On May 6, Gujarat sent a request to the Centre to send in experts from Delhi and Mumbai to help it tackle coronavirus. Correspondingly, it put two of its largest cities, Ahmedabad and Surat, under total curfew, stopping everything except the supply of milk and medicines — the culmination of two months of a progressively worsening Covid-19 situation in the state.
Nearly two months after its first case on March 19, Gujarat has the most number of cases and deaths after Maharashtra, the second highest case fatality ratio in the country after West Bengal and, worryingly, a large proportion of the young among those dying. This is despite the fact that just 1% of the deaths in the state — which has a large diaspora — have been traced to infections from abroad.
Under pressure from the Centre, which named Gujarat and West Bengal as states of concern in a May 6 statement, the authorities have flapped about for answers: from patients reporting to hospitals late, to a different strain, to the Tablighi Jamaat (though only 14 of the 130 who returned to Gujarat from the Delhi gathering of the organisation, that developed into a cluster, tested positive, with one death).
None of the reasons has stuck so far. Meanwhile, even as the Union Home Ministry attacks West Bengal for lack of transparency on coronavirus, starting May 5 (when it reported the highest single-day deaths, 49), the BJP-ruled Gujarat has stopped giving out age and co-morbidity details of its dead. Ahmedabad now also has a new team of officials in place — headed by Additional Chief Secretary Rajiv Gupta who helmed the Statue of Unity project — to handle the capital city’s coronavirus strategy.
Gujarat, that began screening at airports in February, got its first Covid-19 case on March 19. By then, nearly half the states had already reported cases and the countrywide tally had crossed 100.
The first case was a 32-year-old Rajkot resident, who had returned from Umrah in Saudi Arabia. While he recovered quickly, Ahmedabad’s first patient, a 21-year-old who had returned from New York on March 14 and had only mild symptoms, took 32 days to get back home. The doctors said the longer recovery for the younger woman may have been due to the fact that she has asthma.
After the first two cases, the curve started climbing. While it took 17 days for the cases to cross 100 in the state, 90 new cases were reported on April 9 alone — 57 from Ahmedabad. The first death, that of a 62-year-old Surat businessman, happened within three days of the first case being reported.
Officials admit that while Gujarat had its guard up fast enough, testing was delayed. For a long time, a large number of samples were going to the National Institute of Virology (NIV), Pune, and Kasturba Hospital in Mumbai. The daily average even by mid-March was as little as 15 tests, going up to 200-odd by the end of the month. By April-end, when Delhi was testing 1,492 per million and Tamil Nadu 930 per million, Gujarat was testing 721 per million.
In a media interaction at the time, Chief Minister Vijay Rupani said, “Certain states that have lower number (of cases) got clearance for laboratory tests earlier. Had we got clearance earlier, we might have been able to bring the situation under control.”
The state now has 24 laboratories conducting tests. With pool testing, the state is testing more than 5,500 samples a day.
But, Ahmedabad, comprising over 70% of Gujarat’s cases and deaths (4,991 of 7,013 cases; 321 of 425 deaths), is only doing 21% of its daily tests. In fact, testing actually fell in Ahmedabad Municipal Corporation (AMC) areas after April 23, when over 2,400 samples were tested in a 24-hour cycle — to about 1,300 as of May 1 and 1,072 by May 5.
A senior AMC official claims two primary reasons. “When we tested more than 2,400, we had the luxury of accommodating a number of positive patients in our hospitals. With each day, the capacity shrinks and thus we have to conduct tests in a staggered manner, while building more capacity.” The second reason, as per the official, is that the rise in cases also means reduced capacity for new samples. “For a patient to be discharged, we have to conduct at least three tests, as a result of which our on-field capacity reduces.”
That argument is difficult to digest given the state’s growing case fatality rate. At 59 per 1,000 confirmed cases, it is much higher than the national average (33 per 1,000) or even Maharashtra (38 per 1,000).
In contrast, Maharashtra (the state with the highest coronavirus tally) boosted its testing as cases and deaths rose.
THE DEATH PROFILE
April 23 saw the death of a 16-year-old from Dani Limda area, a hotspot in Ahmedabad. While the Covid-19 bulletin showed no co-morbidities in her case, Dr Jaiprakash V Modi, superintendent in charge of the Ahmedabad Civil Hospital where she died, told this paper that the teenager had autoimmune disease Lupus.
