More than 500 infections, protests and several deaths later, India’s doctors in Covid-19 wards seem to have finally got their hands on personal protective equipment to shield them from the novel coronavirus.

Resident doctors ’ associations in Delhi told Newslaundry they no longer face the acute shortage of PPE kits that was seen in March and April. India is now the world’s second-largest manufacturer of PPE coveralls but importantly, they’re also available for doctors at home. A May 30 press release from the health ministry also claimed that 96.14 lakh PPEs have been supplied to states and union territories.

But all is still not well.

As recently as the beginning of June, the resident doctors’ association of the All India Institute of Medical Sciences, Delhi, allegedly expelled a doctor who spoke up about low-grade N95 masks that were supplied at AIIMS. The doctor, Srinivas Rajkumar T, had spoken on Twitter and to the media about alleged quality issues with the mask, and how data from the health ministry and Indian Council of Medical Research was purportedly false.

“The N95 masks do not meet even the Ministry of Health and Family Welfare safety standards, forget international standards,” Rajkumar had told the New Indian Express. “Our relentless pursuit of resident welfare has been met with threats of FIR from administration and attempts to jeopardise the career of RDA executives by the administration.”

In May, a doctor in Visakhapatnam was stripped and beaten by the police when he complained about the shortage of PPE kits and N95 masks.

India’s first Covid-19 case was reported on January 30. However, the Centre took steps to procure PPE kits only in March, floating a tender for the manufacture of PPEs in that month. There were several delays in procurement and distribution of the kits in the early days of the pandemic.

How did this happen?

The initial months

PPE kits comprise coveralls, triple-layer masks, gloves, face shields, shoe covers, and goggles. Each kit shields the wearer against direct contact with Covid-infected patients, and against the aerosol transmission of the virus.

Adarsh Pratap Singh, the president of the AIIMS resident doctors’ association, told Newslaundry that the scarcity of PPEs was felt in hospitals across the country, especially in non-metropolitan cities where doctors were forced to use HIV protective kits, operation theatre scrubs, and even polythene sheets in lieu of PPEs.

“We wrote several letters to the authorities about the problems faced by doctors due to the lack of PPE kits,” Singh said. “Indeed, during the initial days, there was a scarcity of PPEs. When we coordinated with resident doctors’ associations of other states, we came to know how bad the situation was. The virus was infecting health workers. No doctor should pay the price for the lack of PPE.”

“During the months of February, March and most of April, we draped ourselves in whatever we could put our hands on — operation theatre scrubs, surgery gowns, HIV protection kits, you name it!” said the president of a resident doctors’ association in a North Indian state, on the condition of anonymity. “No patient can be left untreated, whether we have PPEs or not. All we could do was draw up every permutation and combination with the gowns, masks and gloves available to protect ourselves from the infection.”

He added: “ By the time PPEs were made available in April, many health workers had already succumbed to infections.”

One of these health workers was Heera Lal, a senior sanitation supervisor at AIIMS, Delhi. Lal tested positive for coronavirus in May and died a week later. Kuldip Singh Dhigan, the general secretary of the AIIMS SC, ST Association, told the Tribune that Lal, who handled the entire sanitation effort at AIIMS, did not have protective gear.

Hospital authorities issued a statement saying this charge was “totally baseless and incorrect”.

But Dhigan told Newslaundry that even as doctors had access to some kind of protective gear, sanitation workers had none.

“Heera Lal-ji — a Covid warrior — succumbed to the infection and died. We have seen so many others among healthcare workers being infected over the months, as everybody dealt with the lack of equipment during the initial days,” Dhigan said. “Class 4 workers, which includes sanitation workers, did not have access to even masks and gloves until 15-20 days after the lockdown.”

Medical professionals are also demanding that PPE kits be made available throughout the hospital.

“PPE kits are available in Covid areas, or the areas of the hospital where infected patients are treated. But there have been cases of medical professionals in non-Covid sections getting infected by coronavirus,” said Singh, the president of the AIIMS resident doctors’ association. “People get infected through droplets and even aerosols.”

