Fifty-one year old Trupti Girkar works as a nurse at King Edward Memorial Hospital, one of the main hospitals in Mumbai for admitting and treating Covid-19 patients.Five doctors working here were sent into quarantine after being exposed to a 40-year-old patient who died because of the virus on March 28.
“We have been told to treat every patient as a Covid-19 patient,” said Girkar, who works in the cardiac surgery theatre.
Despite the high-level of precaution they have been asked to exercise, she and her nursing colleagues have not received any personal protective equipment from the hospital, she alleged. Such equipment – masks, gloves, face shields, gowns and goggles – is needed to prevent exposure to the coronavirus. Different categories of healthcare workers have been prescribed varying combinations of equipment, depending on degrees of exposure.
For instance, the Union Health Ministry’s guidelines restrict the use of N-95 masks to health workers directly attending to Covid-19 patients. But Girkar claimed doctors in her department had been given N-95 masks – but not the nurses.
“We were told that there is no need for masks for nurses,” she said. “This is partiality...Doctors always get priority.”
Forty-two-year old Accredited Social Health Activist Sandhya Devre has been stepping out everyday since the lockdown began to survey around 340 houses in Mahalungi village in Maharashtra’s Buldhana district.
With four cases reported from the district, Devre fears that she too could contract the disease and spread it to her family that includes her 80-year-old father-in-law, 50-year-old husband and two children aged 20 and 19 years.
“There is no mask or sanitiser or coat,” she said. “It is a do or die situation because if someone has symptoms then we have to direct them to the PHC [primary healthcare centre].”
Sanitation worker Jaimukund Gaikwad, 40, has not yet told his family that he collects garbage from the houses of residents who have been quarantined since April 3. He received a mask, gloves and coveralls just two days ago that Brihanmumbai Municipal Corporation authorities said workers would have to wash and reuse.
For sanitation workers at in-patient facilities and ancillary services, the Union ministry recommends the use of gloves with an N95 mask and categorises their work as “moderate risk”. The World Health Organisation, however, recommends a higher degree of protection for cleaners in all facilities. Its guidelines state that they should be equipped with a mask, gown, gloves, eye goggles, boots or closed work shoes.
But as safety gear shortages are being reported by doctors from across India, most frontline workers in Maharashtra have to make do without adequate protection being provided to them.
Limiting the use of safety gear
Maharashtra has confirmed 1,018 Covid-19 cases as of Tuesday, with the maximum number of cases reported from the state’s densely populated capital Mumbai.
More than 50 cases in the city are of nurses and other hospital staff. For instance, a cleaner tested positive for the virus in the municipal-run Kasturba Hospital, while 26 nurses and three doctors tested positive the privately-run Wockhardt Hospital. Staff at both the hospitals alleged discrimination, saying doctors had been favoured over others when it came to the distribution of protective gear.
Municipal-run hospitals in the city continue to treat patients with general ailments alongside Covid-19 patients, said Dr Swati Rane of Clinical Nursing Research Society of India. This means the nursing staff runs the risk of exposure to the virus even if they are not directly attending to Covid-19 patients.
On April 4, the United Nurses Association filed a petition to the Supreme Court with a list of demands that include the availability of protection kits for all health workers, proper accommodation, transportation, cooked meals among other facilities for nurses and other health workers.
“Some hospitals make nurses do anything and there is a degree of exploitation involved,” said Jibin TC of United Nurses Association in Maharashtra. While giving PPEs to all nurses may not be required, he said that those in critical care areas had to be adequately protected. “We have to use PPEs wisely because there is a shortage but we do not want to lose qualified people to the virus.”
Rane added that nurses were missing from decision-making positions and were not represented adequately. “They must be involved in estimation of PPE kits, logistics, isolation and other isolation and infrastructure plans for smooth execution for those at the frontline,” she said.
Nurses say they are even more vulnerable than doctors, given how frequently they come in close contact with patients. “We cannot even maintain social distancing,” said Girkar. “How can we give injections like that? There is barely any distance between a nurse, a trolley and the patient.”
Instead of giving them PPE, Girkar said the authorities had asked them to take 400 mg of chloroquine once in a week for four weeks. “We are taking this instead of other precautionary measures,” she said.
According to the World Health Organisation guidelines on rationalising the use of PPE, health workers at in-patient and out-patient facilities providing direct care to Covid-19 patients or physically examining patients for respiratory symptoms have to wear a mask, gown, gloves and goggles or a face shield.
But a nurse who works in the casualty ward at Dr Babasaheb Ambedkar Hospital in Kandivali in North Mumbai said that nurses were being made to use one-ply surgical masks and HIV kits for the last five days despite making repeated demands for PPEs to the hospital authorities.
“Before that we were wearing a plastic apron,” said the 36-year-old nurse who did not wish to be identified. The nurse said that the hospital had not arranged for a separate accommodation for nurses or prepared a roster to give them time to go into quarantine after working for seven days. “They have only done it for doctors so far,” she said.
