In Karnataka's Covid-19 fight, hard-won gains frittered away

On the night of April 21, Praveen* developed acute respiratory problems accompanied by a rapid decline in his oxygen saturation levels.

What followed next was a harrowing 12 hours during which this 41-year-old painting contractor, lying infirm in a private ambulance, raced around the city, trying to find a bed. He was turned away by six hospitals. By dawn, his oxygen saturation levels were down to 34.

By mid-morning, around 11, he had died, having never left the ambulance.

Hameed A, a 17-year-old student volunteer who lived across the street from Praveen, said he had spent the entire night making well over 70 calls to the state’s official helplines, 108 and 1912. Hameed says both the helplines refused to help — and later stopped taking his calls.

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“One of the operators told me: ‘You didn't get Covid, so you just mind your business.’ They never directed me,” Hameed told DH. “Even today, they haven't called back to confirm his condition. They don't even know Praveen is dead.”

On the same day, visuals of Covid patients sleeping outside a government hospital in Bidar made the national news, adding to the horrifying experience that thousands of people countrywide have undergone over the past few weeks.

Experts and public health experts say that this unfolding crisis, which has overwhelmed the state's medical infrastructure, is of the government’s own making.

As the Covid cases dropped starting in January, the state government, keen on declaring victory over the virus, began to dismantle much of its medical infrastructure and protocols that it had painstakingly built over the past year. Key government officers in charge of these protocols were relieved of Covid duties and reassigned to their previous departments.

Take contact tracing. In February, the departure of the 2,000 - 3,000-strong Booth Level Officers (BLOs) teams who were instrumental in tracking down people saw contact tracing suffer.

In November, the government was tracing about five primary contacts and 5.8 secondary contacts for every positive person. However, from February onwards, less than three people were being traced for every positive case in Bengaluru, as per data. When the second surge began from mid-March, the government moved hastily to reinvigorate contact tracing. Frontline staff, such as medicos at Primary Health Centres (PHC) and swab collectors, were ordered to do contact tracing.

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However, a senior officer involved with the programme said that the PHC staff cannot conduct contact tracing as “they have their hands full with testing and vaccination.”

“Only now is the government moving to reinstate these people,” the source added.

In the middle of all this, there is a serious personnel problem as doctors and other staffers within the jurisdiction of the Bruhat Bengaluru Mahanagara Palike (BBMP) have been quitting due to non-payment of promised incentives.

A zonal official in the city said that the problem started this week after the BBMP paid the basic salaries of many MBBS doctors and other personnel — including nurses and lab technicians — who had not been paid since the start of the new year and in some cases, longer.

Sanjana* a doctor working with the BBMP, said that by February, as Covid cases reached a nadir, many of her colleagues were let go, only to be hired back two weeks later as cases ramped up and a second wave loomed large on the horizon.

Low morale

As morale among the overworked staff is low, many doctors say they are thinking of quitting altogether. “It is hectic. The permanent medical officers don't behave properly. They are intolerant. They start shouting without any reason. So people have quit," Sanjana says.

To make matters worse, a report by the Indian Medical Association (IMA) indicated that just 11 of the 55 doctors who perished during the first wave of the pandemic in Karnataka had received the Rs 50 lakh promised under the Pradhan Mantri Garib Kalyan Package.

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Started on March 30, 2020. the scheme expired on March 24, 2021 and for nearly a month until April 20 when it was reinstated, there was little indication whether the scheme would be continued.

When asked about her plans for the job, Sanjana says, “I joined because I wanted to fight Covid. And this is war time. So I will stay.”

While officials are now expressing concern that entire families are turning positive, which could be linked to improper home isolation, various sources told DH that from January, thousands of civil defence personnel, citizen volunteers and government staffers who enforced quarantining and were involved with the home isolation programme had been relieved of their duties.

Dropping the guard

With the introduction of the vaccine, the government also seemed to have dropped the ball on continuing with the existing infrastructure.

Take oxygen plants. Unlike neighbouring Kerala, which used its industrial set up to steadily ramp up its medical liquid oxygen capacity throughout last year, Karnataka did not work to ramp up its production or even install oxygen storage units at the government facilities.

With cases rising by the day, the Karnataka government is now moving to install oxygen storage plants across the state, something it should have done months ago.

As far back as November 2020, the Tecnical Advisory Committee had advised the government about a possible second wave between January and February 2021, and made recommendations on ways to mitigate this. (See Table)

These recommendations asked the government to continue conducting a minimum of 1.25 lakh tests per day, and keep all Covid medical facilities at October 2020 levels - that is 35 dedicated Covid hospitals (DCH), 174 Dedicated Covid Health Centres (DCHC) and 628 private hospitals for Covid care.