Coronavirus numbers explained | Maharashtra and Gujarat account for 60% of all Covid-19 deaths in India
The following day, among the casualties was a 17-year-old from Behrampura, another hotspot in Ahmedabad. Again, the official note listed her as a Covid-19 death (with no co-morbidity). Her mother, who is quarantined with her two other children, told this paper she had no other conditions apart from a mental disability. “On April 22, she could not sleep the whole night. She couldn’t communicate and I failed to understand what was happening. The next day she had high fever. Within hours, she had difficulty breathing,” says the mother, who took her to the AMC-run Sardar Vallabhbhai Patel (SVP) Hospital.
She says the doctors told her that her daughter was taking medicines for epilepsy. “But no doctor told us anything more. I never saw her have any epileptic fit,” says the mother, who couldn’t be present at the 17-year-old’s funeral. Deputy Municipal Commissioner Om Prakash Machra, who is overseeing operations at SVP, told The Sunday Express, “She had pre-existing conditions and had been on medication since birth.”
However, since then, the explanations have been harder coming. By April 30, 40 (nearly 18%) of 214 deaths in the state did not have any major underlying health condition. By May 6, this number stood at 109 (27% of 396 dead). Also, by then, 31 of the 319 dead (nearly 10%) were below 41 years.
Dr Atul Patel, an infectious diseases specialist who has been working with the state government on coronavirus, said last week, “Gujarat has a lot of patients even otherwise of blood pressure (hypertensive) as well as diabetes. With coronavirus, these conditions further deteriorate. A lot of patients come to the hospital after much delay, with barely any functionality of their lungs left, and we see them dying within six hours or so.”
THE LATE REPORTING
Among the dead is Behrampura corporator Badruddin Shaikh, 67, who succumbed on the 12th day of testing positive. His colleague, Jamalpur-Khadia Congress MLA Imran Khedawala, 53, was discharged on April 27, a day after Badruddin died.
The two are believed to have caught coronavirus while moving among Ahmedabad’s minority-dominated areas of Behrampura, Jamalpur and Dariapur, trying to convince people to come forward if they had symptoms. Of the AMC’s 4,649 cases until May 7, 1,587 or 34% had been reported from the Walled City areas, including Jamalpur, Shahpur, Dariapur and Khadia. The four wards comprise four of the 10 red zones.
Khedawala believes the in-built mistrust of government medical facilities among the minority-dominated areas is a reason for the late testing. Most of these areas are ghettos, where Muslims have been settling through successive communal riots, including 2002. An AMC official admits to lax presence here, both when it comes to sanitation and health.
The Tablighi connection, reiterated by CM Rupani, Deputy CM Nitin Patel and practically every senior BJP leader, has only reinforced the distrust.
“I have been trying to tell the community to immediately see a doctor even at the slightest of symptoms. People pop medicines instead when they get fever or cough. They believe that if they go to a hospital, there is no coming back,” he says, adding that his case recovery should be a positive example.
Indore, which once had the highest fatality ratio among hotspots, managed to similarly turn the corner with positive reinforcements among its minority areas, from where many cases were reported (its fatality ratio is down from 15% to under 5%). In Ujjain in Madhya Pradesh, the authorities changed the protocol to home quarantine for those asymptomatic, to establish trust. In Maharashtra, an outreach has been started in Urdu.
Deputy Municipal Commissioner Machra gives the example of a 35-year-old man from Jamalpur who died on April 29. “While there was no co-morbidity, the patient got himself tested six days after the onset of symptoms,” Machra says, adding he was serious by the time he was admitted. However, he reiterates that most deaths are of patients with underlying conditions, some of whom may have been unaware of the same till admission.
Another patient, a 66-year-old retired bank employee living in the Shah-e-Alam area, did not report to a doctor till three days after he developed fever followed by cough and chest pain. Though he also had hypertension and diabetes, his 39-year-old son did not report the coronavirus-like symptoms when he took him to a local doctor. He died five minutes after he was taken to hospital on April 29.
The son says his father eagerly followed Covid-19 news and hence was well aware of the symptoms, but “did not go to a doctor fearing the family would get into trouble”.
Says Khedawala: “I got tested to create a sense of trust towards authorities… (But) the kind of atmosphere being created will not help. This might lead to a grave situation.”
Former BJP MLA Bhushan Bhatt, for example, has a clear logic about why Khadia, a Hindu pocket in the containment zone in Ahmedabad Walled City, has 440-odd cases (as on May 7). “The biggest mistake we made was to not restrict movement from and to Khadia,” he says.