Protection over insurance
Like other states, Maharashtra has given a range of assignments to Accredited Social Health Activists, or community health workers, all of whom are women. One, they have been asked to trace the contacts of Covid-19 patients. Two, they have tasked with a door-to-door family survey in their areas to check if any new family members have joined a household since the nationwide lockdown began. If they find people with Covid-19-like symptoms, they have been asked to refer them to the primary health centre or district government hospital.
Essentially, the ASHAs become the first point of contact for many Covid-19 patients.
For workers at the community level, the World Health Organisation has recommended maintaining a distance of one metre while interviewing asymptomatic contacts of Covid-19 patients. While interviewing suspected or confirmed patients, workers are supposed to wear a medical mask, maintain one-metre distance and conduct the interview outside the house, the guidelines state.
But ASHA workers have so far ventured out without adequate protection.
“The ASHA workers are the most vulnerable now,” said Jyoti Hekade, 37, an ASHA supervisor in Aurangabad’s Bajaj Nagar in Waluj. “The patient only goes to the doctor after the ASHA reports them. So who should get the safety first?”
“When we ask the medical officer for masks they say that they themselves do not have it so how will ASHA workers get it,” she added.
Devre tries to conduct interviews with family members over the phone when it is possible but is considering purchasing a mask and a sanitiser at her own expense. “Why did they not think of protection before giving us insurance?” she said, referring to the Rs 50 lakh insurance cover given to health workers across India by the Centre.
“I do not think any government takes this seriously because there is no protection for us out there,” said Devre, who earns around Rs 3,000 per month and has worked as an ASHA worker for around 10 years.
In Kolhapur’s Ganeshwadi village, 33-year old Suraiya Salim Terdare surveys up to 100 houses daily, covering 200 houses in two days, only to repeat the same cycle to keep a check on family members to see if they develop any Covid-19-like symptoms. Around 50 in her village have been quarantined, she said.
“I have to check with them everyday and tell them not to step out,” she said. “It is more like counselling. We are not doctors and we feel scared to go back home. Who will take responsibility if something happens to us?”
The gram panchayat gave Terdare and six other ASHA workers in the area cloth masks that they have to soak in Dettol overnight to reuse the next day, three sets of disposable gloves and 500 ml of sanitiser to each worker. “Other ASHAs do not even have this much,” she said. “There is just too much pressure on us and no limit on the work we have to do.”
Aside from the lack of protection, being a frontline worker has other challenges too. Terdare said that there were several disagreements with village residents that made it difficult for her to continue to survey families.
“People question us about what right we have to tell them to stay indoors when we are roaming out,” she said. “They think that we could be the infection carriers. It was difficult for me to survey even 50 homes in one day because of this.”
Working to stay alive
Sanitation workers are expected to continue working amidst the pandemic to collect waste from homes, that too without protective gear.
The WHO guidelines on PPE use state that cleaners in hospitals in all departments must be equipped with masks, gloves, gowns, goggles to protect the eyes and boots to cover the feet.
Workers like Jaimukund Gaikwad were told that they would receive a new kit everyday but this changed a day later: they were asked to reuse the same suit daily.
“They [BMC authorities] told us that it is costing them around Rs 1,200 and they will wash it for us,” said Gaikwad, a contractual worker who earns around Rs 580 per day. “Our life is worth more than Rs 1,200. We do not know how they will wash it or if it is still dirty. We did not get any training for this. How do we remove the gear?”
Gaikwad collects waste from at least eight houses where residents under quarantine live, but said that workers were not taught how to handle the waste except for being given a yellow bag to dump the garbage in.
Forty-six-year old Parshuram Maruti Jadhav is also a contractual worker with the BMC who collects waste from houses where residents are quarantined as well as from Matoshree, the private residence of Chief Minister Uddhav Thackeray, where a tea vendor tested positive for the virus on Monday.
Jadhav’s supervisor provided him with a pair of gloves, mask and coveralls that would have to be reused every day. “I stopped going to work because I am very scared,” said Jadhav. “It is a big concern and I will not go back if they do not give us a new kit everyday.”
Most contractual sanitation workers with the Brihanmumbai Municipal Corporation said that the masks and gloves they received from authorities tore in a matter of days.
Forty-one year old Shankar Kunchikorwe lives and works in Dharavi, the most densely populated slum in Mumbai that has recorded at least seven cases of coronavirus till Tuesday night. Kunchikorwe keeps a close eye on the news and observes the tally of coronavirus cases increasing in his locality, and said that the cloth mask and gloves he received from his supervisor tore within three days.
Despite this, he continues to go to work everyday. “There is a lot of tension but if i do not go to work then I will not have anything to eat,” said Kunchikorwe, who earns Rs 625 per day from 10 pm till 5 am. “We go to work so we can fill our stomachs. We will have to die even if we go out or if we stay at home.”
Even as he continues to work without gloves, there is no provision for workers to wash their hands with soap before or after the shift and the supervisor has installed a hand sanitiser instead, he said.