Coronavirus: All the reasons why Mumbai’s mortality rate remains worryingly high

On May 23, after a chest X-ray revealed that 62-year-old Mohamed Padvekar (name changed on request) had pneumonia, his family doctor advised urgent hospitalisation because he suspected his patient was also infected with the coronavirus that causes Covid-19.

From their home in Byculla, central Mumbai, Mohamed Padvekar’s family called numerous hospitals – his son, Tabrez Padvekar named at least six and said he was missing out on some more – but none had a bed. In desperation, the family even drove Mohamed Padvekar to hospitals, in the hope they would not turn away a senior citizen.

They were wrong.

“One hospital turned us back at the gate, they did not even let us get to the casualty,” said Tabrez Padvekar. Left with few options, the family decided to take him to the only hospital willing to admit him, Nerul’s D Y Patil Hospital, in the neighbouring city of Navi Mumbai, about 35-km away.

The relief Mohamed Padvekar’s family experienced at getting medical care soon dissipated. After promising a ventilator for his father, the hospital reneged and asked the family to arrange for one within an hour, said Tabrez Padvekar.

The family scrambled to find a ventilator. After numerous calls to friends, families and doctors, Tabrez Padvekar finally found a company ready to provide a portable ventilator for Rs 70,000 as one-time rent.

The Maharashtra government had capped the price of a patient’s daily treatment at Rs 9,000, inclusive of a ventilator. But the company insisted on its price.

“We were desperate to save my father’s life and decided to take it,” Tabrez Padvekar said.

It was too late. Within a day, his father was dead.

Inadequate healthcare infrastructure

As on August 12, India’s richest city had 1,26,371 cases, over 5.4% of India’s caseload of 23,29,638 cases, an average of over 1,000 new cases every day. Mumbai also has a disproportionate share in Covid deaths, with over 6,940 of 46,091 deaths nationwide, or more than 15% of all deaths.

This is the second of a three-part series (you can read the first part here) explaining how Mumbai became India’s worst hotspot, marked by a near-collapse of its municipal health infrastructure. That infrastructure has since improved, but tens of patients died every day without adequate healthcare after the city recorded its first case on March 11.

Often, providence decided fates. A 66-year-old Covid patient spent 30 hours in a hospital parking lot before she got a bed. Another 57-year-old died in a hospital’s casualty area, as he waited for six hours for a bed.

A major factor driving Mumbai’s high mortality rate has been a shortage of hospital beds, mismanagement of those available and a lack of medical care for patients with urgent needs.

Public hospitals were overflowing with patients, while private hospitals, which account for about half of the city’s hospital beds, were either reluctant to admit patients, unaffordable for most or, initially, sealed by city officials if they were found with Covid patients.

The first line of warning, private clinics run by general practitioners and others, collapsed almost immediately. The government network is wholly inadequate.

The Brihanmumbai Municipal Corporation runs 187 dispensaries and 20 hospitals in the city, according to an affidavit by the municipal corporation before the Bombay High Court in April 2020. For a city with over 1.2 crore people – under the municipal corporation’s jurisdiction; the larger metropolitan area with about 2.2 crore population is governed by other suburban municipal corporations – there is roughly one clinic for approximately 66,500 people.

In at least four of the city’s 24 administrative wards, this ratio deteriorates to one dispensary for over 1,00,000 people, according to The State of Health in Mumbai, 2019, an annual report on the city’s healthcare facilities by Praja, an NGO.

Collapse of public hospitals

In contrast to its relatively sparse public healthcare, Mumbai has 30,000 privately-owned dispensaries and clinics, according to a 2009 civic Human Development Index report.

The contrast extends to hospitals and nursing homes. While the municipal corporation and the state government together own 80 hospitals, according to the same report, the number of privately-owned hospitals is 1,500.

“Naturally, when the virus hit the city, civic hospitals alone could not have handled the load,” said a senior official at the municipal corporation’s health department, which spearheaded the official response to the health crisis. “We counted on private facilities to shoulder some of the burdens.”

When the pandemic hit the city, the city’s vast network of general practitioners was the first to collapse, in part due to the municipal corporation’s actions.

General practitioners, often the first port of call for those seeking primary healthcare, are spread across Mumbai, even in densely-populated slum areas. A 2012 study by the SNDT Women’s University in Mumbai revealed that 89% of people with minor illnesses preferred visiting private and charitable health clinics rather than civic facilities.

These clinics, the study added, offered various advantages – flexible timings and easy access within striking distance of residences – that municipal facilities lacked.

But as soon as the lockdown was announced in Mumbai on March 20, almost 95% of private doctors shut down through March and April, said Tejas Adhikari, PhD, chief executive officer of TRN Centre, a multi-speciality clinic with diagnostic services.

“There were great fear and panic among private doctors,” said Adhikari. “Personal Protective Equipment (PPE) was in short supply and private doctors were unable to get any of them for them to work safely.”

Those who fell ill were suddenly forced to rely on government facilities already overburdened with an unrelenting surge in coronavirus infections.

