On June 4, Satvinder Singh, a resident of Delhi’s Greater Kailash I, began his day by making frantic calls to multiple hospitals. His father, Lakhjeet Singh, 68, had tested positive for Covid-19 three days earlier at a private hospital laboratory. An asthma patient, Lakhjeet had a fever and a chest infection.

As his temperature rose on the night of June 3, the family decided to drive him to a hospital early the next morning. After unsuccessfully contacting four hospitals, the family finally found a direction: the Lok Nayak Jai Prakash Hospital in central Delhi.

“The operator at the Delhi Covid helpline told us there were about 1,100 beds available in the hospital,” Satvinder told Newslaundry. “So, we rushed there to get my father checked and admitted.” Accompanied by his mother and a cousin, Satvinder and his father reached the hospital at around 7 am.

But finding a hospital was not the only challenge. When the family reached the LNJP Hospital, Singh’s request to admit his father was flatly denied. A doctor said they couldn’t admit Lakhjeet because he had been tested at a different hospital.

“The hospital staff repeatedly told us to take him to that hospital instead. I failed to understand this bizarre logic,” Satvinder said. “Feeling helpless, I begged the doctor to at least come and see the condition of my father.”

Meanwhile, Lakhjeet had fainted in the car. The family, with the help of a passerby, put him on a stretcher and tried to take him inside the Covid emergency ward. The hospital staff denied them entry; it took about 15 minutes of pleading to get one doctor to take a look at the patient.

But crucial time had been lost. Minutes later, Lakhjeet was declared dead.

“My father could have been easily saved if he was admitted on time. First, we had to wait to find a hospital. Once we did, we were being sent away,” Satvinder said

Escalating crisis

The Singh family’s fruitless struggle to get Lakhjeet medical help ended with his death on the doorstep of the emergency ward of Delhi’s biggest hospital dedicated to Covid care. Yet, their tragic story isn’t unique.

Amid a spike in coronavirus infections in Delhi, reports have emerged of a number of Covid patients dying for want of medical attention. In several cases, even if a patient was lucky enough to find a bed, it wasn’t before several hours of waiting. Worse still, accounts have emerged of desperate Covid patients from the capital rushing to neighbouring states like Madhya Pradesh and Punjab to get treated in hospitals.

Such stories illustrate the scale and severity of the unfolding Covid-19 crisis in Delhi. Since the lockdown was relaxed on May 18, Delhi has seen a huge jump in infections and deaths. To get a sense of how quickly the crisis has escalated, let’s look at the numbers between May 18 and June 1.

On May 18, the number of coronavirus cases in Delhi was 10,554, with 166 deaths. By June 1, the cases and deaths had more than doubled, to 22,132 and 556, respectively. As of June 24, Delhi has 70,390 cases, with 26,588 active cases, and 2,365 deaths.

But the worst is yet to come.

A recent assessment by the Delhi government projects a grim picture over the next month and a half. On June 9, deputy chief minister Manish Sisodia said there was prediction of nearly 5.5 lakh cases by the end of July. The figure was based on the prevailing doubling rate of 12.6 days in the city, he said.

According to the government, the estimated caseload will require about 80,000 hospital beds to handle. As of June 23, Delhi has only 13,389 beds.

Beds and healthcare workers

The Delhi government claims to be ramping up its healthcare infrastructure to deal with the Covid surge, but there is a clear mismatch between official data and reality.

For example, the state launched an app called Delhi Corona on June 2 to help citizens find beds and ventilators on a real-time basis. But the app has led to confusion. Lakhjeet Singh’s family, for instance, checked the app and four hospitals listed beds as being available for Covid patients. But the hospitals didn’t admit Lakhjeet — when the family telephoned them, they were told not to come.

The media has regularly reported about the gap between the numbers on the app and the actual availability in several hospitals.

According to a top official in the Delhi health department, who spoke to Newslaundry on the condition of anonymity, the gap in data wasn’t due to a shortage of beds. It was a “technical failure” that the government was trying to resolve as soon as possible.

