By Rahul Shrivastava New Delhi
Releasing a white paper on the pandemic that warned about an impending third wave, Congress ex-president Rahul Gandhi claimed the second surge was a “misfortune foretold”.
An ICMR study based on mathematical modelling analysis, is “foretelling” that the new variant is unlikely to cause a new wave unless it leads to a complete loss of immune protection from a previous infection.
But the crushing tenure of the second wave has created a dread.
SECOND WAVE — A TRAGEDY OR LESSON LEARNT?
The second surge arrived almost 90 days ago and India started gasping for some oxygen inside hospitals, on pavements outside medical facilities, in public transport vehicles and homes. Soon, India’s healthcare system was on its knees.
Oxygen cylinders were stolen, oxygen tankers were hijacked, oxygen concentrator sellers were profiteering even as hospitals and states didn’t have enough oxygen, ventilators or ambulances.
India’s April Covid hell brought immense agony. Close to 20% of all official deaths reported in India due to Covid-19, occurred over the four weeks of April. May brought dismay. While it’s a best-kept secret that the deaths were not being fully counted, the officially declared toll was 83,135.
Next, India ran short of capacity at crematoriums and burial grounds.
India’s “oxy-panic and distress made global headlines. The manic scramble for oxygen landed in courts, which told the central government “You can put your head in the sand like an ostrich, we will not.”
The distress created anger, which like a tsunami, dwarfed the Modi government’s popular mandate of 2019. Aware the second surge had eroded the governement’s political equity and a third could entail political calamity, the government prepared to battle the mutating pandemic and hostile opposition awaiting a political opportunity
CHALLENGES BROUGHT CHANGE
Did India change after the first two waves of the pandemic? Has adversity shaken off the seven decades of apathy towards building public health infrastructure?
Through a series of review meetings starting March, Prime Minister Narendra Modi started a status check of decisions taken on availability of oxygen, ventilators, oxygen plants and other essentials since March 2020.
PROOF OF APATHY
The last National Sample Survey (NSS) on health conducted in 2017-18 had highlighted that India’s public health matrix was poor, private health system was expensive, and good only in Metros and a large population in rural India depended on small, private and informal medical care providers.
The survey underlined that 45% of India’s rural population depended on Govt/public sector health facility, 51.9% on private facilities (hospitals, clinics and practitioners) and 2.4% on Ngos/charitable/informal health facilities.
Experts said this public-private distribution changes in case of critical illness or medical emergencies like the one brought by the pandemic. Rural India has little option but to shift towards public sector health facilities due to the accessibility and affordability factors
Before the pandemic, the cost of treatment in a private health facility for rural India was 6 times higher than a government/public health facility and eight times higher in urban centres. This means the rural low-income segment can’t afford treatment in private hospitals in urban areas.
When the pandemic-hit India, many private clinics shut shop, many private facilities refused to accept Covid patients while others were too expensive for the poor, who then turned towards public hospitals
Soon the demand for oxygen, oxygen concentrators and life-saving ventilators far outstripped the availability.
Facilities at public health Centres || April 2020
For example in April 2020
India’s public health facilities run by the Centre or state govts had just 16,644 ventilators. While 16,325 were in state government-run facilities, there were only 319 in central government run centres.
Source : MoHFW
Experts feel, during the first and the second surge, nearly 65% Indians were dependent directly on public health facilities.
This figure roughly translates to nearly 87.75 crore people depending on 16,644 ventilators or simply there was an average 1 ventilator for every 52,000-odd people.
If one takes into account the entire population of the country with 16,644, India had one ventilator in public health facility for every 81,110 people
It’s important to note that the distribution of ventilators in public health system was extremely skewed.
For example Tamil Nadu’s public health system with 7 crore population had 3,495 ventilators, which translates to one ventilator every 20,000 people.
But Uttar Pradesh with over 24 crore population had only 723 ventilators in public health system. That works out to one ventilator for every 3.31 lakh people of the state in the public health system.
Worse, Bihar with 12 crore people and 380 ventilators, had one life saving machine per 3.15 lakh people.
Maharashtra, another state which has stayed at the top in terms of cases during both waves has 11.5 crore people, but in April 2020, it only had 1,456 ventilators in public hospitals. That means, one ventilator for 75,000 people.
Delhi, which witnessed perhaps one of the most visible tragic sequence of events in April-May, had only 55 ventilators in public health facilities for the state’s 2 crore population, which translates to one ventilator for 3.63 lakh people in public system.
That’s why, when the second surge crashed in and a large percentage of patients turned towards central and state-run health facilities, the system was virtually crushed.
