‘Crisis Waiting to Happen’: Can Mumbai Handle COVID-19 & Monsoons?
“They don’t care about healthcare workers. We are already overwhelmed, it will be a crisis when the monsoons hit.”
“There is sheer helplessness among us. We are all scared - there is no plan that has been communicated to us,” says a doctor at a BMC hospital.
“It’s going to be chaotic. We are already struggling, I don’t know how will we handle the monsoons and the surge in cases,” adds another doctor from Mumbai.
“There may be a collapse of systems.”A BMC healthworker
Floods, malaria, dengue, and a tough few months for Maharashtra. It’s the same story every year.
But 2020 has a twist. Maharashtra is the worst-hit state with over 70,000 COVID-19 cases and over 2000 recorded deaths as per the Union Health Ministry.
Doctors, nurses and other healthcare workers are already overburdened and hospitals are nearly at capacity.
How will the maximum city handle the predicted rise in COVID-19 and monsoon-related illnesses that will peak around the same time from mid-June to July?
“We are all so overwhelmed with corona, active monsoon preparedness is not seen.”A doctor from Bhabha hospital
On top of this, Mumbai braces for the incoming cyclone Nisarga today, and the crisis situation looks like it will only escalate with problems of increased water-logging and more destruction weighing down an already overworked healthcare system.
The only silver lining will be if preparedness taken for the cyclone translates into further monsoon planning for the rest of the season.
Dengue, Malaria Have Similar Symptoms Like COVID
For Mumbaikaars, its like groundhogs day every year from July to September. The monsoon comes, there is flooding, roads are jammed, trains are stuck, and peoples lives are in peril. Rinse and repeat every year. This year, the already stressful situation is poised to get worse with COVID-19.
A fundamental challenge will lie in diagnosing fever and differentiating diseases.
“Diagnosis of fever in India has always been a challenge due to the five diseases that account for most cases of “Acute Undifferentiated Fevers” between June and September: malaria, dengue fever, scrub typhus, typhoid fever, and leptospirosis. Health systems have a limited capacity to cope with these fevers. This year, with COVID-19 added to the fever syndromes, distinguishing these diseases shall become even more difficult,” says Dr SP Kalantri, Medical Superintendent of Kasturba Hospital and MGIMS, Wardha, Maharashtra.
“Every fever case - which is a common symptom for dengue, malaria, typhoid, etc.- is for now taken as a suspected COVID case. Manpower is tied up with the current COVID cases but we cannot ignore other epidemics.”Dr Suranjit Chatterjee, a senior consultant of internal medicine at Indraprastha Apollo Hospitals.
Dr Kalantri says that these diseases have a significant clinical overlap so history and a physical exam alone are not enough to accurately distinguish them.
“Besides, dengue and COVID can co-exist, as shown by recent reports. COVID-19 can masquerade as dengue, as shown by the Singapore reports.”Dr SP Kalantri, Medical Superintendent of Kasturba Hospital and MGIMS, Wardha, Maharashtra.
The fear of the pandemic may also end up taking lives. “Right now, if you get a cough or a fever you will not think of malaria or dengue but COVID. Healthcare workers will have to recognise and respond to this fear.”
Trends reveal that while malaria is declining since the past 10 years, it is still a difficult disease to tackle.
Rapid diagnostic tests for dengue and malaria need to also be ordered and stocked in advance but with the focus elsewhere, these processes have been affected.
"There are no rapid tests for scrub typhus and we need to send blood samples to the labs. There are no good tests in India for leptospirosis so the diagnosis is presumptive; the newer rapid antibody-based diagnostic tests for typhoid have only moderate diagnostic accuracy in-field testing," adds Dr Kalantri.
Another doctor at Mumbai’s Bhabha hospital says this procurement is usually done in June but “it is not being chased nowadays. We are not bothered about monsoon preparedness.”
“It is a crisis waiting to happen it authorities do not act fast,” adds Dr Chatterjee.
“Unlike chronic illnesses that can wait, these acute undifferentiated fever illnesses cannot wait even for more than 24 hours. If you are seriously ill with dengue and your platelets are falling, you need an ICU bed. How hospitals respond to this will be a task”Dr SP Kalantri, Medical Superintendent of Kasturba Hospital and MGIMS, Wardha, Maharashtra.
What Does the Monsoon Do to Mumbai?
Water-borne diseases flourish when there is flooding and “the dirty water is lying stagnant,” says Dr Chatterjee.
Dr Sangeeta Pikale, a gynaecologist at S L Raheja Fortis Hospital in Mumbai, also warns of additional staff shortages and transport issues as floods often leave the roads ravaged.
“Usually in May, we have the gutter cleaning, but with the current crisis, all eyes were on that, so I am not sure if it has happened. I am not aware. I am also worried about the plastic waste in all our gutters that will cause water clogging. Every house now uses masks, gloves, and there is increased rubber waster and reduced cleaning.”Dr Pikale
Low-lying areas like Dadar, Kurla, Santacruz and Sion are often worst affected by waterlogging.
Mr Kambale, a deputy PRO at BMC says that “the BMC is working on monsoon readiness, we are ensuring roads issues are being looked at, gutters are being cleaned in each ward.”
He added that one of the primary sources of flooding, the pollution in the Mithi river, is also being looked at and cleaned.
“We are setting up additional health camps and COVID care centers as well to deal with the influx.” They are also ramping up bed facilities in private and public hospitals.
In mid-May, BMC’s monsoon readiness taskforce chairman Sanjay Oak said that they have asked the government to step up efforts as water-borne diseases like diarrhea and jaundice can worsen the coronavirus situation.