“No hospital, be it private or public, will hide numbers. It’s just that everyone is overworked and real-time updating is not happening,” the official said.

Delhi’s 13,389 Covid beds are distributed across five state and as many central government hospitals, and 108 private hospitals. Nearly 55 percent of the beds are in private hospitals.

If not beds, is there a shortage of staff that is prompting hospitals to turn patients away? No, the health ministry official said, and added, “This is a technical challenge, not a human resource problem. We are constantly urging all hospitals to fix the gaps in terms of data.”

But staff shortage will certainly be a problem going forward, if it isn’t already. The Delhi government is currently trying to create a massive pool of hospital beds and equipment. But does it have enough healthcare providers to run them?

A number of doctors and public health experts that Newslaundry spoke with were sceptical.

Dr Ambarish Satwik, a vascular surgeon at Sir Ganga Ram Hospital, said hospital beds will be required for patients with breathing difficulties and other complications. This means that a good number of the beds would be fitted with oxygen support. “Such arrangements would require the support of additional medical professionals such as doctors and nurses. But to create that force, there’s no news of any recruitment drive yet,” Satwik pointed out.

As of March, there were about 84,000 nurses registered with the Delhi Nursing Council, according to its president Anita Dhall. The majority of them — between 50,000 and 55,000 nurses — are with the city’s private hospitals, said Rince Joseph, president of the Delhi chapter of the United Nurses Association, a pan-India association of nurses working in private hospitals.

Nearly 12,200 nurses are available in Delhi’s 10 government hospitals dealing with Covid patients, but only 4,000 are assigned Covid duty, said Anita Panwar, president of the All India Government Nurses Federation. It’s difficult to get a definite number for private hospitals, said Rince Joseph, but on average, about 60-65 percent of the total nursing staff deals with Covid patients currently.

According to a central government audit of medical professionals available to handle Covid patients, Delhi had about 18,000 MBBS doctors in April, 2,500 MBBS students, 12,000 dentists.

Going by these numbers, there is enough staff to handle a few thousand more Covid beds. But a major surge, like the one predicted by Sisodia that would require 80,000 beds to deal with, will stretch the existing pool of medical professionals.

Though the Delhi government hasn’t started large-scale recruitment yet, some steps have been taken in the past week to increase the availability of healthcare providers.

On June 19, an order was issued directing all final-year postgraduate medical students to join the Delhi government’s Covid hospitals for a period of six months. The order also roped in final-year postgraduate and undergraduate nursing students for ICU duty for six months. Further, except for the "most compelling circumstances", the government cancelled the leaves of all employees, including doctors and support staff, of its hospitals.

To man the additional beds set up in community spaces, the government is speaking with doctors’ associations to rope in private practitioners. Each doctor has been asked to manage 50 beds and the payment will be made for services per bed. While doctors have been found to handle 7,000 beds so far, the target is to find staff to man a total of 18,000 beds.

Why is Delhi seeing a surge?

An obvious and immediate reason for the spike in coronavirus cases in Delhi is the easing of the lockdown. But there are other factors in play.

Dr Giridhar R Babu, head of lifecourse epidemiology at the Public Health Foundation of India, said the presence of dense clusters and “non-observance” of Covid norms by the public could explain the surge in a city like Delhi. Japan, for example, successfully contained the spread even without a lockdown, Babu said, by preventing gatherings, especially of high-risk people.

“In close contact settings, Japan made it mandatory for everyone to wear masks. Growing evidence shows that the mandatory use of masks can alone reduce the transmission, even without a lockdown, to a great level. But that hasn’t been the case in Delhi,” Babu said.

Once the lockdown was over, he added, many people stopped following the norms, assuming India had overcome the crisis. “Here, the government authorities have failed to enforce mask-wearing and maintaining social distance in the city,” he said.