Machra says people from lower-income groups also do not come in for testing, fearing loss of income if quarantined. It is difficult to convince them, especially if they remain asymptomatic, the AMC official adds.
Some patients from Khokra area in Ahmedabad, admitted at the Ahmedabad Civil Hospital, say as much. Natwarbhai Dabhi, 45, told The Sunday Express, “We are vegetable sellers, we were just randomly picked up. Why this injustice? They told 24 of us are positive, but we don’t even have fever.”
Even as the vendors blame buyers, “who have cars so they never test positive”, the AMC has termed the vendors “super spreaders”. Nearly 14,000 of them are to be tested and accordingly given “health cards”.
AIIMS Director Dr Randeep Guleria, among the experts called by the state from the Centre, toured hospitals in Ahmedabad on Saturday. He too attributed the reasons for the state’s high mortality to the stigma attached to the disease. “There is still fear,” said Dr Guleria, adding how a person can be mildly symptomatic but still have critically low oxygen levels in the blood (a phenomenon known as happy hypoxia).
Now, establishments run by Muslim-majority trusts have offered spaces for Covid-19 facilities to bridge the gap. The first such establishment, Haj House in Walled City, saw a welcome response, as many observing Ramzan see it as a more acceptable space.
Dr Rajesh Mishra, a critical care specialist based in Ahmedabad, says that as a disease, Covid-19 is difficult to detect in early stages. It directly attacks the lung, without necessarily showing up in the upper respiratory tract. “Data shows that 40% of the time a test may be negative. That is why, in suspect cases, in the third or fourth attempt, a person may test positive,” Dr Mishra says.
He calls for detecting low oxygen levels in blood through markers. “Accordingly patients can be put on blood-thinning and anti-inflammatory drugs… If we start this early, it improves the chances of a patient.” A clinical trial along these lines, the WHO Solidarity trial, which includes comparative study of administering a cocktail of drugs vs standard care, is underway at BJ Medical College.
Dr Atul Patel of Sterling Hospital, among the three designated hospitals for treating Covid-19 in Ahmedabad, has suggested that Gujarat might be seeing the “more virulent” ‘L-strain’ of coronavirus, as seen in China, than the ‘S-strain’. However, there is little consensus on this, with the ICMR, as well as Dr M M Vegad, Head of Microbiology at B J Medical College, saying there is no evidence to support such a hypothesis.
Principal Secretary, Gujarat Health and Family Welfare Department, Jayanti Ravi, said that with nearly 80% of coronavirus cases asymptomatic and another 15% mildly or moderately symptomatic, their focus are “the nearly 5% who come in as critical patients”. “It is not possible to test all the six crore population of the state, but the main thing is proper surveillance. Cases are expected to increase,” she says, while talking of “growing herd immunity”.
An AMC official says that more than the deaths, what is of concern to them are “preventable deaths”. “In a city of 80 lakh, even if less than 1% or around 80,000 are critical, we won’t be able to handle it. This is an issue with the health system everywhere. So the approach is to slow down or stagger the disease, create a system of rotation in place.”
That is the reason the government has worked out home isolation for people with mild symptoms now.
Apart from putting Ahmedabad and Surat under total lockdown, the Gujarat government has pressed in the BSF and CISF to patrol containment zones. Amidst talk of the Centre being unhappy, a Gujarat government statement pointed out that the Inter Ministerial Central Team sent to the two cities was “satisfied” with what it saw. “The team expressed satisfaction at the administration’s alertness and success in detection of patients owing to large-scale testing from the very beginning,” the statement said.
On Saturday, Ahmedabad began a massive sanitation campaign, involving retrofitted fire-tending vehicles, drones and other equipment.
Gujarat, meanwhile, can already see a silver living: by May 5, the doubling rate was up to 12.6 from six days.
Even given the bitterness between West Bengal and the Centre, few might have expected it to spill over into the efforts against coronavirus. Now the numbers seem stacked against the Mamata Banerjee government: between 9.75% (the state’s estimation) and 13.2% (the Centre’s), the state has the highest mortality rate in the country.
There have been problems from the start. The first case, on March 18, was the son of a state government officer who returned from London, tested positive, and was allowed to roam around Kolkata for two days before finally getting himself admitted to a hospital. The first death followed seven days later, of a 57-year-old from Dumdum.