This meant reserving 22,602 beds, 11,452 central oxygenated beds and 1,902 ICU beds with ventilators purely for Covid-19 patients.

But by mid-February, daily testing rates fell by about 50% when compared to the first wave; the dedicated Covid infrastructure was slowly diverted back to tackle the increasing burden of non-Covid diseases.

“We thought that the pandemic was over because the numbers were declining. The fact that this second wave would hit us in such strength was unexpected,” said Rajendra Cholan, Special Commissioner (Health), Bruhat Bengaluru Mahanagara Palike (BBMP).

He added that the TAC’s prediction of the second wave had been less than clear and that the second surge, when it did materialise, had not occurred within the time-frame postulated by the experts.

Added a second officer who did not want to be named: “Nobody at the policy decision had made a prediction about the second wave or expected the wave to come. I also did not expect the wave, and I never thought it would be this bad.”

But the crisis of high cases should not have been entirely unexpected, said Dr Arvind Kasthuri, Professor, Department of Community Health at St John’s National Academy of Health Sciences.

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He pointed out one of the thumb rules of a pandemic is that there are several waves. “The second wave is generally worse than the first wave and the third wave is generally milder than the first wave. It is unfortunate that while lessons were learned in the first wave, we did not learn as much as we should have,” he said.

The government’s data about daily Covid infections indicates that the second wave began on March 12, when 833 cases were recorded — a 43% increase when compared to seven days before. Since then, Covid cases have increased by a staggering 2,700%, clocking numbers that have surpassed anything seen even during the peak of the pandemic last year.

This deluge of cases has swamped a downsized health infrastructure. Patients like 31-year-old Shivaji*, who was allocated a bed at a private hospital in Hebbal, Bengaluru, claimed he was kept waiting for eight hours before a bed was finally allotted to him.

Government response

The government’s response to the crisis has been one of vacillation and arm-twisting. From the beginning of the pandemic, the state government had a penchant of going back on decisions and directives that it has carried onto the second wave of the pandemic. (See Table)

On April 2, a set of orders shutting down gyms and swimming pools and capping occupancy at pubs, bars and restaurants were overturned over the next few days, before being enforced again.

Despite the Chief Minister Yediyurappa’s repeated insistence that no lockdown would be imposed, stringent curfew orders were issued on April 22, creating confusion even as police went around shutting down shops deemed non-essential.

And the government’s response: Setting up an oxygen control room but withholding key information about oxygen availability; directing private hospitals into reserving 50% of their beds for Covid patients, and ramping up the demand to upto 80% of beds are moves that have not gone down well with the private medical establishment.

The Director of the Department of Health and Family Welfare, Dr Omprakash Patil, defended the move. “In the time of the pandemic, the first priority is addressing the disease. Non-covid ailments are secondary at the moment,” he said.

“It is a knee-jerk reaction, since the numbers are growing. There is no logic behind that. It is a political rather than a scientific statement,” added Dr H M Prasanna, President of the Private Hospitals and Nursing Homes Association.

“We need to discuss how to increase the ICU - HDU beds, rather than asking for more number beds,” he says.

He also added that the government requisitioning more beds from private hospitals will affect Non-Covid patients, like in the first wave of the pandemic.

Guruprasad B R, the Chief Marketing Officer of Sparsh Hospital was more outright in his criticism. “If they are taking over 80% of the beds, they might as well take over the hospital and pay the salaries of the staff. We will not be able to run the hospitals as we have cash flow issues."

Guruprasad claims his hospital is yet to receive Rs 60 lakh in reimbursement from the previous year from the government.

Information accessed by DH from the Suvarna Aarogya Suraksha Trust (SAST) indicates that as against the Rs 408 crore being claimed by private medical establishments across Karnataka since March 2020, Rs 302 crore (89% of claims) have been settled, leaving Rs 106 crore payments pending.

Since the beginning of the pandemic, the SAST has received claims worth Rs 519 crores in all, and has paid out Rs 363 crore, leaving some Rs 156 crore payments pending.

To make matters worse, oxygen supplies to private hospitals remain dismal.

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“The situation has not improved. Last night (April 23) there were frantic calls from hospitals across Bengaluru asking for oxygen. The government has set up a room and washed off its hands. The government is not doing anything to help these hospitals," Dr Prasanna said.

“Sometimes they shout back at the hospitals. They ask 'Why do you need refills two times a day?'"

Now, the government is scrambling to get things in order and is staking its hopes in the second surge ending soon. Officers said that the outbreak might plateau after it hits about 35,000 cases per day. As of Friday, it had reached over 26,000 cases per day.

*names changed

(With inputs from Prajwal Suvarna)