As per the government’s guidelines, an area is declared a containment zone if three or more coronavirus cases are found in close proximity. Once defined, a containment zone has clear entry and exit points, and no movement is allowed except for medical emergencies and essential goods and services. But people familiar with the situation, in slums and other dense clusters, claim such guidelines are not enough to prevent the spread.

Indranil Mukhopadhyay, a professor of public health at OP Jindal Global University and co-convener of the Jan Swasth Abhiyan’s Delhi chapter, has worked closely with ragpickers in the city and is thus familiar with the slums most of them live in. He said many such areas were declared containment zones but the residents weren’t adequately screened. This was a problem, he pointed out.

“Suppose there are two cases in a slum which has 1,000 people. Enclosing the slum alone won’t work,” Mukhopadhyay said. “You also need to test the 1,000 people living there as contact tracing is difficult in dense neighbourhoods.” By the time the two cases are detected, he added, 20 other people might have been infected already. “But you don’t know that unless you test them all. Since this didn’t happen, cases spread in the city.”

At 13,446 per million, Delhi’s testing rate was among the highest in the country until June 11. According to a submission in the Delhi High Court that day, the city had approved 40 approved labs for coronavirus testing, 17 public and 23 private, with a combined capacity of 8,600 tests per day. Between June 1 and June 9, however, the city tested far fewer samples than its capacity, averaging just 4,853 tests a day.

The low testing rate was a result of the Delhi government deciding on June 2 to stop testing asymptomatic direct and high-risk contacts of confirmed cases. This changed only after an intervention from lieutenant governor Anil Baijal on June 8, prompting the state government to direct all labs to stick to the guidelines of the Indian Council of Medical Research.

Scaling up health infrastructure

The surge in coronavirus cases has put tremendous pressure on Delhi’s public health infrastructure. In response, the government has enhanced the capacity over the past few weeks, setting up Covid beds, for one, in private hospitals, hotels, and large public spaces.

On June 14, after a meeting with the Delhi government, the Centre pledged to make available 500 railway coaches that have been converted into Covid patient treatment wards. The coaches have around 8,000 beds and are equipped with necessary medical equipment to treat Covid patients. Last week, 267 of these coaches were parked at the Anand Vihar railway station and 50 at the Shakur Basti station. The rest will be placed across seven other stations in the city.

The Centre also said it would provide Delhi with resources such as oxygen cylinders, ventilators and pulse oximeters. According to the Delhi government’s Covid website, the city has 708 ventilators, of which 463 are currently in use.

Additionally, preparations are underway to erect a 10,000-bed temporary hospital on the premises of the Radha Soami Satsang Beas, a spiritual organisation, on the border with Haryana. Since critical patients will require oxygen support, the government recently ordered 2,500 portable oxygen concentrators to attach to the new beds.

Concerns have also been raised over the lack of sufficient cremation and burial spaces in the city for Covid fatalities. The rising death toll has forced many families to wait for hours to conduct funerals. Currently, six cremation grounds, four graveyards, and the city’s one cemetery managed by civic bodies are allowed to handle the bodies of Covid-19 victims.

To handle the load, the Delhi government recently allowed the use of wood pyres, in addition to electric and CNG furnaces, for cremating Covid-19 victims. The working hours of crematoriums have been extended as well; they can now operate from 7 am to 10 pm instead of 9 am to 4 pm. The city’s civic bodies have also added options of cremations as per Covid protocol at six new places in Mangolpuri, Inder Puri, Beri Wala Bagh, Wazirpur, Seemapuri and Ghazipur cremation grounds.

Delhi is clearly racing against time to gather enough resources and expertise to deal with the Covid surge. The rush is an indication that the government failed to see the coronavirus trend beyond the lockdown. A private hospital doctor who asked not to be named said it was the natural course of an epidemic: that once it spread in dense urban clusters, there was no way to contain it.

