New Delhi: In a hearing on 5 May 2021, the Supreme Court asked the Centre to, within a day, present a plan to provide hospitals of Delhi the 900 metric tonnes of oxygen they needed.
The ultimatum to the Narendra Modi government came after days of fatal sparring between the centre and the state over medical oxygen supplies to the capital: at least 57 hospital patients have died in India’s capital city due to a lack of oxygen, as countless patients and their families desperately hunt for medical oxygen. Following similar deaths in a hospital in Meerut, Uttar Pradesh, the Allahabad High Court on 4 May likened deaths due to a lack of oxygen supply to “genocide”.
As India’s Covid-19 crisis spirals into a catastrophe, it is clear that governments and hospitals did not prepare over the past year for an increased requirement of medical oxygen that would accompany a new wave of cases. This, despite clear warnings from a parliamentary committee and 4 high courts (see Article 14 story here) over the past six months to augment oxygen supply.
An example of heeding early warnings and preparing for a possible second wave comes from the remote, tribal district in northern Maharashtra. Nandurbar‘s example shows how an administrator in one of the most marginalised parts of the country has been able to avert the ongoing crisis of Covid-19 deaths and a desperate hunt for oxygen with foresight, planning and judicious use of state finances.
Rajendra Bharud, MBBS, Nandurbar’s 33 year-old district collector, hit the headlines recently for taking action to equip hospitals in the district with their own oxygen plants, starting September 2020. The district now has five oxygen plants and is self-sufficient in oxygen. The Maharashtra government is asking other districts to follow the Nandurbar example and set up their own plants.
A Bhil Adivasi and the son of a farm-labourer single mother, Kamaladevi, Bharud is a first-generation learner who overcame hardship to study medicine and then join the civil services. The district he heads is located on the border with Gujarat and Madhya Pradesh and spread across nearly 6,000 sq km with forests and hills to the north, and scattered hamlets that still lack road access.
India spends no more than 1.5% of its gross domestic product on the public healthcare system and has among the developing world’s worst health outcomes. In Nandurbar, 60 primary health care centres and 290 sub-centres (as per 2020 district data) cater to a population of over 1.6 million, about 70% of whom are scheduled tribe communities.
“Most of these centres do not have enough staff, well maintained buildings or staff quarters which affects service outcomes,” said a 2021 official note prepared by the district administration. While the district has augmented its Covid-19 medical staff over the past year, mostly with contractual appointments, officials say attracting and retaining public healthcare system staff who can serve in the district’s remote rural areas remains a major challenge.
Edited excerpts of the interview with Bharud:
Can you describe the Covid experience of Nandurbar of the past year, and how you and your team approached it?
Last year, when the first cases were detected in April-May, people were very puzzled, and also scared about this new illness. Nandurbar is a largely rural district with the majority of our people from tribal communities, and things like masks and hand sanitisers were unheard of for most people. When the first cases came, there was no testing capacity in the district. Not a single private hospital was willing to start Covid treatment. We had a 200-bed district civil hospital, with 95% occupancy at most times, since a bulk of the people of the district are dependent on government healthcare facilities. If we turned that over for Covid care, where would the non-Covid patients go?
There was a hospital project whose construction had been paused mid-way from several years for a number of reasons. We worked day and night and finished it in three months, adding 200 beds. We requested private doctors to help us with setting it up, and we have also recruited about 200 doctors and nurses in the past year. So, that is how we spent the first three to four months.
During the first wave, the maximum number of cases in a day that we recorded was 190, possibly due to the fact that tribal settlements are scattered. Meanwhile the first wave was receding. But looking at other countries, like Brazil, we had realised this is a temporary reprieve, and Covid will come back in a big way. So, we thought we should use this time to prepare ourselves. When Covid began, we had no testing lab and had to depend on the Government Medical College in the adjoining district of Dhule. We set up our own labs, and today we can conduct 1,800-2,000 RT-PCR tests per day in the district. We have made 28 mobile teams for rapid antigen tests, [they] can go around villages and wards to take swabs from people who might not be able to afford coming to a centre to get tested, or might not feel safe. We have also set up 7,000 isolation beds across the district, and 1300 beds for active treatment across government and private hospitals.
We acquired Remdesivir worth 50 lakh rupees under CSR funds and distributed some to private hospitals too. I prepared public awareness videos and disseminated them about the prescription and use of this drug since it’s indiscriminate use can be harmful. Our current daily patient load is 200-250. About 10% of patients need it, so our requirement is 20-25 injections per day. So we are not facing any shortage of Remdesivir.