Flipflop with private hospitals

In late March, then municipal commissioner, Praveen Pardeshi, asked private hospitals to screen patients and create isolation facilities for Covid-19 patients and suspected cases.

But by April, the municipal corporation started sealing hospitals, if staffers tested positive for the virus. In some cases, hospitals were sealed even if a patient within was positive.

Even major private hospitals struggled to deal with the pandemic despite being better resourced. Jaslok, Wockhardt and Bhatia hospitals, accounting for close to 900 beds, were forced to shut admissions after many healthcare staff tested positive for Covid-19 in early April.

The hospitals continued to treat critical patients already admitted and could not be discharged or transferred. But with entry and exit points sealed by the municipal corporation, they could not admit new patients.

Overnight, the city’s top hospitals were unavailable. Some news reports said as many as 15 major hospitals were sealed by the municipal corporation between early April and the end of the month.

“Owners wanted to avoid the legal, medical and economic costs of having their hospitals sealed, while health workers did not want to take a chance,” a doctor of medicine at a private hospital in Mulund told Article14 on condition of anonymity. “As a result, most hospitals decided to remain shut or take only those not showing any Covid-19 symptoms.”

By mid-April, reversing its earlier decision, the municipal corporation requested private hospitals to open.

But even hospitals that were open were struggling. A doctor at a top private hospital in Mumbai’s western suburbs said that the facility initially accepted patients with Covid-19 symptoms but struggled to cope.

“We created a separate isolation ward for suspected cases because we could not treat them in the emergency ward, as there were all kinds of patients coming in,” he said. Soon, the ward was full. “We found it very difficult to plan the logistics of treating both Covid and non-Covid patients, at the rate at which patients were coming in.”

Despite the fact that the Brihanmumbai Municipal Corporation is the country’s richest municipal body – its budget outlay of Rs 33,441 crore is more than the budgets of Goa and Mizoram combined –its inability to put in place simple technological solutions proved fatal to many.

For instance, even though it had helplines for patients in search of a hospital bed, the helpline was barely of use, as patients who spoke to Article 14 for this series testified.

One key reason, municipal insiders explained, was that the municipal corporation had no data of real-time availability of hospital beds across its own facilities, let alone private hospitals.

For patients and their families, this meant being on their own in search of medical care, as it happened with my uncle Dilip Purohit, 59, whose story features in the first part of this series.

After a persistent dry cough and bouts of breathlessness for six days, Purohit was finally able to breathe normally when he was taken to one of Mumbai’s top private hospitals, getting tested for Covid-19 with an oxygen mask strapped to his face.

But the relief was short-lived. Purohit was taken off the oxygen, as soon as the Covid test was done. “The doctors said they would only stabilise him enough for tests,” said his nephew, and my cousin, Yash. “They had no beds available to treat him.”

The next day, on June 3, just after noon, Purohit became violently breathless.

For the next four hours, family members worked the phone lines. Someone called one hospital, another called a different one, and a third called for an ambulance.

Four hours later, they had found neither a hospital nor an ambulance. A neighbour with a car, after dithering initially, agreed to transport them to a civic hospital.

Purohit was dead before they reached.

A ‘functional’ dashboard

By the end of May, two months after the pandemic had claimed 1,319 lives and after criticism it was not doing enough, the municipal corporation finally created an online dashboard with bed availability in real-time.

“Bed allocation was a big problem as there was no real-time data,” conceded I S Chahal, the municipal commissioner in an interview on May 27 to the Economic Times. “We now have a dashboard that will be updated every half an hour.”

This dashboard was expected to ease the process of finding a bed. Chahal said that the city had “enough and more beds”– waiting to be allocated to patients who called their landline.

Manoj Gupta, 33, laughed at the claim.

On May 26, when his 62-year-old mother, Sarshwati’s fever refused to come down for the second day, he started searching for hospitals. She was diabetic, and he was worried about what lay ahead.

A local private hospital, which the family frequented, refused to admit his mother. He did all he could do to find other hospitals. He called up the best ones, the closest ones, even those run by the municipal corporation or the government, but he had no luck.

The next day, Gupta finally found a small private hospital nearby that agreed to admit his mother. But his mother’s health only deteriorated – from fever to breathlessness, her days in the hospital only made her weaker, he said.

There was another problem, the hospital was charging him over Rs 30,000 a day and the family was running out of money, forcing Gupta to borrow money from friends.

Since the day he had his mother admitted, Gupta called the municipal corporation’s helplines, asking for a bed with a ventilator.

“I would call them multiple times a day, I would even call municipal corporation-run hospitals directly,” he said. The hospital where she had been admitted was “not treating her well”, and the family was running short of money.

Despite a “functional” dashboard”, Gupta’s pleas went unanswered. “Not only did they refuse to help, but there were also days when civic officials even abused me for calling them repeatedly,” he said. By the eighth day, on June 2, his mother was dead.

Chahal admitted to Article 14 that the lack of a centralised dashboard impeded the search for beds and that helplines could not cope.

“We were seeing approximately 1,500 cases every day, and each of them would make numerous calls to the only control room we had,” said Chahal. “Handling this volume of calls effectively every day was not possible, so we decided to create ward-level helplines.”

