The prevailing atmosphere among healthcare providers in Mumbai cityhas turned unpleasant following continued threats from the authorities. With Covid-19 infections growing through roof, Mumbai- the financial and Covid-19 capital of India, is slated to go the New York way in Covid19 situation. In initial part of the Covid-19 epidemic, doctors were equated with the god, with accolades showered by the Prime Minister while addressing the nation. That followed symbolic honours, like sound of bell on one Sunday, flashing lights on next Sunday and showering flower-petals by Indian Air Force on yet another Sunday. Such memories were short-lived for the frontline warriors – the doctors – who keep performing their humanitarian dutiesirrespective ofgetting bouquets or brickbats and more aggressively during any crisis. In fact we should have sensed by now, that too much sweet can taste bitter after a while! The threatening orders, of May 6 for mandatory duties of private doctors for Covid-19 patients and of May 19 for criminal cases against hospitals for not reopening, have negated the healthy ambiance created a month back. Our war should be against the virus, not against each other!We experienced similar things during initial days of HIV epidemic. There are many lessons to learn from HIV epidemic and take appropriate measures to adopt good ones andalienate wrong ones.On May 6,the Maharashtra government notification made it mandatory for private doctors, below 55 and without any co-morbidity, report to Covid-19 designated hospitals in Mumbai, asking to provide treatment to the Covid-19 patientsfor 15 days. Failure to report to the hospital will lead to their medical license being revoked, invoking the Epidemic Diseases Act, Disaster Management Act, and Maharashtra Essential Services Maintenance Act in issuing this order.1 Maharashtra is the only state where such orders are enforced.
On May 19, the newly appointed Brihan-Mumbai Municipal Corporation (BMC) Commissioner ordered to register a criminal offence against private hospitals, clinics and nursing homes that have failed to reopen inconveniencing several non-Covid patients and reserving 100 beds including 10 ICU beds of private hospitals in each ward (Mumbai city is administratively divided in 24 wards) for Covid-19.2Such noble thoughts were lost, while sealing the private hospitals. Finally on May 21, in consultation with private hospitals registered under the Public trust act, the BMC has takenover 80% beds of their beds capping daily all-inclusive hospitalization charges to Rs.4000 for bed, Rs.7500/- for ICU bed and Rs.9000/- for bed with ventilator support.The intention here is to serve Covid-19 patients that are on upward spike as also non-Covid patients, but the mannerism of getting it done should not behigh-handed.This can be achieved through a meaningful dialogue with representatives of medical bodies and trustworthy partnership. Harsher steps could be reserved if there is dereliction in discharging responsibilities. The rising Covid-19 trend is part of a natural history of this pandemic, as seen in different parts of the world, for which medical community is not responsible. Then why such crudity on us? When Mumbai and Pune emerged as Covid-19 hotspots and medical frontline warriors were trying to outsmart the Coronavirus by providing their untiring services despite compromises on personal protective equipment (PPE); there was a new worrying development- though not unexpected. The healthcare workers started testing positive for COVID-19 in one after another hospital. The shockwaves followed by wide coverage on 24x7 channels and punitive actions singularly against private hospitals by authorities. No such actions were initiated against public hospitals where the situation was similar if not worse.Analysis showshow first the hospitals were shut down high-handedly, were defamed blatantly as they are some ‘Wuhan-like’ centres spreading the virus and were threatened with criminal cases if they won't reopen immediately.
It started on March 14, with partial sealing of Mumbai’s tertiary care Hinduja Hospital and quarantining 82 staff including doctors, when a 64-year-old heart patient tested Covid positive. He was shifted to Kasturba Hospital, though a designated Covid-19 centre but ill-equipped for critical patients and had no ventilator. On March 18, hedied of Acute Respiratory Distress Syndrome (ARDS) and became Maharashtra’s first Covid-19 and third in India.On March 28, BMC had sealed Mumbai's Saifee Hospital, after 85-year-old retired urologist died of COVID-19 and his 50-year- old son found infected.And that set the ball rolling for more closures of private hospitals one by one. Later Saifee hospital was converted into a dedicated Covid-19 facility, when BMC realized they are short on Covid-19 beds.On April 6, the Wockhardt Hospital in Mumbai central was sealed and declared a containment zone by BMC, when 26 nurses and three doctors tested Covid-19 positive. Later, this hospital was designated as Covid-19 facility. On April 7, Mumbai’s premier Jaslok hospital had a similar fate and BMC ordered it to be sealed too.On April 9, the BMC sealed Mumbai’s Bhatia Hospital, after three emergency ward patients tested Covid-19 positive and was declared a containment zone. After 10 days BMC permitted them to reopen, but they couldn’t, astheir entire support staff is outsourced and the contractor refused to send staff, on Bhatia hospital being widely defamed as city’s worst Covid-19 infected place! Finally, Bhatia Hospital thathad 45 of its staff Covid-positive, has reopened on May 12.In this period, on April 9, while the staff of Breach Candy hospital has been quarantined after they came in direct contact with a patient, the BMC did not seal the hospital premises. This was possibly because it is home to VVIPs and if all hospitals in country’s richest territory of South Mumbai are sealed, in case of emergency where would VIPs or their families go?
In another issue, the BMC issued an order making physical examination mandatory for advising Covid-19 test and said any doctor doing so will face criminal charges, in addition to cancellation of medical license. This is contrary to what is being practiced globally. Do we expect a doctor to wear PPE to physically examine a suspected Covid-19 patient to prescribe Covid-19 test. If so, why and how were Covid-19 tests done on police, CISF, media personnel and other such groups, all without physical examination or a doctor’s prescription? The city has 25,000 registered doctors of which 30% or nearly 7,500 doctors would be around 60 years of age. Rest 30% are employed with government hospitals.The Maharashtra Medical Council president Dr.Shivkumar Utture stated, "If a doctor is above 60 years and co-morbid, he will not open his clinic. That is why we have given the doctors permission legally and officially to consult patients on telemedicine and telephone. The aim is to see that emergency patients get advice or treatment".Telemedicine is now legally allowed with the notification from Ministry of Health and Family Welfare, Government of India, enabling Registered Medical Practitioners to Provide Healthcare Using Telemedicine by the Medical Council of India on March 25, 2020 with itsguidelines been prepared in partnership with NITI Aayog.Doctors are always under threat, so also hospitals! Physical assaults, abuses and vandalism have become routine. Doctors hardly have any golden hours in their lives, beyond the joy derived after recovering critical patients and gratefulness expressed by other patients. The hope of winning war on Covid-19 is in two folds – to reduce its transmission in our country and to minimize its death rate. Undisputedly, the doctors play a pivotal role towards at least the later. Authorities issuing orders for closure and reopening hospitals ‘on drop of a hat’ and expecting it to work like an electric switch, should think realistically, that too at during the current continued lockdown time since March 20. Several hospital staff stay in suburbs beyond the network of BEST buses. Mumbai’s lifeline, the local-trains are closed. Other means of transportation are severely impacted, so also other logistics like repairs and maintenance of machines and equipment and food supply!Lack of coordinated actions have already cost us dearly and such circulars will do more harm than good.We don’t want unhappy places (hospitals) and sad faces (doctors) to serve Covid-19 patients, in aiming at reducing case fatality rate.
Dr. Ishwar Gilada is consultant in HIV and Infectious Diseases in Mumbai, is President AIDS Society of India and Governing Council Member, International AIDS Society. Email: [email protected]