There was no liquid oxygen plant and we were dependent on Dhule and Surat (in the adjoining state of Gujarat). The question before me was that, in the future, if there is a shortage in those districts, and they cannot give us (oxygen), what will happen to us? Last year in September, we decided to build an oxygen generation plant at our government hospital, using funds from the District Planning and Development Council. I also convinced two private multi-speciality hospitals that you start your own oxygen plant and do not be dependent on anyone. As cases went up, we installed a second plant in the civil hospital in the month of February, which could fully meet the demand. Shahada (a tehsil town in Nandurbar) had no hospital. We converted a hostel building into a hospital, and also installed a plant there which can today cater to 100 oxygen beds.
So we have five oxygen plants in the district right now, with a cumulative capacity of 48 to 50 lakh litres per day. We plan to set up two more plants in Navapur and Taloda in the coming days.
We are also procuring oxygen concentrators through government and CSR (corporate social responsibility) funds, which can be deployed in remote talukas like Akrani and Akkalkuwa.
Was there a particular moment or a case last year which made you realise the importance of making the district self-reliant in oxygen?
Yes, absolutely. In the initial months of Covid, news reports were coming in that patients from Nandurbar were going to Nashik or Surat for treatment, and they were facing a lot of hardship. Also, oxygen therapy is critical in treating Covid. That is when I told myself that this should not continue: Nandurbar district might be seen as backward but we can address this issue and remove the dependence on anyone.
If you set aside the tendering process, it takes about 10 days to set up a plant. So, it is very doable. Installing a plant costs about Rs 85 lakh. A plant can fill up 125 jumbo cylinders in a day. If you calculate the cost of filling a jumbo cylinder, we recover the installation costs in three months. So we are also saving government funds in the process (by not buying oxygen).
More importantly, we have none of that tension of ‘when is the oxygen tanker coming from another state?’ The aim is that no one should die for lack of oxygen.
As per today’s data before me (1 May 2021), as many as 300 oxygen beds are available in our district, and this is because of the coordination and advance preparation that we put in before this rise in cases came: 15% of our patients right now in our hospitals are from Gujarat and Madhya Pradesh.
The Supreme Court has now asked the Modi government to clarify its vaccination policy. In particular, it has asked how will economically marginalised groups, as well as those without access to digital resources access vaccines, given the government currently requires a person to first register online on the Co-WIN site in order to hunt for a slot to receive the vaccine. In a recent interview to Article 14, India’s former Health Secretary K. Sujatha Rao also reiterated that the government must, “keep the vaccine free, buy it centrally, distribute it to the states and conduct a decentralised mass campaign that empowers district collectors to make Covid-19 vaccination a success”. How are you rolling out the vaccination program, given that so many people in Nandurbar lack access to a smartphone device, and internet and mobile connectivity?
How do people, especially rural people, get the vaccine comfortably: that is the main challenge before us in a district like Nandurbar with so much (sic) remote hilly terrain, poor road access and rural communities who have misgivings about the vaccine. Across the country, there are people who cannot access an app, do not have the Internet. What about them? To have a portal and administer the vaccine via that actually reduces the speed of vaccination. And there are serious concerns (of access) as you pointed out. Cowin has come. But not everyone has a mobile. Not everyone can download such an app or go to the website and register on it. Wait for OTP. Enter OTP. There is a server issue. Internet issue. Mobile connectivity is required. All these will come up as hurdles and only lead to delays and people getting left out. Vaccination must be taken offline to reach such people.
If you see the story of vaccination programs in India, whether it was polio, tetanus, or DPT, we have always relied on offline data from frontline health workers. What we have been doing is adopting a practical and decentralised approach. We have made teams of teachers and trained them. They have been tasked with going to villages and counselling the public about taking the vaccine, and doing the registration of people in a selected area over four-five days. Then two or three rooms of the government school are allotted and from morning to evening vaccines are administered to people in batches of 50 or so. Besides the vaccination centres, we are deploying 16 mobile vaccination vans: four each for Dhadgaon and Akkalkuwa blocks, which are hard to reach, and two each for the remaining four blocks of the district, who are equipped with medical staff who go and do the vaccinations after a certain number have been registered by the teams of teachers. We have to be very thankful to all these hard working frontline workers. But much more is needed. The speed at which we would like to vaccinate, we are not able to do because of this entire connectivity issue and also the shortage of supplies. We have about 600,000 people above the age of 45, of whom 74,948 have got their first dose and 15,479 have got both doses. We have over 800,000 people in the district above 18 years, and most of them are yet to be vaccinated.
