Lessons from the Covid Tsunami

March 2021 marked a full year of our battle with Covid 19 in India. At Max Healthcare, this was a time for us to look back and more importantly to look ahead with confidence. Clearly, the worst of Covid appeared to be behind us. We had already fought off two successive waves of Covid 19 in the summer and in the late autumn last year, the Covid numbers were declining fast, the vaccination drives were underway and the spring was awash with hope. We believed that, while Covid will continue to bother us for a while, the chances of Covid 19 taking over our lives once more were remote.

The next 15 days turned everything on its head. We were hit by a massive Covid tsunami which inundated everything in sight. The disease was fueled by a capricious mutant virus now dubbed as the Delta virus, about which we knew very little. The hospitals suddenly had no beds, no oxygen, no medicines and no ventilators to support the relentless march of patients. They were overwhelmed, yet most of them, continued to provide great patient care and support. Their staff turned up for work, put in incredibly long hours, they added beds and managed to find supplies of oxygen and Remdesivir and ventilators. While the politicians fought amongst themselves, the leadership teams of the hospitals put their heads together and focused on the task at hand – saving as many lives as possible.

So what made this possible? Here are some thoughts and learnings.

It isn’t the beds that are important but the person besides the bed who matters – The politicians never shy of telling us how well prepared the city is against Covid 19 by citing the number of beds available for patients in city hospitals. They hardly ever bother to share how many trained and willing people are available to take care of patients on those beds. The real lesson, while handling the Covid crisis has been that the most important resource in the battle against Covid 19 are trained and resolute professionals willing to do their duty even in the face of insurmountable odds. They are the ones, who keep the flame alive. Hospitals, aspiring to fight and win against a deadly foe like Covid must have a way to keep the frontline healthcare workers and their immediate supervisors motivated and well looked after. They need to know that they are indeed the most valuable resource that the organization has and that their own needs will be taken care of and that they will be recognized and rewarded.

Those who move fast, succeed – In a crisis, agility is critical. The speed of execution is everything. Thus, the operational teams need to be suitably empowered to act fast and take decisions rather than wait for someone higher up to ‘approve’. If more beds need to be converted to Covid 19 beds, if more people need to be deployed in Covid wards, if more staff needs to be hired and put to work in the Covid areas and if they need to be paid more or supported better , the hospital operations team should have the authority to take these and more such decisions without hesitation. They should know that they have the full support of the leadership team in moving ahead fast.

Resourcefulness and Flexibility are Critical Attributes – In a crisis of this scale, we have seen the governments muddle through their policy agenda. The hospitals are often confronted with conflicting policy directives from various government bodies and they struggle to wade through the quagmire of daily changing regulations. It is thus important to build flexibility in the system and be prepared (as best as one can) for the changing government policies. One day, the hospital might be told to increase bed capacity overnight, the other day their might be an order to source medicines from a ‘nodal’ agency and another day their might be another impossible order to reserve ‘80% of ICU beds’ for Covid 19 (without giving a thought to what the hospital does with non-covid patients in the ICU). These should be assumed to be par for course and the best is to be prepared to execute as best as possible.

A Focused and Committed Leadership – The role of leadership in healthcare companies during the crisis will be evaluated by experts in the months ahead. In my experience, the leadership team contributes the best by aligning itself to the greater cause and issuing unambiguous directions for the teams to follow. It is essential that the leadership team takes and supports bold initiatives and focuses on the most critical aspects of the crisis. In the middle of April, Delhi had a major shortage of liquid medical Oxygen. The demand had sky-rocketed and it was impossible for the oxygen suppliers to produce enough medical oxygen to meet the demand. The politicians were busy squabbling amongst themselves and the courts too had jumped in the fray, with orders that were well-nigh impossible to execute. The Max Healthcare leadership team resolved that they will not allow a single oxygen related death in their hospitals. The leadership team formed a whatsapp group and relentlessly pursued their oxygen supplies. They pleaded, they yelled, they had people escorting their oxygen supplies from the manufacturer’s plants, they moved courts and pleaded with the government mandarins and they stayed awake late every night to ensure that their hospitals did not out run out of oxygen. They did not even once fail their operational and frontline teams. They remained focused and committed to managing the most intractable problem during the crisis. They led from the front.

Communication ties it all together – We often communicate what needs to be done in clear unambiguous terms. However, while this is necessary, I believe what truly motivates the teams is an explanation of why a task needs to be done. This is something that usually gets left out. In difficult times this is of far more importance because we are asking our teams to get many things done and mostly in impossible timelines. During a crisis, the hospital communication channels need to be always open and buzzing. The directions and the reasoning behind those directions should be clear and couched in a language that is easily understood. In these times, it is also important that we appreciate and communicate the good and selfless work that is happening everywhere around us. That, adds to the magic immeasurably and motivates the hospital teams to do better.