Dr Manish, the president of the resident doctors’ association at the Vardhman Mahavir Medical College & Safdarjung Hospital, told Newslaundry that private players and NGOs pitched in to donate PPEs in the early days of the pandemic.

“Nationwide, PPEs were in scarcity. Several NGOs and private players wanted to donate to the hospital...We therefore told them to donate in the form of PPEs and not money,” he said. “Fortunately, we never got to a point where we had to stop work due to the lack of protective equipment.”

Delay in PPE standards and specifications

On February 27, the World Health Organisation sounded the alarm on the availability, or lack thereof, of PPE kits on a global scale. Issuing guidelines on the “rational use” of PPEs, the WHO noted that the global stockpile of PPEs is “insufficient”.

“Surging global demand — driven not only by the number of Covid-19 cases but also by misinformation, panic buying and stockpiling — will result in further shortages of PPE globally,” the WHO said. “The capacity to expand PPE production is limited, and the current demand for respirators and masks cannot be met, especially if the widespread, inappropriate use of PPE continues.”

This was followed by a press release on March 3 on how the shortage of PPEs was “leaving doctors, nurses and other frontline workers dangerously ill-equipped”.

Meanwhile in India, the Centre banned the export of PPEs on January 31, a day after the first Covid-19 case was reported in India. The ban was lifted on February 8 to help China fight the pandemic.

The order was again revised on March 19, however, when the Ministry of Commerce and Industry issued a new order banning the export of surgical and disposable masks, ventilators, and textile raw material for masks and coveralls.

Specifications on standards for the manufacture of PPE kits were finally issued in March, when the first tender for manufacturing the kits in India was given to two associations representing nearly 200 manufacturing units.

Sanjiiiv Relhan, the chairman of the Preventive Wear Manufacturers’ Association of India, told Newslaundry that the specifications for PPE components were released just before the first lockdown in March.

In April, the Bureau of Indian Standards published the National Standards for Bioprotective Coverall, which applies to the coveralls that are part of PPE kits. “However, the standards were withdrawn within four days of publishing for reasons best known to them,” Relhan added. On April 17, the bureau said that standards specified by the health ministry would be applicable.

Rajiv Nath, the forum coordinator for the Association of Indian Medical Devices Industry, said the government began to procure PPEs from manufacturers even before the health ministry’s specifications were issued. The procurement was done on the basis of a single synthetic blood leakage test — before a comprehensive standard was specified.

“As there was no Bureau of Indian Standards standard available, various state governments were coming up with their own buying specifications in the tenders, which was very confusing for manufacturers, because there was a big variation in the raw materials depending upon the specifications, following which the PPE was supposed to be made,” Nath said. “So approximately until the third week of March, the standard specifications were not clear and manufacturers sought a national specification or standard.”

He added: “The experienced medical garments manufacturers, however, insisted that the government send out detailed specifications.”

Other miscalculations

There was a series of miscalculations on the government’s part in the entire process of manufacturing PPEs. One of them was in the approval of the PPEs being manufactured.

At present, India has around eight approved laboratories to test the prototype samples of PPE coveralls according to the health ministry’s specifications. However, these laboratories were approved only in May. In the early days of the lockdown, only one laboratory was functional: the South India Textiles Research Association in Coimbatore.

“Due to the lockdown of every service, most manufacturers in North India were not able to send their samples [to Coimbatore] for testing,” Relhan explained. “Hence, they were not able to manufacture and supply the PPEs.”

HLL Lifecare Limited, a public sector company, was made responsible by the Centre for procuring the PPE kits from manufacturers and suppliers, assembling them, and sending them to the Coimbatore laboratory for testing.

Manufacturers also faced issues in packing and transporting the PPEs.

“Everything was shut during the lockdown. From getting raw materials for manufacturing to getting packaging materials, everything was a tough task,” Relhan said. “The workforce was not able to come to manufacturing units. We often had to persuade transporters for days to transport raw materials to our manufacturing units — and that too at almost thrice the normal charges.”

Newslaundry reached out to the ministry with a questionnaire. The story will be updated if a response is received.

This piece is part of a project supported by the Thakur Family Foundation. The Thakur Family Foundation has not exercised any editorial control over the contents of this research.