In an article by Live Mint, BMC’s additional municipal commissioner (health) Suresh Kakani says, “We are doing our best to reduce monsoon-related diseases. We have deployed more than double the number of teams compared to last year and have sanitized and sprayed insecticides at over 108,240 premises, including 14,850 COVID-19 positive premises, 9,033 home quarantine premises and over 12,000 municipal premises.”
Another issue? The lockdown and corona have resulted in a lack of blood in blood banks that’s needed for dengue and malaria patients.
“We usually get mails from higher authorities in May about monsoon preparedness: blood bank issues, ordering of dengue rapid kits, malaria kits, number of ventilators. But this year it has not come,” he added.
“We Are Already Overwhelmed With COVID; Scared for the Monsoons” : Mismanagement & Confusion in Hospitals
“None of the Mumbai hospitals are prepared for the rains,” says a BMC doctor.
And this year, there is “sheer helplessness” the doctors feel as the already difficult monsoon situation has gotten worse as all eyes are on COVID-19.
Understandably, as the country has shown an increase of 8,000 cases every day for the last three days with Maharashtra being the worst-hit in terms of cases and deaths.
“There is enough confusion as is with COVID-19,” with new guidelines and information about the never-before-seen virus.
“Our beds are at full capacity, we have to make choices and turn down patients who are not that critical. Patients who we would normally admit we have to turn away, and I understand their plight too, but we are helpless, I can’t put two patients to a bed, can I? Eventually this patient collapsed and then we had to treat her but we had to ask her to go home and self quarantine still. Her lung saturation was fine and according to the government guidelines she was not classified as critical yet. It’s very difficult.”
The doctors added they were scared of the peak, predicted to come around July, which is the wettest month for the state.
Monsoons also typically mean it becomes difficult for staff, especially allied healthcare workers like nurses and ward boys, to come to duty.
“Already they are scared of coming because of COVID. It’s all blind and unplanned it seems. There is no incentive to work, but we try to come for the patients.”
A doctor at Bhabha hospital says they have only 20 extra beds currently, it is “all occupied by COVID - and we may soon not have any beds if this ward of 20 is also used.”
The same is the case across most Mumbai hospitals, as they were all forced to open up COVID-19 beds. It’s time to make room for non-COVID beds and hospitals need dedicated empty wards for the monsoons, he advises.
What about the cross-infection of COVID? “This can happen in the community as well,” says the doctor although perhaps separate hospitals (and not just wards) for COVID and non-COVID patients may help.
Dr Pikale says, “We should make nursing homes which provide maternal care and pediatric care, and small surgeries, into strictly non-COVID spaces. We cannot overload hospitals and confuse patients. We need to allow certain hospitals to refuse and redirect COVID patients.”
But this is easier in theory, as the doctor from Bhabha explains that even non-COVID hospitals end up catering to COVID patients. “What is happening is non-COVID hospitals are given fewer PPEs on that basis, but then they become accidentally exposed to COVID patients who did not realise they were infected. This has happened in 3-4 BMC hospitals.”
How Will Inner Parts of Maharashtra Manage? Some Answers
In the town of Sevagram, Medical Superintendent of Kasturba Hospital and MGIMS, Dr SP Kalantri has different concerns than the rest of Maharashtra, especially Mumbai.
“In rural settings, we need to ensure a seamless integration of primary, secondary and tertiary level care. We need accurate bedside point of care diagnostics. Sequential testing is a rational approach for each disease and a complete blood counts for all patients. We shall need special efforts to keep the cost of diagnostics affordable and the use of technology can help.”Dr SP Kalantri, Medical Superintendent of Kasturba Hospital and MGIMS, Wardha, Maharashtra.
The doctor says that a study in The Lancet talks about interventions for primary healthcare that include additional digital support, guidelines for the rational use of PPEs for infection control and increased training.
The government has set up fever clinics for COVID, he says, but the scope of these need to be expanded to pick up acute undifferentiated fevers.
Testing Criteria Needs to Change & Other Ways Ahead
- Open up testing criteria
One major roadblock is ICMR’s restricted criteria for COVID tests. “They need to expand this, because short of this it will be difficult to distinguish COVID from non-COVID fever diseases,” says Dr Kalantri.
This would be tough as labs are already overburdened with COVID and the testing kits are expensive and not readily available. How will public health hospitals respond to the surge in demand for tests? “The government will have to step in.”
- Regularise COVID treatment module
We also urgently need a regularised treatment module for COVID. “Most patients are treated with expensive antibiotics which are often not needed. This indiscriminate use can also lead to a country-wide antibiotic resistance.”
He adds that this would mean we have to treat malaria with anti-malarial drugs or viral diseases with anti-viral drugs not any other treatment option.
- Focus on ICU & Ventilator Availability
Thirdly, ICU and ventilator availability. “For us currently there are enough available, but with competing illnesses, in July these beds will all be occupied. It will be very difficult now because a large number of beds are already earmarked for COVID.”
“In August, in Sevagram, we have 2500 OPD patients, and roughly say 20% have a fever - this means every day we have 500 fever patients visiting the hospitals. How can we handle this load, separate them as non-COVID, and organise the care? We don’t have enough human resources for this,” says Dr Kalantri.
- Consult stakeholders engaged in ground work for a plan
“We need to decentralise the approach. We have never only relied on ICMR for guidelines, it is surprising that NGOs and local healthcare workers were ignored in the pandemic.”
But is all hope lost?
It's important to remember that we are not starting with a blank slate - the systems or guidelines for dealing with water-borne diseases are in place, its now a question of balancing it with COVID and organising healthcare.
“It’s chaotic - but we have the luxury of a month before the monsoons hit and we need to plan now.”A doctor from a private Mumbai hospital.
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