The Vaccine brings Hope and Relief

The vaccinations against Covid began in India on Jan16th . On a cold, rather blustery Saturday morning, I along with colleagues and journalists from assorted media houses waited at the doorsteps of the Max Smart Hospital for the first set of healthcare workers to emerge after completing the vaccination. There were policemen lounging under a tree, the hospital had set up a tea-stand for everyone and the atmosphere was generally one of quiet satisfaction. Something, akin to having sailed through a storm with the far shores now visible on the horizon.

Max Smart Hospital has been relentlessly battling Covid since early April 2020. The hospital has been a dedicated Covid facility for the last 9 months and has been much ravaged by Covid 19. It has over these months built a reputation of being the finest covid 19 facility in the NCR. It is battle-scarred, bruised and fatigued but unbroken in its resolve to win the battle against Covid 19. Many of its staff has been on Covid duty for months on end, many have themselves fallen prey to the scourge, yet they have continued to battle the virus. The vaccination drive starting now is a quiet vindication of their resolve, a sort of victory against an unforgiving foe. The first jabs being administered to the healthcare workers would hopefully be the beginning of the end of the virus.

The hospital has been supplied with Covishield, the Astra Zeneca vaccine, manufactured in India by the Serum Institute, a private sector enterprise, which is considered to be one of the largest contract manufacturer of vaccines in the world. They made an early bet on the Astra Zeneca vaccine developed by scientists at Oxford and now the bet is paying off. Over two billion doses will be needed to vaccinate the entire country. Apart from Serum Institute, other manufacturers and vaccine candidates are also in various phases of completing clinical trials for the efficacy and the safety of their vaccines.

The government has billed the vaccination drive as the world’s largest such endeavor and on the hospital premises there are huge boards announcing the drive. The Prime Minister, never one to miss such opportunities, kicked off the vaccination drive with an emotional speech earlier in the day. He has been exhorting citizens to take the vaccines and do not worry about their safety as these have been duly cleared by the competent regulators and leading experts.

Unfortunately, leading up to the commencement of the vaccination drive, there has been some controversy regarding the emergency use authorisation granted to Covaxin, an indigenously developed vaccine by a Hyderabad based Indian company. This vaccine is yet to report its phase 3 clinical trial data and the approval appears to be a political decision. It buttresses the government’s claims of a new resurgent, atam-nirbhar Bharat. Even in these times of the pandemic, politics seems to have trumped science. All this could have been easily avoided had the government come clean and said that the full data isn’t available, however in the light of the pandemic and as an extra-ordinary measure the experts have allowed the use of Covaxin. That should have been fine for most people.

The media folks are keen to meet the Covid warriors who are now also the first ones taking the jabs. There is curiosity about the ill-effects of the vaccine that one might temporarily experience. As soon as Ashutosh Chaturvedi, a nurse serving in the Covid ward for the past 9 months emerges after the vaccination, he is mobbed by eager journalists. All, he says is that he is delighted to have received the vaccine and that he is feeling fine. He explained to the journalist the vaccination process, which is being supervised by government officials, is working fine. He received a sms from the authorities asking him to come for the vaccination to the hospital and he complied. Ashutosh later said that he has been staying away from his family including a 9 months old toddler, whom he hasn’t seen in the last 9 months. He was now hoping to visit them soon.

The effort to develop a vaccine against Covid 19 in just over an year of the outbreak must count as one of the greatest scientific achievements of mankind in recent years. I am sure, as time goes by the vaccines will improve and become safer for everyone. We need not score political points over who developed the vaccine or who was faster or whose is better.

Let us now focus on ensuring that everyone gets a shot and we finally get rid of Covid 19.

The Covid 19 Mess in Delhi

For the last few weeks the NCR Delhi has been reeling under a sustained Covid 19 assault. The daily infections hit a high a high of close to 8000 last week and the infection rate stands a shade under 14%. The mortality rate too has jumped to a little more than 1%. These are worrying numbers, yet when I step out of my work-place heading home every evening, I have been witnessing buzzing markets. The pavement vendors are doing brisk business, the shops are full of people buying gifts for Diwali and there seems to be very little concern about catching the disease.

On the other hand, the hospitals are inundated with patients. We are running out of ICU beds in the city. The medical community coping with the disease for the last several months is by now completely exhausted. The endless stream of patients, the punishing Covid 19 duty in sealed off wards and in suffocating PPE’s with the omnipresent fear of catching the disease is taking a severe toll on our medical teams.

Yet, the citizens of Delhi are least bothered. It seems that they are almost thumbing their collective noses at the virus. There seems to be some kind of schizophrenia afflicting the residents of the NCR. 

It is impossible to handle a public health crisis unless the public itself is willing to participate in the fight. The citizens of Delhi have a duty to themselves to behave responsibly and follow basic guidelines of isolation, physical distancing, avoiding crowded places and wearing masks. Unless the citizens of the NCR are willing to behave responsibly, how fair is it to ask healthcare workers to continue to put their lives on the line to try and save the reckless citizenry?

