In Gujarat, a crisis of epidemic proportions

While the ferocious second wave of COVID-19 is slowly on the wane, Gujarat has recorded the highest number of mucormycosis cases in the country. Mahesh Langa reports on how a State with poor public health infrastructure and manipulated data was unprepared to tackle the surge in cases

However, within a few days, Desai’s cheeks began to swell like small melons and his muscles became numb. He was referred to the Civil Hospital, where he was diagnosed with mucormycosis, commonly called the ‘black fungus’. Desai had never heard of it. He was shocked to learn that this aggressive infection could affect his eyes, nose and even brain. Desai found himself back in hospital. This time, the doctors had to remove his left eye to save his life. “I don’t know if I should feel happy that I have survived two deadly infections or sad about losing an eye. The other eye has just 70% vision,” he says.

 

Desai is among the 5,000 cases of mucormycosis that have been reported as of June 3 in Gujarat. Official records state that more than 250 people have died from the invasive fungal infection. With the State already grappling with a deadly COVID-19 wave, the rise in cases of ‘black fungus’ is a new cause of concern.

A surge in mucormycosis cases

Over the past few weeks, mucormycosis cases have increased across Gujarat, with Ahmedabad, Surat and Rajkot reporting very high numbers, particularly among those patients who, during prolonged hospitalisation, were administered high doses of steroids and antibiotics. Patients suffering from the fungal infection usually have a stuffy and bleeding nose, swelling of the eyes, blurred vision, and droopy eyelids.

“In Ahmedabad Civil Hospital, we have had 850 patients with mucormycosis. The ENT division has conducted 498 surgeries on patients who had the fungal infection,” says J.V. Modi, Medical Superintendent of Civil Hospital. At the time of going to print, more than 100 patients with mucormycosis were waiting in hospitals for their operations. “In Surat alone, around 100 people must have lost their eye or even their jaw bone due to the infection. It is more dangerous than COVID-19,” says a doctor from Surat’s Civil Hospital.

According to doctors, mucormycosis normally progresses slowly from the nose to the eyes and brain, but the real enemy this time is COVID-19. A host of factors can trigger mucormycosis. First is a weak immune system. The heavy use of steroids during COVID-19 treatment among diabetic patients can increase their sugar levels and create a conducive environment for the fungus to grow and thrive in the body, they say. So, a rational use of steroids and constant monitoring of sugar levels are important.

Though the State Health Department declared the fungal infection as an epidemic and created separate wards in Civil Hospitals in Ahmedabad, Surat and Rajkot, it has not made public the details of the number of cases, deaths, surgeries conducted, or people who have lost their vital organs as a consequence of the infection.

“As soon as the second wave of COVID-19 started declining in Surat, the city witnessed a sudden surge in mucormycosis cases,” says Manoj Mistry, a newspaper editor from the Diamond City, which saw thousands of COVID-19 deaths from early March to mid-May.

The government has also not fixed the treatment costs for patients of mucormycosis who are being attended to in private hospitals even though Gujarat had emerged as the State with the highest number of mucormycosis cases in India by the second week of May.

Luckily for Desai, treatment for the infection in Civil Hospital, a government hospital, did not cost him much. However, his stay at a private hospital for two weeks for COVID-19 treatment depleted his savings by half. “Despite the charges capped by the government for COVID-19 treatment in private hospitals, it’s still very high and beyond the means of any middle-class family,” he says.

Those who been treated in private hospitals for both the infections have paid huge sums for treatment. “More than COVID-19, treatment for mucormycosis is expensive because it also involves delicate surgery by specialist doctors,” a medical practitioner says. “Normal surgery will cost not less than ₹1 lakh in addition to expenses on medicines, hospitalisation and so on.”

To tackle the epidemic, the Gujarat government notified a State-controlled distribution policy of the anti-fungal drug Amphotericin-B, used to treat mucormycosis, for private hospitals after the issue of shortage of the drug was taken up by the Gujarat High Court that sought a response from the State government. And on May 27, an 11-member State-level task force comprising experts and doctors was formed and will play a key role in framing Gujarat’s policy on mucormycosis treatment.