This process, from hiring doctors to handle these helplines to creating the infrastructure for these local helplines, took close to a month and was up and running only by mid-June.

Chahal said the city now had enough beds to tide over the pandemic, even if cases rose. “It was difficult to predict the tsunami of cases that came our way,” he said. “But now we are prepared, even if there is a second wave.”

Lack of planning

The shortage of hospital beds in Mumbai is compounded by the shortage of staff.

Gupta said only one doctor attended to his mother once a day. “Even then, he would not come close to her,” said Gupta. “The remaining time, there were only nurses around, not even junior doctors.”

Tabrez Padvekar, whose father died at D Y Patil Hospital, had a similar experience.

On the day of his death, the family had still not been told the result of Mohammed Padvekar’s Covid-19 test. Six hours after his death, the family was told he had tested negative.

“We went home, conducted some funeral rituals with about 20 family members and buried him,” said Tabrez Padvekar.

The next day, the hospital called back and said that his father was Covid-19 positive.

Tabrez said he was horrified and ridden with guilt. After a struggle to get the family tested, his mother and sister too tested positive. Fortunately, both were asymptomatic and were quarantined at home.

Article 14 called D Y Patil spokesperson Kamlakar Chougule many times, but he did not respond. If he does, we will update this story.

Mumbai’s response appeared to suggest the lack of a proper plan, especially in utilising private healthcare facilities, said Oommen John PhD, an intensivist and senior research fellow at The George Institute, a Sydney-based global medical research centre.

“In cities like Mumbai, private doctors and their clinics act as the primary healthcare system and, in a sense, our first line of defence,” said Oommen who also served on the Measles Aerosol Vaccine Development Program of the World Health Organisation. “These doctors should have been activated through a plan to conduct public health surveillance.”

According to the WHO, a robust public health surveillance system serves as “an early warning system to identify public health emergencies”.

“What the authorities could have done is to create a masterplan, where private doctors would identify vulnerable patients and those showing symptoms to the government for testing, beds etc,” said Oommen. “Their knowledge of the local communities could have helped immensely in chasing the virus.”

The municipal corporation used that knowledge to striking effect when fighting the pandemic in Mumbai’s most-challenging neighbourhood, Dharavi.

The Dharavi model

Spread over 2.4 square km and home to more than 8,00,000 people, Dharavi is one of the most densely-packed slums in the world. G-North ward, under which Dharavi falls, has a population density of 66,000 per sq km.

When the virus reached Dharavi, municipal officials had to move fast.

On April 1, Dharavi recorded its first case of Covid-19. In a month’s time, 590 people had been infected and 20 were dead. Private clinics had shut down, despite government orders to the contrary.

“People who were falling sick were forced to go to government hospitals that did not have the capacity to treat them,” said Ajay Pachnekar PhD, a Dharavi general practitioner and vice-president of the Association of Medical Consultants, a group of over 11,000 private doctors in Mumbai and its neighbouring municipal areas. “So, we asked the government to allow doctors to open their clinics and start seeing patients.”

By early May, 250 of Dharavi’s roughly 300 clinics reopened.

Private doctors with an established practice in the area helped in two ways, said Pachnekar. First, they referred patients with Covid-19 symptoms to government facilities for testing. Second, they accompanied civic staff on door-to-door surveys to screen those with symptoms.

“When people saw familiar doctors at their doorstep, they felt confident enough to reveal whether there were any symptomatic cases or if they had any travel history,” said Pachnekar. “This helped civic efforts immensely.”

The municipal corporation conducted 2,921 fever clinics in G North ward, the highest in any ward citywide, according to municipal data

Using hospitals, lodges, sports arenas, schools and even vacant plots, the municipal corporation created 12 quarantine centres with the capacity to quarantine over 8,500 people.

“The idea was to decongest Dharavi and isolate as many people as we could, so the infection didn’t spread,” said a civic official of G North ward, speaking on condition of anonymity, as he is not authorised to talk to the media.

Kiran Dighavkar, the assistant municipal commissioner for the ward, remained unavailable for comment despite repeated attempts.

These efforts complemented the municipal corporation’s efforts at quarantining and tracing contacts in the densely-packed alleyways of Dharavi.

Dharavi, as on August 11, had 2,634 cases of which only 81 were still active infections. From a high of nearly 100 cases a day in May, Dharavi recorded only eight cases on August 11. In early July, the municipal corporation shut down two quarantine centres with a combined capacity of 1,000 beds because of the decline in infections.

Dharavi’s experience in crushing the curve carries important lessons for authorities in Mumbai and other cities grappling with the virus, such as Delhi and Bengaluru, said Deepak Baid PhD, president of the Association of Medical Consultants.

“The way ahead is for private healthcare systems to work closely with public authorities,” said Baid “That’s the only way to beat the virus.”

This the second part of a three-article series on the pandemic in Mumbai. Read part one here and part three here.

Kunal Purohit is an independent journalist based in Mumbai.

This reportage was supported by the Thakur Family Foundation. The Thakur Family Foundation has not exercised any editorial control over the contents of this reportage

This article first appeared on Article-14.