Can you describe the importance of collecting and disclosing information through the district Covid dashboard. How have you used your control room?
This is one of the most important things we have learnt. If we are not transparent, and do not disseminate information proactively, we will create conditions for fear and panic in the people. They are already in a state of worry when they test positive for covid. The help should be easily available to them at that time. Control rooms have been established in all the talukas. When they call the control room, they are counselled and their requirements are taken down. Where to isolate? Which hospital to get admitted to; such guidance is given.
If oxygen level is low, a bed is allotted accordingly. If there is any grievance call made to the control room, then we send our team there to check. And if we find [there is] truth in the complaint, then we take action against that hospital.
We had made the website last year when cases had gone down, and it showed its value when cases went up. It is a replicable model for many districts, displaying daily updated information on the list of hospitals and bed availability, and the list of vaccination centres. All our ambulances and vaccination vans are GPS tagged, so we can see the availability and the location. It gives an overview of what are our resources and where more action is needed. We update it daily with the number of cases, deaths, recoveries.
From 1,500 to 2,000, our caseload went up five to six times to 10,000 to 12,000 this April. When the caseload rises like this, you have to use technology, and you have to use a centralised control room to allocate resources. If you don’t do that how will you deal with so many calls and so many requests for help and enquiries? It becomes manageable only if you have a proper system in place.
For example in Mumbai, the city has been divided up into seven zones, seven control rooms and one control room overlooking the whole effort. Some of these basic principles remain the same whether it is Nandurbar or a big city like Delhi. The problem in India often is that nobody listens to those who are in the remote districts and to those who are working in the field. But where we work does not matter, what matters is the passion with which we are working.
How did you involve the private sector?
I am myself a doctor, and I always respect doctors. Not because it is a very noble profession, but because I know through my own experience how hard it can be to get a medical education. So, my approach was to motivate the people, to say please open the hospital, please start the services and help us too. We have three private hospitals; we pushed them to do things like setting up their own oxygen plants. We have regular zoom meetings about government protocols and ICMR (Indian Council of Medical Research) protocols, and there is good teamwork and coordination among us in these fora, from the availability and use of medicines to oxygen. We had some rare instances of overbilling, and I had to take action against them and lodge FIRs (first information reports), but there has not been any major trouble since.
Your own life story is inspiring. How has that influenced your work in this public post?
I was born in the neighbouring district of Dhule, but my school education happened in this very district, Nandurbar. And I am from the Adivasi community of Bhils. And that has helped me understand not just their issues but also those of other marginalised communities. For example, I instinctively understand that they cannot afford to take an autorickshaw and come from their home to take a test or a vaccine. Or to go and register on an app is just not something they can afford or can do. We have to be people-centric and take services to them as much as we can.
Poverty is a great teacher. My father passed away before I was born, and my two siblings and I were brought up in a shack by my single mother, who worked as a farm labourer. She and my grandmother also brewed and sold liquor made from mahua flowers. As I remember, they were always very determined. My mother despite being a widow, and neither having any land of her own nor money, never gave up on hope for us. I studied all along in government schools like the Navodaya school. Because I was good in maths and it was the wish of my teachers that I should do something for society, they encouraged me to become a doctor. Once I finished my medical degree, I took the civil service exams thinking that I will have a greater scope as a public servant to do good for people, and entered the IAS (Indian Administrative Service) in 2013. With money, one is only rich until a certain point.
As a doctor and an administrator, how do you see the crisis raging in many parts of India now where people are desperately struggling for medicines, hospital beds, oxygen cylinders, and the large number of deaths every day.
Until strict isolation is not adopted, the chain cannot be broken. This is not rocket science. Anyone who is positive has to be isolated so that the infection is not passed on. Our cases suddenly exploded in the second week of April. Within a week to ten days, we are able to reduce it from 1100-1200 to 200. So that is a 75% reduction. We have come down from a 50% positivity rate to 15%. The challenge is how do you do it. For that you have to have an isolation policy – schools, hostels, hotels, wherever you can arrange for food, water, and living facilities, isolate the patients so that the chain is broken. Otherwise the growth becomes exponential and then it becomes very difficult to manage. Then you have to resort to lockdowns and implementing that brings its own costs including risks for field workers such as police.
Vaccination is very important in this fight but it will take 3-4 months minimum. What will you do until then? Both isolation and vaccination have to progress side by side. And you have to work day and night and on a war footing to create the necessary infrastructure such as oxygen plants. The death toll is very tragic and the actual figures are likely much higher. But numbers are just numbers. Those who are losing their loved ones know the pain behind these numbers.