Throwing caution to the winds

Meanwhile, the government is also busy trying to get the pandemic under control. Gujarat has seen an avalanche of COVID-19 cases during the second wave. On March 1, 427 daily cases and one death were reported. This shot up to 2,410 daily cases and three deaths on April 1 and then 13,847 daily cases and 172 deaths on May 1. On June 1, there were 1,561 daily cases and 22 deaths.

The virus has officially killed about 6,000 people since mid-March. However, data from hospitals, crematoria and burial grounds suggest that the number of deaths is as high as 15 times the official number. According to doctors, the official data on deaths capture only those who did not have co-morbidities and died of COVID-19. “For those who had COVID-19 but also suffered from diabetes or hypertension, the cause of death is attributed to the co-morbidity,” a medical practitioner says. Leading regional language newspapers such as Gujarat Samachar and Sandesh have raised questions on the government’s data by devoting increasing numbers of pages to obituaries. The State government has also not been forthcoming about casualties in homes. However, the Chief Minister has maintained that the State follows the guidelines of the Indian Council of Medical Research. During the second wave, the virus also spread to remote villages, where public health infrastructure is especially rickety in such demanding times, making the government’s work even more challenging.

The Gujarat government seemed ill-prepared for the brutality of the second wave. From December 2020, the State began to shut some of its COVID-19 care centres unlike neighbouring Maharashtra which kept them open and even began to build more such centres. Gujarat also dereserved COVID-19 beds in private and government hospitals since the pandemic appeared to be on the decline. In February, Gujarat turned its focus to elections for municipal corporations like Ahmedabad, Surat, Rajkot, Vadodara, Jamnagar and Bhavnagar, 31 district panchayats, 231 taluk panchayats, and 81 municipalities. Voting was held in two phases on February 21 and 27. In the first phase, all six municipal corporations went to vote and the results were declared on February 23. The results for the second phase of polling for panchayats and municipalities were declared on March 2.

In the run-up to the election, there was aggressive campaigning across the State. Much like in other parts of the country, caution was thrown to the winds at these gatherings. Neither the leaders nor the public observed physical distancing or wore masks despite the fact that the Chief Minister himself contracted the virus during campaigning.

“In Gujarat, the second wave was invited by the authorities and political parties which were more interested in local elections than in following COVID-19 norms. As soon as the elections ended in the State, COVID-19 cases began to surge,” says a prominent doctor and member of the State government’s COVID-19 task force. He adds that the cases had in fact started rising from the second week of February, but the authorities suppressed the data as holding elections was given more importance than public health.

“As a member of the medical fraternity, I am also partially responsible for not going public and warning government authorities as well as the public at large. As part of the IMA [Indian Medical Association], we should have expressed and communicated our apprehension about the second wave to the government,” says another leading doctor.

By the first week of March, the pandemic curve began going north in the State and by mid-March, there was an alarming rise in cases and deaths in all the major cities. By the end of the third week, COVID-19 cases began to be reported from semi-urban places and by March end, from the villages. It was when cases began rising rapidly that the government began to prepare at a feverish pace, adding beds and ramping up facilities.

“Undoubtedly, the local elections brought the virus to the villages, which had escaped its clutches during the first wave. Every village had an election meeting or a rally without any COVID-19 norms,” says the District Collector of one of the worst-affected districts.

Also read | Women flock religious procession in Gujarat to ‘eradicate’ virus; 23 held

From mid-March onwards, the State administration shut down public transport services in the cities, banned mass gatherings, restricted movements in markets and religious places, and limited participation in social events and family events. However, those measures came too late. Many say these were attempts to close the stable door after the horse had bolted.

A summer of horror

April 2021 was arguably the most cruel month in the history of contemporary Gujarat. The healthcare sector was bursting at its seams and thousands of deaths were being reported every day. The administration appeared to be struggling in dealing with the crisis.

A relative of a patient shifts him to a wheelchair in the mucormycosis ward at Civil Hospital, Ahmedabad.  | Photo Credit: Vijay Soneji

 

“It’s not that the administration was not working but our all efforts were falling short because of the sheer number of cases and deaths that were taking place. We were overwhelmed. There was a shortage of hospital beds, essential medical supplies, ambulances, and even mortuary vans to take the dead to their final destination,” a senior official says. The State and its people never anticipated a second wave, he says.