Within days, the state became the first in the country to set up a “death audit committee”, which would certify whether casualties could be attributed to the virus or not. This stirred accusations of fudged numbers. Exactly a month later, the gap stood stark when Chief Secretary Rajiva Sinha gave out the first numbers, saying that while there had been 57 deaths of people “with” Covid-19 in the state, it considered only 18 “due to” Covid-19.
Incidentally, with deaths rising, several states have now started making that distinction — including the badly hit Mumbai — while West Bengal has itself virtually disbanded the audit committee under pressure from the Centre. Addressing media persons on April 29, CM Mamata Banerjee said, “We have to correct ourselves because we make mistakes. I do not know everything as I am no expert.” On May 4, the Chief Secretary said the administration had found “missing data” and acknowledged gaps in numbers.
Consequently, the rise of cases in Bengal has been swift. On May 7, the number stood at 1,548, with 151 deaths. West Bengal has also amended its health bulletin to go back to original — reporting again total number of cases rather than just “active positive cases”.
On April 21, the Union Home Ministry sent two Inter-Ministerial Central Teams to the state, to check on its Covid-19 efforts. Almost overnight, the state made another course change — from 400-450 tests per day, to 2,500. West Bengal has said it couldn’t ramp up testing earlier due to unavailability of kits from the Centre. It is yet to start random testing. A state official said: “Initially, the Centre did not supply sufficient kits, now we have procured these from the market.”
Says Trinamool Rajya Sabha MP Shantanu Sen, a doctor himself, “We never tried to suppress any data. The Centre was not prepared enough… Now, they are blaming states.”
However, National Institute of Cholera and Enteric Diseases director, Shanta Dutta, had earlier told The Indian Express, “We have enough kits… We would welcome more samples for testing.”
In a letter to the state on May 6, after the IMCTs submitted their final report, Union Home Secretary Ajay Bhalla said, “The response to Covid-19 in West Bengal is characterized by very low rate of testing in proportion to the population…. ”
Among those who accuse the state government of “late response” are doctors’ organisations, who have alleged severe shortage of protective equipment. Health workers account for more than hundred positive cases in the state. Says the secretary, Association of Health Service Doctors, Manas Gumta, “The lockdown gave time to prepare. But the government did nothing.”
THE DEATH PROFILE
The perceived reluctance to share data also extends to deaths, be it age or co-morbidity details. In his first remarks on the matter after announcement of the Central teams, Chief Secretary Sinha said, “Maximum persons who died were old. So, we are suggesting older people should stay at home….” Later, he advised a uniform format for death certificates, with “the immediate cause of death, antecedent cause of death and underlying cause of death”.
In its first report, before it clammed up, the death audit committee mentioned several co-morbidities, such as cardiomiopathy with chronic kidney disease, renal failure, as well as heart conditions and hypertension.
The case of a 70-year-old woman, a patient of a lung disease, is symptomatic of the dearth of details. Her son says she fell ill on April 24, and the next morning, he took her to a private hospital, which denied her admission and referred her to state-run NRS Medical College Hospital. According to him, when both NRS and state-run SSKM Hospital turned them away, they returned home. “Next morning (April 26), my mother’s oxygen level dipped. I could not get an ambulance till 5 pm. With the help of friends, I shifted her to NRS.” After initial treatment, the authorities asked them to take her to MR Bangur Hospital as they lacked necessary equipment.
“We took her there. However, the on-duty doctor said they did not have the required medicines or instruments. He suggested we shift her to NRS again,” he says. This time she was admitted to an isolation ward at NRS Hospital; the son says he had to carry her himself. When he returned in the evening to visit her, he was told she had died and that they would do a Covid-19 test. On April 28, the Health Department called to say his mother had tested positive and that the family should stay in 14-day quarantine and also get tested. He, however, says no one “from the government come to get our samples”. On May 2, the Kolkata Municipal Corporation called to tell him his mother had been cremated on April 29. He says the saga continued and, on May 6, he got a call from the Health Department, asking, “How is your mother now?”
NRS Hospital Superintendent Tarun Kumar Pathak says, “If a patient dies, we cannot do anything. The family can approach the Health Department. But if a family submits any complaint to us, we can look into the matter.”
Since the arrival of the Central team, the state has not only brought in major changes in management of the Covid-19 but also stricter lockdown especially in containment zones. From April 7 to May 3, the state claims to have surveyed 5.57 crore households for severe acute respiratory illnesses and influenza like illnesses, and identified 872 and 91,515 respectively.