In a city like Delhi, which has hundreds of slums and dense urban clusters, the rapid spread of coronavirus was easily foreseeable, he added. “All the arrangements they are planning now should have been made during the extended lockdown. The government failed.”

What Delhi should be doing

Several doctors and public health experts told Newslaundry that a key lacuna in Delhi’s Covid strategy is that it does not prioritise Covid patients.

Both Dr Satwik and Dr Babu emphasised the need to distinguish between patients who require isolation and those who need hospital care. A number of people who do not have breathing complications are currently occupying beds in hospitals and care centres, Satwik said. “This is a waste of beds as well as healthcare workers on people who can recover through home isolation,” he said.

He added that the optimal utilisation of resources is crucial. Currently, nursing officers across private hospitals have been entrusted with monitoring if patients are admitted under the right protocols, he pointed out. “This is a clerical job which doesn’t require a nurse. You can’t afford this kind of misutilisation of human resources in the days to come.”

According to Babu, another major challenge for Delhi is arresting the fatality rate. To reduce it, he said, the government must focus on vulnerable sections, such as elderly people with comorbidities. “Such people, at the slightest display of symptoms, must be immediately shifted to a super-speciality hospital,” he said. “For that, all hospital beds must be fitted with high-flow oxygen support, as some states have already done.”

As the national capital, Delhi has some of the country’s best healthcare infrastructure. But the city’s capacity to fight the raging pandemic on its own is dwindling. Since its neighbouring states aren’t overwhelmed yet, perhaps Delhi should count on them for support.

Arun Panda, who headed the Centre’s empowered group to augment human resources for Covid strategy until his retirement on April 30, advocates this option. “Trained professionals like doctors and nurses need to be roped in from other states which can release them,” he said. “I am sure there will be understanding and cooperation among the states as the crisis can hit anyone at any point.”

The central government has also stepped in to help Delhi. On June 14, home minister Amit Shah announced that Covid-19 tests would be carried out at every polling station in containment zones. Additionally, comprehensive house-to-house health surveys would be conducted in hotspot areas for contact tracing.

Accordingly, the Delhi government began doing rapid antigen tests, which yield results in 30 minutes, in and around its containment zones on June 18. A total of 341 teams were involved in the rapid testing exercise. But it has fallen way short of the daily target of 22,000 rapid tests, prompting the Delhi High Court to describe the numbers as “abysmal” on June 22.

The strategy for testing, tracing and isolating infected people has proven crucial in the fight against the pandemic. For example, Kerala, the first state to record a coronavirus infection in India, managed to slow down the outbreak by implementing this approach from the panchayat level up. Implementing the same strategy in a city like Delhi which has dozens of dense clusters is a challenge, though.

Bhalswa, Delhi’s largest slum, houses around two lakh people as per the Census 2011. A report in the Citizen pointed out that the slum witnesses 50-100 deaths every year due to waterborne diseases. As most households have no access to running water or toilet facilities, around 50 people on average share a single unclean toilet every day, the report added. Such practices could not only lead to community transmission of coronavirus, but also make tracing and isolating infected people difficult. So, Delhi’s success in combating the pandemic will depend to a great extent on how effectively these measures translate from paper to the ground.

The signs are increasingly worrisome even as preparations are continuing on a war footing. Yet, the situation is still manageable, some experts said.

As per the Centre’s guidelines, Babu said Delhi’s condition is of “a large outbreak amenable to containment”. Instead of the frequent blame game between different agencies, the crisis now mandates a single-point decision-making body, he emphasised. “This body, in turn, must constitute and oversee different technical committees for different aspects like critical care, isolation and hospital beds, among others.”

A city governed by multiple authorities has finally seen a collective response to the challenge at hand. Cooperation between the Centre and the Delhi government over the past few days signals towards a joint, cohesive strategy. This is the path to follow if the national capital is to avert a catastrophe.

This story is part of the NL Sena project, which four of our readers contributed to. Contribute to our next NL Sena project, Long Wait for Home, and help to keep news free and independent.

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