While, one understands that most people are quite sick (pun intended) of the virus and the restrictions it has placed on ordinary life, they can hardly decide that they will do as they please and the virus be damned. That we are all rather fed up with the virus does not give us the license to be reckless. Fatigue must not breed complacency as that may lead to a catastrophe.

To make matters worse, the government appears to have given up the ghost of a fight altogether. In populist moves, it continues to open up markets, cinema theatres, gymnasiums, public transport services and restaurants and bars. The unmistakable message is that life is now as good as normal and the people of the city can return to their wayward ways. This too is highly irresponsible. The Chief Minister of Delhi is busy organizing public pujas and exhorting citizens to join him in this spectacle rather than sending out cautionary messages and advising them to be careful. The disease is all around us and spreading like wildfire, yet the ‘netas’ are not bothered.

The medical infrastructure in the city is crumbling. The government hospitals, which claim to have thousands of beds are lying empty, while the private hospitals are finding it hard to cope with the increasing burden of the disease. Unbelievably, doctors and clinical staff in municipality run hospitals have not been paid for months, because of a never-ending fracas between political parties, which control the municipality run hospitals and the government of Delhi. Instead of taking care of their patients, the doctors have been forced to take to the streets demanding due wages!!! Such is the apathy of our elected representatives towards healthcare workers, the greatest asset in the fight against Covid 19.

Since, the government can’t run its own hospitals, it is forcing private hospitals to ‘reserve’ more and more beds for Covid 19 patients. The latest diktat is that private hospitals must keep 80% of their ICU beds reserved for Covid 19 patients. This essentially crowds out everybody else. What happens to patients needing urgent or emergent surgeries is anybody’s guess. Also, keeping in mind the highly contagious nature of Covid 19, many hospitals will find it impossible to comply with this quixotic order. In an ICU, which is usually a ward with multiple beds, how does one secure 80% of beds, while keeping 20% for non-Covid patients? My colleague Dr Mradul Kaushik suggested in a tweet a couple of days ago that it might be a better idea if the government was to ask private healthcare providers to temporarily run their Covid hospitals. That would of course be so politically incorrect that no government would even think of it. 

In Delhi we have been hit not only by Covid 19. We are facing greater challenges involving apathetic citizens and completely uncaring local governments more interested in settling political scores than working together to make things better. 

We all can surely do better than this.

The views expressed are personal

Lessons From a Brush With Covid -19

In early August, my mother who would be 80 later this month called up to inform that she was having a high grade fever, cough and a sore throat. She had been confined to our home in Lucknow for the past 5 months and had only briefly stepped out a few days earlier. Getting a Covid 19 test done in the state of UP was tricky – there were bizarre laws where the government machinery would swing into action and literally cart away the patient to an unknown quarantine centre somewhere in the city. The hapless patient and her family would have little idea about the patient’s whereabouts or even her health. Under the circumstances I thought it best to arrange a private ambulance and get her to a hospital in Delhi.

My mother was admitted at Max Hospital, Saket, New Delhi the next day. The hospital ran the rapid antigen test and the more reliable RT-PCR test, the gold-standard for Covid 19 as soon as she reached the hospital. They also ran a battery of other tests and considering her weakened state, agreed to admit her to the hospital. The rapid antigen test came negative and a few hours later we were much relieved to learn that the RT PCR too test was negative. It seems our fears were ill-founded and whatever the infection, this didn’t look like Covid 19.

Dr Sandeep Budhiraja, who is Group Medical Director of Max Healthcare though wasn’t convinced. He asked for a chest CT as well as he suspected incipient pneumonia. The chest CT showed ground glass lesions typical of Covid 19 pneumonia. Dr Budhiraja had decided to trust the CT report, diagnosed the infection as Covid 19 only and put my mother on aggressive Covid 19 treatment protocols. He discussed the reasons with me, essentially saying that the RT -PCR test wasn’t 100% reliable, the chest lesions were typical of Covid 19 and any delay in starting the treatment, may lead to life-threatening progression of the disease. Some in my family raised doubts and felt that we were over-treating and there was not enough justification to start Covid protocols. Dr Budhiraja was however quite certain of his diagnosis and decided to continue with Covid 19 treatment protocols, even when her subsequent RT-PCR tests too came negative.

My mother had an uneventful stay in the hospital and she was discharged in one week. We were grateful for her recovery, however, we still did not know whether she had Covid or not. The question in any case had little relevance now. After her discharge from the hospital, she had lingering fatigue, was often drowsy and would become breathless on little physical exertion. Over the next 4 weeks she regained her strength and gradually made a complete recovery.

6 weeks after her discharge from the hospital, I asked permission from Dr Budhiraja to take her back to Lucknow. He readily agreed and said that we should get a Covid antibody test done before she departs. When, I shared the antibody report with Dr Budhiraja, he gave me an all knowing smile and allowed her to travel. She had developed strong Covid antibodies, confirming what Dr Budhiraja had suspected all along and treated with such confidence. I remain very grateful to him for his expertise and skills that were put to such wonderful use while treating my mother.

