Representative image. Photo: PTI/Vijay Verma.
The coronavirus pandemic is humanity’s biggest crisis, possibly since World War II, and the response to it needs to be similarly well-planned and comprehensive. Mumbai has done well on the preventive front in this battle. However, when it comes to the treatment front, we do not have a great plan, as a result of which Mumbai’s COVID-19 mortality is almost four-times that of Delhi.
What can Mumbai learn from crisis management strategies? The three essential components to tide over a crisis successfully are to have a well-defined and experienced team, a well-thought out and well-implemented strategy, and well-trained and well-equipped crew. Unfortunately, each of these three prongs still remain to be strengthened in Mumbai.
Getting the best team on the task
No one can miss the renowned Dr Anthony Fauci by the side of US President Donald Trump in his press conferences, commenting on the medical aspects of the disease. This is a great example of letting the medical expert take the medical decisions in the chain of command. While preventive measures need public health officials to strategise, the responsibility of planning treatment measures has to involve clinicians actively treating COVID-19 patients, and not be limited to officials sitting in government offices.
Mumbai has a number of renowned chest physicians, infectious diseases experts and intensivists in both public and private hospitals. The health authorities need to create a team of experienced clinicians to be in charge of the medical management of COVID-19 – a team that understands the seriousness of this disease and the limitations of our public and private health facilities. A team that can communicate the gravity of the situation to health officials, that understands the nuances of public and private hospitals, their strengths and weaknesses, what innovation is possible and what is not, and local turf wars and politics that could cause friction, etc. Unfortunately, there appears to be no such all-encompassing team in place for now.
Crisis management plan
The team has to then fashion a comprehensive strategy to tackle the pandemic based on evidence or at least evolving consensus. The current medical decisions in Mumbai are relatively opaque and the thought process behind them is not well-communicated. A case in point is the decision to make Kasturba hospital, a place without an ICU or dialysis unit at the time, the COVID treatment centre. Similarly, the lockdown of hospitals as soon as a health care worker (HCW) is detected to be COVID-19-positive has no precedence in the rest of the world.
The plan has to be dynamic and constantly updated as new information on treatment strategies becomes available, be it newer management strategies or novel treatments like plasma therapy, where Kerala has already taken the lead.
Well-trained, well-equipped crew
In the West, COVID-19 mortality is higher than 3-4%, and rising further despite an advanced level of care led by a team of sub-specialists from across multiple medical fields. It is imperative that we use our best medical facilities to fight COVID-19, otherwise it will be like the Dothraki fighting the Whitewalkers[footnote]In the popular TV show ‘Game of Thrones'[/footnote].
The KEM, Sion and Nair Hospitals – all run by the Brihanmumbai Municipal Corporation – and the state government-run JJ Hospital are Mumbai’s best multi-speciality public hospitals. They have more than 6,000 beds and over 500 ICU beds between them. The medical staff has great experience in handling complex cases, with KEM receiving accolades for its excellent management of injuries people incurred during the 2006 serial bomb blasts, found to be at par with the Royal London Hospital’s management of the tube bombings.
But surprisingly, they have been left out in the COVID-19 battle for way too long. As any medical expert will confirm, COVID-19 is a new disease and there is a learning curve vis-à-vis optimal management, even for senior doctors. Even when a large hospital gets involved, it takes a few weeks to become a well-oiled machine when handling COVID-19 patients, since a lot of institutional restructuring (into COVID-19 and non-COVID-19 areas), creation of institute-specific policies and SOPs, mock drills etc., are required. Besides, thanks to the lockdown, these large public hospitals are anyway functioning at a limited level; KEM is in fact conducting only a tenth of the surgeries it normally does. This means the hospitals have enough capacity to take optimum care of COVID-19 patients.
Thankfully, health authorities realised their mistake when a Filipino patient being treated in Kasturba Hospital had to be transferred to a private hospital due to the absence of a dialysis unit and adequate ICU facilities. Now, a small portion of KEM has been converted to a COVID-19 isolation ward (albeit with only 46 beds), including some beds in the emergency ICU. These unfortunately still remain extremely limited measures for the crisis we face; many of these beds are already full. In fact, a COVID-19 positive patient on dialysis was recently made to wait for 13 hours at KEM for a bed.
We need to expand our intensive care capacity for COVID-19 patients as soon as possible, as our current strategies are not sufficient to save everyone who can be saved. On April 13, Maharashtra created a dedicated COVID-19 critical care task force of physicians to help reduce COVID-19 mortality. This again is a great – but belated – initial step. One hopes that their role is expanded to all aspects of medical management of COVID-19 patients as soon as possible, beyond just critical care.
The medical fight against coronavirus is an all-out contest between life and death, and an empowered team of our best physicians who create a comprehensive medical plan, which actively involves and is executed by Mumbai’s large and very capable public hospitals along with the private hospitals, has the best changes of swinging it in ‘life’s’ favour. Hopefully the authorities will take notice and act on these issues quickly.
Dr Akshay Baheti is an assistant professor at a hospital in Mumbai. The views expressed here are the author’s own.