ADVERSITY BROUGHT REMEDY
The centre had started planning, ramping up the infrastructure in March-April 2020. Shortage of medical equipment like ventilators and cylinders was identified. Three companies were short listed to manufacture India-specific ventilators.
Cut to 2021, the total number of ventilators is up to 57,557 from 16,644.
Bulk of funds for this came from the PMCares fund, criticised by the opposition.
A large percentage of these had reached the states way back in October. However, the declining numbers of cases as the first wave created a sense of complacency. States like Punjab, Bihar and UP sat on hundreds of ventilators.
These states lacking trained personnel, facilities like piped oxygen and sheer administrative will, had to be sent reminders by union health secretary to install the equipment provided. This was happened as late as April 23 when the second surge was peaking.
But by May-end India’s ventilator availability map, as far as public sector health facilities are concerned, has improved.
If the earlier average in April 2020 was one ventilator for every 81,000 citizen, now it’s one ventilator for every 15,245 people.
Compared to 723 ventilators pre-April 2020, Uttar Pradesh now has 3,997 ventilators in public facilities, Bihar has 764 against 380 earlier and Maharashtra has 12,647 compared to 1456 in April 2020. Delhi now has 2,044 ventilators in public health system compared to 55 earlier.
While speaking to India Today TV, a senior health ministry official said: “This is bound to have an impact if there is a third wave. Since the public health system is critical, the attempt had been to beef up this infrastructure. India is now better prepared to handle critical Covid cases, which need ventilators for medical intervention.”
Kerala’s health care system has proved to be better managed compared to most of the states. The Kerala experience proves that a well equipped public health system has potential to withstand pressure
Interestingly at the time when medical facilities in states like Delhi were displaying “no ICU/oxygen or ventilator beds available”, Kerala’s superior primary health system ensured less pressure.
That’s why kerala’s Covid First Line Treatment Centres recorded the highest occupancy rate of 34% on May 8 when second surge had climbed to its highest peak across India. The Covid Second Line Treatment centres recorded 40% occupancy on May 8 and the peak of 41.9% on May 31.
The ICU and ventilator occupancy rate in public health facilities in top five Kerala districts was way higher than private.
For example, in Trivandrum average ICU occupancy has been 48.59% at government facilities while it was a little over 15% at private facilities. The ventilators’ occupancy in the city’s government facilities has been 28.57% compared to 16.66% in private sector.
Source : Kerala Health Department
Commenting on central supplies of ventilators Dr. Mohammed Asheel, executive director, Kerala Social security mission, said,” Kerala received around 500 ventilators from PMCares and yes they have been helpful as they added to our inventory of improving our health system surge capacity.”
Kerala health minister Veena George told India Today TV, “The department of health has formulated and is implementing a surge plan as the third wave will affect children as well. Facilities in medical colleges, other government hospitals and private hospitals have been augmented. Pediatric facilities have been up and running since last Monday. Expert training has also started. In Paediatric ICU, the number of beds will also go up.”
Jaiprakash Shivhare, the health commissioner of gujarat, which now has 6,389 ventilators compared to 1,438 in April 2020 said,”The centre has worked hard with a view to improve the health infrastructure in the state. A lot of equipment has come in and more is expected.”
OXYGEN AVAILABILITY & PREPAREDNESS
The centre faced flak from Opposition, courts and public as oxygen and machines that deliver it for sick lungs, turned new gold. As cylinders need refilling and facilities that can produce large amounts of Liquor Medical Oxygen were located in remote regions, the Centre keen to reduce the transportation time and upgrade availability, focused on creating local large, medium and micro-oxygen generation hubs.
OXYGEN GENERATION PLANTS
One of the key focus area for quick availability of oxygen in case of a crisis are PSA (Pressure Swing Adsorption) plants.
The plants are being established in hospitals to enable them to become self-sufficient in generation of Oxygen. Under PM Cares, 162 PSA plants were sanctioned in 2020, out of which 77 are up and running and the rest will be on stream by July ’21.
An additional 1,051 PSA Plants sanctioned under PM Cares Fund in March & April 21 are being procured through DRDO and CSIR and will be installed in the next three months in phases.
This means by September, there will be over 1,200 oxygen plants up and running with the public health facilities.
The second surge nudged states like UP, which suffer poor primary health care system and a hugely deficient matrix of government hospitals, to upgrade its public health system by installing more oxygen generation plants.
Using funds from PMCares and other state departments, 528 oxygen plants were cleared. Of these, in a very short period, 105 PSA plants have been installed and 423 plants are being set up.