Lessons

It is futile to question your doctor’s judgement. Yes, have an intelligent discussion, but there is no point in second guessing or questioning his competence. Trust him to do his job to the best of his abilities. At times, he may go wrong, like any of us. Allow him to course correct. Medicine isn’t an exact science and 2+2 is rarely 4.

Experience, an eye for the unusual and something, which can at best be called judgement or maybe a gut-feel are tools that your doctor possesses. In-spite of all its knowledge, Google still lacks the wisdom, which comes only from seeing and treating thousands of patients every month.

Your doctor knows better. And, if you do not believe in this, find a doctor whom you believe knows better.

Views expressed are personal

The Healthcare Worker’s Safety to the Fore

The Covid pandemic has been ravaging India for the last 6 months. At Max Healthcare, we had started work on tackling the disease in end February and by mid-March we had the plans and the treatment protocols ready. These were of course based on the data and the knowledge that was trickling in from other parts of the world where the disease was already playing havoc with the lives of patients and an ill-prepared army of healthcare workers. As the stringent lock-down imposed by the Government of India from the last week of March till almost the end of May delayed the deluge of patients in the hospitals in India, we got time to fine-tune our response to the disease and also secure supplies for the protection of the healthcare workers on the forefront of the fight.

It is hard to imagine anything good, which has emerged from the global scourge. Yet, there is one heartening thing that comes to mind. The disease has put a sharp lens on the issue of the safety of healthcare workers. This is indeed a welcome development. In the past, the hospitals were mostly focused on patient safety. I recall being part of long and somewhat dreary meetings discussing patient safety data in almost all the hospitals that I have worked in. These would include large presentation decks slicing and dicing data around patient safety parameters and alarms will be raised even if there were minute transgressions from established norms. This focus on patient safety was always reassuring. It was good to know that the hospitals were serious about patient safety issues and alert to any possible errors leading to compromised patient outcomes.

Strangely, I do not recall even a modicum of such rigor when it came to the safety of healthcare workers. Apart, from an odd slide about the omnipresent needle stick injuries (NSI) and perhaps a mishap or two, there were hardly any deliberation on the safety of the healthcare workers. It was mostly understood that these folks will take sufficient precautions on their own and look after themselves.

Healthcare workers have been exposed to unprecedented personal risk during Covid 19 pandemic. As they look after sick Covid patients they run a great risk to their own health and also to their families. This is even worse than soldiers on our borders, who are constantly at physical risk but mercifully, their families remain safe. While well aware of the situation, healthcare workers have steadfastly continued in their solemn duty of looking after the sick even if they and their loved ones came in harm’s way. The hospitals have also realized the grave danger faced by these intrepid warriors literally every day from an unknown, unseen and unforgiving foe. While, in the initial days of the pandemic one witnessed utter chaos in the hospitals in the country with personal protection equipment being in short supply and hospitals scrambling to shore up supplies from vendors across the world, things settled down in a few weeks. Hospitals have since than mostly ensured that their front-line workers are well protected.

At Max Hospitals itself, we have seen over 750 healthcare workers catching the disease and falling sick. All these patients were provided healthcare support by the hospital and those needing admission were treated at the hospital. The insurance cover provided by the organization to all its healthcare workers took care of the in-patient expenses, all outpatient expenses were borne by the hospital. The healthcare workers were also provided quarantine facilities in and around the hospitals and all their expenses during the quarantine period were met by the hospital. I am sure other leading healthcare providers in the country would not have done anything different. This is as it should be.

Covid 19 has led many hospitals in India to review and revise their policies regarding their healthcare workers. There is a far better realization of the value of each individual, be it a nurse or a support staff team member or a clinician. There is greater appreciation and concern for their safety and well-being. I will not be wrong in stating that today the safety of healthcare workers at their work places is considered as important as patient’s safety in the hospital.

This change is a fundamental change and not driven by the exigencies of the pandemic alone. While, the extremely contagious nature of the disease and the high risk it posed to all healthcare workers triggered the shift in thinking, it has taken deep roots in a relatively short albeit taxing period of time.

One hopes that this will last well after the Covid crisis is done and dusted.

The views expressed are personal

The Need for Destination Cancer Centres

In-spite of all the progress that has been made in the treatment of cancer over the last two decades, cancer remains a fearsome foe. A diagnosis of cancer is a moment a patient or a caregiver is never likely to forget. The overwhelming emotion is usually of disbelief often accompanied by anger and an immeasurable sadness. It hits patients and their families hard. However, most patients now understand that this need not be a death sentence and they do have options of combating the disease. They may still go down, but they do know that they have the choice of giving the disease a real good fight.

The diagnosis of cancer leads to a quick search for cancer hospitals, oncologists and opinions are sought from close friends and relatives about choosing the right cancer hospital. This is a critical choice. Cancer treatment today requires a combination of great skill from individual oncologists, team-work amongst the onco-clinicians and high end technology support. All these elements need to work together to achieve a successful outcome. While, this may appear simple enough to achieve, in reality this is a herculean task and requires investments in well trained doctors, processes and IT solutions, which allow them to work together seamlessly. It also involves tremendous investments in some of the most advanced medical equipment to be installed and managed at the hospitals.

