19 cases. “When we reached, it was still dark,” Steven said. They found their way to the nurses, who saw their letter from the hospital, noted their names, and handed them paracetamol tablets and chyawanprash. “Then they told us to find beds on our own,” Steven said. They stumbled along the dark corridor tip-toeing around people sleeping on the floor. They managed to find a room with 10 beds, six of which were occupied.

“The people in the room wanted to know if we were Goans and when we told them we were locals, they let us take the beds,” Steven said. “We were quite stunned.” By daybreak, they saw that there was just one bathroom for the 30-40 people housed at the Shiroda primary health centre and the patients had to clean the place themselves.

“I knew I couldn’t stay there,” said Steven. He used his contacts and moved with his colleague to the Colva Residency Covid centre in South Goa. This was slightly better and cleaner but even there, “we were not allowed to keep any windows open. It was suffocating,” he said. Eighty-four Covid-19 patients were housed in the hotel’s 35 rooms for the 20 days that Steven spent there. He shared the room with his colleague. They had two single beds on either side of the room, which had an air conditioner and a fan.

Food was sent to their room thrice a day. Breakfast was bread with bhaji. Lunch and dinner was either a vegetarian thali or a fish thali. “They would leave the food outside our door, knock and run. We would wait for 30 seconds before opening the door,” he said. Two nurses came every day for a general check-up. No one came to clean the room or the passage outside; no one came to change the linen either. “I requested them to change the sheets after 10 days and they complied,” he said. Compared to the Covid care centre in Shiroda, which was essentially “a hospital where every room was turned into a dorm”, the one in Colva was much better organised, Steven said.

The Mormugao councillor had similar experiences to narrate: “A few of my colleagues had tested positive. They were asymptomatic and were at a Covid care centre. They complained that their bedsheets were not changed for four days and the rooms were not cleaned regularly. This had also led to people avoiding going to the care centres altogether,” he said.

On July 13, the Goa Human Resource Development Corporation released a notice for walk-in interviews for a 100 vacancies for the position of “utility attendants”–cleaning staff–at the various Covid care centres. The positions offer a temporary contract for six months.

Currently, there are seven dedicated ambulances for Covid-19 patients in Goa. “We get nearly 80 calls everyday. And it takes at least an hour to ferry each patient,” said a health official. At a press conference on July 13, Almeida announced that they were pressing into service nine buses at various health centres to transport asymptomatic patients to Covid care centres.

Staff, motivation crunch

Frontline workers – healthcare staff and police personnel – are also among those affected by the pandemic. At least 40 healthcare workers and 53 police personnel have been infected, according to a report. “One of my nurses contracted the virus after attending to a Covid-19 patient who died,” said Almeida, adding that doffing the personal protection equipment is when one is most susceptible to contracting the virus. “When you doff is when you tend to touch your face, your body, and that is when you are most vulnerable,” she said.

Some of the staff at Covid-19 facilities are demotivated, Almeida said. “They have fear of the disease. ‘Why us? Why are we here?’ they ask. “They feel that they are stuck at the wrong end of the stick,” she said.

To tackle this, Almeida put in place a “buddy system” where nurses were paired and each was responsible to monitor the other. Each of them got a “self-monitoring kit” consisting of a digital thermometer, a pulse oximeter, a strip each of paracetamol, vitamin-C, zinc, calcium tablets, two strips of hydroxychloroquine tablets, a bottle of betadine and a packet of small-sized balloons. Buddies made sure these kits were regularly used. A “spirit captain” would visit the hospital once a week to deliver a “pep talk” to keep the nurses motivated.

Currently, the ESI Hospital, a 220-bed facility, is housing 110 patients with a staff of 62 nurses working in shifts. “I have enough staff at the hospital. But we need more healthcare staff and volunteers for the rising number of Covid care centres,” she said.

The latest guidelines from the Indian Council of Medical Research recommend asymptomatic and mildly symptomatic patients who are not immuno-compromised to self-isolate at home. However, in Goa, the state protocol requires all asymptomatic patients to be admitted to a COVID care centre for 14 days. “In Goa, all persons who are positive are admitted here either at COVID care centres or COVID hospital,” said Almeida. Each care centre needs medical officers, nurses, multi-task staff and cleaning staff.

Stigma gone viral

Social stigma is another problem Covid-19 patients and staff face. Almeida narrated an incident of Covid-positive nurses who were very upset when health officials visited their villages for contact tracing and sanitisation. People of Vasco and Mangor Hill areas were treated like “outsiders”, said the Mormugao councillor. “The disease is here to stay for some time, and there needs to be an attitude of helping each other,” said Betodkar, Goa’s Covid-19 nodal officer.

On the evening of June 26, when Goa had crossed 1,000 Covid-19 cases, Chief Minister Pramod Sawant conceded that community transmission had begun. “We are getting cases from across the state. We will have to say there is community transmission, we have to accept it,” he was quoted in a tweet by ANI. However, a week later, he had retracted the statement. On July 11, a prominent chain of diagnostics labs in an industrial estate in Goa was shut down after a large number of Covid-19 cases started emerging.

At a press conference on July 13, when asked to comment about the rising number of cases in Goa, health secretary Nila Mohanan said, “The numbers are increasing also because our testing rates are high. We are, perhaps, the highest in the country compared to any other state. Per million, the figure is more than 60,000 per million population. So, naturally when you are testing more, you are more likely to get more positive cases.”

Take all necessary precaution, she said, and above all, “Please, do not panic.”

This article first appeared on IndiaSpend, a data-driven and public-interest journalism non-profit.