UP’s health ministry spokesperson said, “Since May 5, 80,000 nigrani samitis ( surveillance committees) have carried out a door-to-door survey in the villages across the state besides the house-to-house surveillance in the urban and rural areas covering 18 crore people population. Based on the findings, UP now has 80,000 ICU and isolation beds.”
To future-proof the public health system against a feared third wave, the government went in for capacity enhancement of Cryogenic tankers.
It has increased by over 60% from 1,040 tankers (12,480 MT) in March 2020 to 1,681 tankers (23,056 MT) in May 2020.
Instead of going in for a buying spree, 408 existing Nitrogen and Argon Tankers were converted into oxygen-carrying tankers to increase capacity.
LIQUID MEDICAL OXYGEN AVAILABILITY
To ramp up oxygen supply for future production of Liquid Medical Oxygen (LMO), manufacturing was ramped up by more than 10 times from a paltry 900 MT/day in pre-Covid times to 9,300+ MT/day (as on 17th May 2021). At the current rate of production of 9,300 MT/day, India achieved the total LMO production of 2019 over in May.
Prior to April 2021, majority of India’s oxygen plants located in distant Eastern regions of India were too far away from the-worst hit states of west and north India.
The Railways and Indian Air Force transported Oxygen over long distances and ensure adequate supply. Based on experiences of
April-May period, a detailed blueprint for maximum oxygen transportation in minimum time is in place.
Railways have operated 245 sorties now and has a tested capacity of 25 oxygen-special trains to transport 967 LMO tankers & 15,938 MT of LMO over long distances through Roll on-roll off services.
After conducting 557 sorties domestically, IAF has a potential to airlift 403 oxygen tankers of 7,596 MT.
In April-May, IAF also conducted 98 international sorties by airlifting 95 cryogenic oxygen storage containers (1,693 MT); 1,252 empty 02 cylinders; 3 oxygen generators (1,331 MT); 360 oxygen concentrators. The Air Force is ready to replicate this effort in case of a crisis linking the production hubs to consumption points involves high cost and transportation time. To cut cost and time, Jumbo Medical facilities are being set up by Steel & PNG (Peteoleum and natural gas) sector.
Work is on to set up 11,000 beds (8,200 by Steel companies, 2,800 by PNG companies). A large number of them have already become operational in plants in Gujarat, Maharashtra, & Andhra Pradesh.
To face the challenge of an anticipated third wave, a matrix for diversion of industrial oxygen to medical oxygen, has been put in place. The use of oxygen has been restricted for medical use only (except for some exempted categories) & industrial manufacturers have been receiving fast tracked permissions to produce LMO.
Ministry of Steel has committed the entire safety stock of 11,909MT from steel plants in case of an exigency.
To facilitate faster movement of LMO, the Centre facilitated import of ISO tankers and conversion of LNG tankers from oil marketing companies like Indian Oil. Of the total 418 ISO containers ordered, IOCL is arranging 208 ISO Containers.
Of these, 50 ISO Containers are being manufactured in India. Till last week 50-odd IOCL tankers/containers and 125 imported ISO containers have been deployed by private companies.
The tragedy that unfolded across India during April and May also made Centre and the state governments realise the need for dynamic mapping of oxygen supply and requirement.
Oxygen supply plan is now in place by mapping production across all the plants in the country with demand based on current and future cases. The centre has aligned oxygen allocation to the estimated demand for each state inline with the MoHFW formula based on the hospital infrastructure, including ICU beds in each state
Compared to ventilators needed to treat seriously impacted patients, oxygen concentrators were identified as equipment that can provide immediate relief to patients with slightly aggravated symptoms.
The centre sanctioned procurement of 1 lakh oxygen concentrator units under PM Cares Fund.
India’s COVID vaccine diplomacy had generated global goodwill and 10,558 units were received by India from foreign countires. These were dispatched/delivered to all 36 states & UTs by 21 May.
The levies on concentrators has been reduced to bring down the cost to promote purchases by smaller health facilities and individuals.
The Covid-19 second surge also taught a painful lesson that India’s health care system was terribly dependent on oxygen cylinders and tankers.
During April and May 2020, a whopping 1,02,400 oxygen cylinders were procured and distributed to States to enable easier access of medical oxygen to end users. But April-May 2021 crisis underlined the inadequacy of cylinders in the country. Orders were placed for additional 1,27,000 cylinders in the third week of April and deliveries of the same will start by the end of April.
The procurement includes 54,000 jumbo cylinders (D type) as well as 73,000 regular cylinders (B type). Of these, nearly 24,000 have been distributed to States/UTs. In addition, 1.5 lakh SPO2 based oxygen control system cylinders are being procured by DRDO