Thus, to provide world class cancer care, what is needed are dedicated cancer centres, which bring together all the elements of cancer care (people, processes and technology) along with little valued but a critical ingredient – focus. While, large multi-speciality hospitals do have reasonably good cancer services, I believe, they lack the focus and the attention to detail that a dedicated cancer service would bring.

The other important advantage of a dedicated cancer centre is that it creates a great eco-system for comprehensive cancer services. It brings together clinicians and care-givers who have dedicated their lives to cancer care. Most of them dive deep and develop unique expertise in their specialized fields of cancer work. They speak the same language, the bring a great passion to the fight against cancer, they foster the same spirit of innovation and a can-do attitude towards combating the disease. Essentially, everyone who works in a dedicated cancer facility has a common mission – to beat the disease. These are incredibly committed people, united by a mission to beat an implacable enemy. They tend to work together as a team. With such a team fighting for the cancer patients, the chances of success improve significantly.

Dedicated cancer facilities also tend to spawn research institutions and bring together the brightest cancer researchers to collaborate with clinicians at the fore-front of the battle against cancer. Many of these clinicians pursue academic work adding rigour to the clinical work that they do. These are folks who are willing to fight with their patients every inch of the way.

From a patient’s point of view a dedicated cancer facility is just about ideal. The knowledge and expertise is deep, the technology is state of the art and the processes designed with a single objective – to conquer cancer. The care-givers are committed and are willing to walk with the patient every step.

Yet, we hardly have any dedicated cancer facilities in India. This is particularly jarring when one considers the enormous and ever-growing burden of the disease in the country. We also do not lack in clinical expertise at least in the large metros. We have very good clinicians, trained in the finest institutions abroad, completely committed to the cause of fighting cancer.

The reason we do not have dedicated cancer centers is perhaps the very high upfront investment needed for a dedicated cancer facility and a long gestation period. Business-wise this is perhaps a very long haul and hard to sustain.

I believe the time is ripe for dedicated cancer facilities to come up in large metros in India. With their unique advantages, these hospitals should be able to attract patients from far and wide. They will become destination centres for patients seeking world-class cancer treatment. With increasingly discerning patients, carefully choosing their partners in the battle against cancer, the stand-alone cancer hospitals would break-even a lot sooner than thought possible so far.The opportunities for growth are limitless.

So are the opportunities to do good and to create an unbeatable legacy.

Covid Price Caps- The Contrarian View

Late last month, the government of Delhi announced price caps for the treatment of Covid 19 patients in private hospitals. This came around the time, when the disease was rapidly peaking in the city and there was panic all around. The media went to town highlighting the horror stories being played out in public sector hospitals and running stories about rampant profiteering in the private sector. The ordinary patient seemed to be caught in the middle, poor medical services on one hand and unaffordable ones on the other.

The government intervention cited two pressing reasons for imposing the price caps. One, it wanted to make good quality healthcare available to patients at ”affordable” prices and two, it was aiming to come down on alleged ”profiteering” rampant in the private sector.

These are indeed laudable objectives but the medicine prescribed unfortunately does not work and also has wholly undesirable side-effects.

Let us first address the issue of ”profiteering”. The government has been accusing the private sector of profiteering without any evidence whatsoever. Yes, the impression of profiteering comes from high prices being charged by private sector hospitals for Covid treatment. The high prices, however does not necessarily imply,”profiteering”. High prices are a direct consequence of high costs involved in the treatment of Covid 19 patients. The costs emanate from a slew of factors related to the complete unpredictability of the disease and its highly contagious nature. Doctors treating Covid 19 patients agree on one point – that the disease behaves differently in different people and it is impossible to predict its course. Thus, the treatment options cannot be standardized and different patients need varying treatment over a long period of time. Many do not need any treatment at all and many, particularly those with co-morbidities and the elderly need long stay in the hospital, often in intensive care.

Moreover, because of the highly contagious nature of the disease the safety of healthcare workers assumes paramount importance. They are indeed our most precious resource in this battle and if they become sick, we have no way of fighting the scourge. Realizing this private sector hospitals made elaborate arrangements to protect their healthcare workers. The healthcare workers were provided with expensive personal protective equipment; they were housed in hotels near the hospitals, kept in quarantine after their duty periods and treated free if they acquired the infection. All these are additional and significant costs. The private hospitals had no choice but to pass these on to the patients, leading to higher bills reinforcing the impression that hospitals were minting money and profiteering from the crisis.