According to another bureaucrat, more people may have died for want of oxygen, hospital beds or essential medicines rather than COVID-19 in April. “We could have saved thousands of lives if there was an adequate number of beds, supply of oxygen and perhaps proper pandemic management,” he says.

A senior staff member at Civil Hospital describes the situation as being “completely chaotic”. “There were long queues of patients waiting to be admitted, there were 80-90 ambulances carrying patients for admission outside hospitals… At least 100 people must have died just waiting to be admitted,” he says.

The administration was forced by the Gujarat High Court, which took suo moto cognisance of the situation, to swing into action. It was only after the High Court’s intervention that the Health Department started conducting RT-PCR tests at all the district headquarters. Before that, there were no laboratory facilities to even conduct tests in half of the 33 districts of the State.

There also appeared to be no mechanism in place for oxygen procurement and supply in the initial stages of the second wave. After the situation became dire in April, the government appointed two bureaucrats as nodal officers for oxygen supply.

Though the State government has denied that deaths were caused due to the lack of oxygen, Mistry says patients have died without oxygen in several hospitals. Local media reported dozens of deaths in the north Gujarat and Saurashtra regions due to shortage of oxygen in hospitals in remote districts.

“The Centre had allotted 1,000 tonnes of oxygen to the State based on the number of cases and patients, while our requirement was around 1,350 tonnes. Why was Gujarat given less oxygen than required, you may ask. That is because it fudged cases and projected low figures,” says a top bureaucrat and core group member who was involved in pandemic management.

Also read | Gujarat urges Centre to raise oxygen allocation to State

The IMA in Ahmedabad and Surat even warned that there would be a law and order situation in the cities if oxygen supply was not ramped up in hospitals.

The neglect of public health

Gujarat’s health infrastructure struggled to cope during the health emergency despite the fact that the State saw a lower number of daily cases compared to neighbouring Maharashtra or even southern States like Karnataka and Tamil Nadu. The official number of daily cases never crossed 20,000 in Gujarat compared to Maharashtra where daily cases touched 70,000 and Karnataka where they touched 50,000.

“Yet the situation seemed worse in Gujarat. All the figures from daily case numbers to daily tests to cases of hospitalisation and deaths were lower than the actual count. That made our job more difficult because the numbers were kept artificially low, but in reality, there were no beds available anywhere in the city,” says the CEO of a top hospital in Ahmedabad.

There are huge numbers of vacancies in healthcare centres. There are almost 8,000 vacancies of medical and paramedical staff in the panchayat-run primary and community health centres in districts and municipal-run health centres in the cities, for instance.

“When the High Court asked the State government whether all the districts have HRCT (High Resolution Computed Tomography) machines to conduct CT scans since in certain cases the virus is not detected in RT-PCR tests, 15 out of 33 districts had no CT scan machines in government-run hospitals and health centres,” wrote Congress spokesperson Manish Doshi to the Chief Minister.

Also read | Chidambaram mocks ‘Gujarat model’, reacts to The Hindu report

In the last two decades, while the private health sector has grown visibly in cities like Ahmedabad, Rajkot, Surat and Vadodara, public healthcare has not seen concomitant growth. “The State will have to now promote public health infrastructure and manpower. The pandemic has shown that it cannot rely on the private sector to compensate for public health,” a senior bureaucrat says. He says the State should follow the examples of Kerala or Tamil Nadu while investing in public health.

In 2017, the Comptroller and Auditor General of India pointed out in its audit report the poor healthcare conditions in districts and rural areas. It said that in some hospitals, patients were being forced to sleep on the floor in rural health centres as there were no beds available. The condition of rural and district hospitals and health centres does not seem to have improved since. Total spending on health remains below 4% of the Budget.

“In my district, in the main Civil Hospital, there were almost 700 patients with only a dozen medical staff including two doctors, a few nurses and paramedics to attend to them. This was the situation in April when the pandemic was at its peak,” says a District Collector from the Saurashtra region. “If we don’t draw proper lessons now and improve our healthcare, the next wave could be even more fatal,” he says.

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