Now, with the price caps on, private hospitals have no option but to cut back on some of these, making their staff work longer hours at greater risks and resort to salary cuts. This will demotivate healthcare workers and affect patient care and employee productivity. The hospitals will also look at standardizing and straitjacketing clinical care, for a disease, which we know is completely unpredictable. This too will lead to compromised outcomes. These are inevitable steps to make ends meet. Many private hospitals will be forced to either curtail services or simply shutdown. This at a time, when every hospital bed is a precious.

To make matters infinitely worse the price-caps on the private sector have been imposed when thousands of beds in the public hospitals are lying vacant. These beds are free, yet have no takers. While, the price caps have made the service ”affordable”, there is a very high cost attached to this.The government instead of improving medical services at its own hospitals will end up with effectively diluting the high quality of care offered by the private sector hospitals. This would be an inevitable and somewhat unintended consequence of arbitrary price-caps in the private sector.

The reason for this madness is not far to seek. The politicians running the city want to look good to their electorate. One sure way of doing this is to threaten ”big bad private enterprise” into submission. The electorate loves to see the governments of the day championing the underdogs, the poor and the disadvantaged who unfortunately can not afford private healthcare. Thus, bringing in price-caps to tame private healthcare helps them get more votes when the elections come around. The electorate will not remember the sorry state of public hospitals but will certainly remember the ”stern” action of the government of the day.

This is rather unfortunate. Instead of price-caps on private enterprises, what we do need is much higher levels of investments in public healthcare. We need better paid and better trained staff with far more empathy at our public hospitals. This will inspire greater confidence in these hospitals, encourage citizens to choose them over the ”profiteering” private sector hospitals.

We must remember that the responsibility of providing affordable healthcare to the citizens who can not afford private healthcare rests squarely with the government. This is true during a pandemic as much as in any other time. That the governments have chronically under-invested in public healthcare and failed to provide adequate and affordable care, does not mean that private healthcare providers should now be forced to provide these services at prices that do not even cover their costs.

There is no doubt that in times like these, profiteering in any manner must be viewed harshly. The government must ensure that they come down heavily on those who aim to maximize profits through other people’s misery. At the same time, they also have a duty to ensure that they don’t drive private healthcare, the only ones delivering world class Covid care, to an early grave.

The views expressed are personal

Surgeries in Covid Times

With India recording over 14000 fresh cases of Covid 19 yesterday, it is little wonder that we are completely immersed in Covid 19. The social media is agog with covid figures, positivity rates, fatality rates, the increased risks to people with co-morbid conditions and the elderly. The government policy making on Covid can best be described as bizarre, with new and often contradictory guidelines emanating from different mandarins. Essentially, we are drowning in Covid.

Yet, it is important we shift our attention to more mundane but equally pressing matters such as the care we need to provide to other patients who have serious medical conditions and cannot wait for Covid 19 to go away. These patients have been postponing their surgeries and treatment in the hope of going to a hospital, which is Corona free. Unfortunately, with the pandemic still running its course, hospitals are seeing only more and more covid patients. No one knows, when the situation will return to normal. Thus, waiting for covid 19 to subside does not seem to be a good idea anymore.

Patients requiring heart interventions, cancer treatments, tumour surgeries and even transplants should plan their surgeries because for them getting timely medical attention may be far more important than waiting for corona virus to go away. While, the fears of these patients are understandable, they must realize that a far greater danger lies in not seeking appropriate medical care when needed.

With the battle with Corona virus now over three months old, many hospitals have learnt their lessons and have built expertise in tackling Covid 19. They have created stand-alone facilities, developed isolation areas completely segregated from the covid areas and put in place stringent infection control measures to ensure not only the safety of the patients but also of their clinical and other staff. In the initial days of Covid 19, the hospitals were still figuring out ways of managing Covid patients, while ensuring safety of everyone else. Many healthcare workers (HCWs) caught the disease, were quarantined and even hospitalized and the media went to town highlighting such cases and painting hospitals as truly dangerous places. A lot of that was the usual media exaggeration and hype. Now, three months in the covid battle, the HCW infections have significantly come down, patient infections are almost nil and the media has gone quiet.

While, it cannot be disputed that patients in times of a pandemic will always face higher chances of infection, they must evaluate this risk against the risk of postponing a treatment, which can potentially be more harmful. This is clearly not an easy decision, as patients will hardly have sufficient knowledge to evaluate their options and make the right choice. Even if they had, the ability to grasp the nuances of the risk involved, many a times their doctors and the hospitals do not share the full details.

This should not be the case.

It is the responsibility of the clinicians to advise their patients about the urgency of a procedure required and the risks associated with a covid infection or the chances of an adverse outcome in the covid times. This is most crucial as the patient and her caregivers must have a clear understanding of the pros and cons of what they might be getting into. The clinicians must explain in sufficient details all the aspects of either catching a Corona infection or (as the case may be) of a greater probability of an unexpected outcome. They must share data supporting their views and enable the patients and their caregivers to make an informed and intelligent choice. Pushing the patient into a hurried surgery or delaying an urgent medical procedure are both equally dangerous. The patient deserves an honest opinion more than anything else.

The hospitals on their part must ensure that they help the doctors walk the talk. The clinicians can advise a patient only if they themselves are confident that the hospitals will be able to support them. The hospitals must demonstrate to their surgical teams that they are really equipped to handle these procedures with minimal risk to either the patient or the hospital teams including the surgeons. Their is no room for any slippages here and empty talk can prove hugely detrimental to the patients as well as the surgical team. They must realize that a surgeon operating a patient in covid times is doing so only because his patient needs the surgery and does not have the choice to wait out the pandemic. Unlike, other times, the medical team too is risking a potentially serious infection while operating the case. They know they have to be doubly careful for the patient’s sake as well as their own.

These decisions are not easy, either for the patients or for their doctors. They must be taken with great care after evaluating various options and understanding the risks to everyone. The medical teams and the patients are in this together, far more than in normal times.

The views expressed are personal

The Invisible Healthcare Costs Behind Covid 19

The Supreme Court of India, yesterday, asked the government that why should private hospitals not be asked to provide free services to patients suffering from covid 19. In an earlier bizarre judgement (which the court had on reconsideration modified) had ordered free testing for covid 19 at private labs. The court must realise that there is nothing called a free service in the world. The service is free to the user only because someone else is picking up the tab. When government delivers public goods free of cost, essentially it is the government and the taxpayers who pay for the service. In the case of private healthcare providers it would mean the investors in the enterprise who pay for it.

The investors in a private enterprise expect a reasonable return on their investments over a period of time. They also do not have unlimited resources to fund the battle against a pandemic. A global scourge of this proportion has to be primarily fought by the government with help from all other stakeholders. The epidemic has exposed the pitiable state of our public health. Sadly, the public sector healthcare spending in the country stands at a measly 0.9% of the GDP and has been sliding over the years. However, this is not the time to quibble over these numbers.

If the courts impose these kind of arbitrary decisions on the private healthcare providers, we will see hospitals closing down for want of resources to keep the enterprise running. That is hardly a solution, in a crisis, where every available bed counts.

This leads us to addressing the charge of excessive greed and profiteering by private sector players in these extraordinary times, to which the courts are ostensibly responding. It cannot be gainsaid that private healthcare must not charge excessively and profiteer from the misery surrounding us. Most responsible private sector healthcare companies understand this quite well. Yet, the media outlets in the country have gone to town highlighting two contradictory strands. One, private healthcare companies are aiming for excessive profits and two; they have not been adequately supporting the efforts of the public sector hospitals in fighting Covid 19. Now assuming that Covid 19 is an unprecedented opportunity to make huge profits, why the allegedly profiteering private healthcare shying away from stepping up and joining the fight against Covid 19? The fact is that both these allegations are false. Covid 19 is a tough disease to fight. We have seen how it has brought far more advanced healthcare systems to their knees in far more developed markets. The private sector healthcare in India is mostly unorganised ”mom and pop” small hospitals and nursing homes, who have very limited capability to fight the epidemic. Even the more organised corporate healthcare players have struggled to put together a cohesive response to the disease. While, many have become organised and learnt on the go, they have made sizable investments and have seen their running costs go up significantly. This causes price escalation, which leads to false allegations of profiteering.

Let us deconstruct some of these costs. The ones, which are visible, are of course, the Personal Protective Equipment (PPEs), worn by healthcare workers, while working in the isolation wards. Simple arithmetic shows that in a typical 10 bed ICU, the consumption of the PPE’s is at least 8 units per day per patient. Priced at INR 1000 per suit, this adds Rs. 8000 per person per day of stay in the ICU. Not understanding this, we have seen media houses going to town with wild theories of profiteering, accusing private hospitals of selling a Rs 800-Rs 1000 PPE unit for Rs 8000. This is sheer ignorance or worse.

Let us now examine some invisible costs that are peculiar to managing Covid 19 patients. The healthcare workers looking after Covid 19 patients need to stay either on the premises of the hospital or in a quarantine facility (a hotel or a guesthouse) near the hospital. This is to prevent the high risk group of HCWs returning to their own families and communities and putting those at risk. The hospital bears their stay, food, travel and other day to day expenses. These expense easily go up to INR 3500 per person per day.The HCWs after finishing their 14 day duties have to be rested for another 14 days in a secured isolation facility. This too entails a similar cost.

Since the healthcare workers work only 14 days in a month against the usual 25 days, the productivity nearly halves. Additionally, the HCWs serving in covid wards do a 6-hours duty instead of the usual 8-hours as it is impossible and inhuman to have them working longer hours wearing the suffocating PPEs. Thus, a higher number of HCWs are required to manage a Covid 19 ward leading to higher manpower costs.

There is another element of cost often missed out, while looking at the Covid 19 costs. This is of the treatment and care of HCWs who catch the infection, while treating patients. These HCWs are provided free medical care by the hospital and are also supported by way of paid leaves during the period of their illness and quarantine post recovery. This is quite a significant cost as well and often remains invisible.

These are just the operational costs. Hospitals handling Covid 19 patients also need to reconfigure a large part of the hospital into isolation areas, which are completely segregated from the rest of the hospital. They need to source more ventilators and supportive equipment to handle large volumes of patients. Renting or buying these add to the cost.

The need of the hour is for the concerned governments to enrol private sector healthcare providers as partners in the effort against Covid 19. They need to understand and keep in mind their operational as well as financial concerns as they formulate policy. The private sector is not asking for profit and many are even willing to work at no profit no loss basis. They are not an adversary in the fight against Covid 19 but valuable allies. However, they themselves need to survive the Covid 19 onslaught to be effective in the battle against the pandemic.

Views expressed are personal

Healthcare Warriors and All That

A couple of days ago NDTV aired a film shot at the Nanavati Hospital, Mumbai (disclosure – Nanavati Hospital is part of Radiant Lifecare, which is merging with Max Healthcare, my employers) where its ace anchor Srinivasan Jain and reporter Maryam Alvi spent some time in the Covid ward ICU of the hospital. The team donned the full PPE’s and interacted with doctors and other medical staff on duty, saw first hand what it means to be a covid 19 warrior on the frontlines of the battle. They experienced for themselves the stifling and claustrophobic environment in which clinicians and healthcare workers operate. They learnt that once in their PPE’s they can’t have a glass of water or use the washroom for the entire duration of their 6 hours shift. A doctor mentioned that he worries about his elderly parents at home whom he has not seen in two months.

This is a reality well-known to people who are working in hospitals. They look in awe at the sacrifices being made by all the healthcare workers looking after covid 19 patients. The government has made attempts to recognise their efforts. Prime Minister, Narendra Modi had on two occasions asked the citizens to support and motivate the healthcare workers (HCW’s) by stepping out on their balconies, banging pots and pans and by lighting lamps. A dutiful nation, spellbound by the Prime Minister’s theatrical gifts generously obliged. The lamp lighting was followed by fireworks!!!

The Armed Forces did their bit by sending the air force jets on a flypast and we had army choppers showering petals on hospitals with excited healthcare workers waving from the hospital terraces.

Sadly, all this has been symbolic. The reality is very different. Consider these facts.

The Resident Welfare’s Association of the tony GK1 Enclave in South Delhi stopped HCW’s going off duty to check-in into a OYO guest house rented by Max Healthcare in Delhi. These healthcare workers had completed their 14 days Covid duty and were to rest for the next 14 days before they resumed their duties. The healthcare workers were sent back to the hospital as the vigilante association demanded certificates that the HCW’s were covid 19 negative. The hotel too was warned of stringent action if it allowed HCW’s to stay on its premises. All these HCW’s were asymptomatic, had no unprotected exposure to any patient and were well with in their legal rights to stay at the hotel. To make matters even worse, Wg Cdr. Virender Sharma, the Secretary of the RWA proudly and shamelessly sent out a whatsapp message narrating the incident titled ”Successful Disaster Management in GK Enclave -1”. The ex-air force officer, didn’t see the irony of the air-force showering petals on the same HCW’s, who were persona non-grata at a hotel in the locality.

This is not an isolated incident. At Max Healthcare, we have recorded incidents where residents of Vaishali, Ghaziabad have objected to nurses staying in a hostel in their locality and the RWA in Rohini in North West Delhi have threatened to disallow nurses to stay in another hostel. The other day, newspapers carried stories of a doctor returning home in the South Delhi locality of Vasant Kunj after recovering from Covid 19 was beaten up by her neighbour. I am sure other hospitals treating covid 19 patients have faced similar situations where their healthcare workers have faced unwarranted stigma, ostracism and assault.

In the light of all this, we must ask ourselves, what kind of a society and nation have we become? We take great pride in symbolic gestures but when it comes to showing some spine, we buckle. We show great respect and pride in the work being done by the HCW’s but when it comes to taking care of them even at a minimal risk to ourselves, we blanche. We are happy admiring hard working dedicated professionals but from a safe distance. We are happy abandoning those whom we would likely depend upon when the need arises. What would happen if the same healthcare workers choose not to treat patients from let us say GK 1 Enclave? Will that be justified? Of course, this would never happen, professional HCWs will never turn away patients because they have been mistreated by the very people who might now be knocking at their doors.

Speaking for all the HCWs, I can confidently say that they are not seeking great honour or appreciation from anyone. They are not hungry for idle adulation from fellow citizens. They are not asking to be hoisted on eager shoulders or be paraded amongst fawning crowds. Most of them are doing their duty and fulfilling the oath they took many years ago when they chose medicine as their profession. They are making personal sacrifices not because it is glorious to do so but because of their total commitment to their calling. They are taking great risks because that goes with the terrain and not because they don’t have families to go back to.

And, all they expect in return is some kindness to them and their families, some respect and courtesy in the ordinary course of life and a little support in these difficult times.

We must ask ourselves, is that too difficult for us to offer?

The views expressed are personal