The COVID-19 pandemic is the largest public health crisis faced by the modern world and over the last few months cities and countries have struggled to cope with this highly infectious virus.
Across the world, large metropolitan cities have borne a disproportionate burden of the pandemic, since they were the entry points to international flights that brought in the COVID-19 virus. When this combined with the density of population in these large metropolises, there was a rapid spread of the virus. Delhi too faced such a crisis. In the month of March — even before the process of screening and quarantining of international travellers started — more than 35,000 international passengers landed in Delhi.
India started a nationwide lockdown on March 25. While the lockdown helped contain a rapid spread of the COVID-19 virus, it brought with it other socio-economic crises with people losing their jobs, daily wage earners being left with no means to earn a living, migrants being stranded without food and shelter, and an acute fall in government revenues. It was clear that a lockdown couldn’t be a long-term strategy and the economy would need to be gradually opened up.
Unlock 1.0, announced by the central government, which started on June 1 did begin to pick up the economy, but brought with it difficulties for Delhi. In the first week of June, Delhi started witnessing a rising number of cases, a rising number of deaths and because of these a rapidly rising panic amongst the citizens of Delhi. Yet a month later, each of these seems to have plateaued. So what is it that Delhi has done in the last one month that has controlled the rising cases, deaths and panic?
CONTROLLING THE NUMBER OF CASES
The key to controlling the number of cases is a strategy of aggressive testing and isolation. Only if COVID positive patients and their high-risk contacts can be isolated and quarantined, can the spread of the disease be reduced. However, this strategy is often bottle-necked by the fact that people are scared of getting tested. Why? Because they have seen images — in their neighbourhood or on WhatsApp — of coronavirus patients being dragged away in ambulances, by police officers and medical staff wearing scary PPE kits.
This created a stigma for the family in the whole locality. This was one of the reasons why many people — despite having clear COVID-like symptoms, did not get themselves tested. Unless someone became severe and needed hospitalisation, people won’t come forward. Those with mild symptoms would not get themselves tested. Such people would keep roaming around and spreading virus. And since people were not getting tested, aggressive isolation was not possible. So what changed? How was the Delhi government able to break the psychological barrier for people to get themselves tested? The answer is simple: by promoting ‘home isolation’.
Home Isolation and its Awareness Drive
The Delhi government aggressively promoted home isolation of COVID-positive patients who were asymptomatic or had mild symptoms. These constitute almost 80 per cent of all COVID-positive cases. After a visit of a medical team to their homes explaining home isolation, regular monitoring and guidance was done with daily phone calls from healthcare workers. This meant that patients could recover in the comfort and emotional security of their homes. Their family members could also be quarantined in the same house for two weeks and this ensured that they did not become spreaders. An important component was the public awareness campaign that the government ran on ‘home isolation’, which made people realise that they could recover in their own homes. Even more importantly, this awareness campaign helped reduce the stigma around being COVID-positive.
This normalisation of being COVID-positive and the confidence that patients could recover in their own homes, made it possible for the Delhi government to pursue an aggressive testing strategy.
Aggressive Testing and Isolation
Delhi was following a strategy of high testing from the very start. Even before the end of June, Delhi was testing more than any other state in India at about 10,500 tests per million on May 31. Once the stigma around being a Covid-19 patient was successfully reduced, it was possible to further ramp up testing. From the first week of June, a strategy of aggressive testing was started, with a focus on areas that were becoming hotspots. In the first week of June, Delhi government was conducting 5,500 tests per day. With the help of Centre’s support in providing antigen test kits, by mid-June, this figure stood at 11,000 tests per day and by the first week of July at 21,000 tests per day. While increased testing seemed to increase the number of cases, what it meant was that COVID positive patients were now being traced and isolated in a timely manner. With thousands of patients and their families being isolated every day, within a fortnight the success of this strategy was visible. And as can be seen in the table below, despite high testing, ‘Active Cases’ began to plateau despite high testing, from 16 June onwards and ‘New Cases’ began to sharply decline 23 June onwards.
In a public health emergency, assuaging public fears is as important as medical interventions, since public behaviour affects the process of pandemic management. As cases began to rise in Unlock 1.0, there began a spread of panic, especially through social media. Several measures were taken to reduce this panic and build public confidence.
Rapidly Increasing Hospital Beds
Till early June, there were only 8 private hospitals that were treating coronavirus patients and these had a sum total of 700 beds available. This was in addition to 2,500 beds in Delhi government hospitals. When the cases started rising in the first week of June, the aforementioned 8 private hospitals reached their capacity and when patients reached some of these hospitals they found no beds available. Some patients even went to 2-3 of these private hospitals and did not find beds. While more than a 1,000 beds continued to be available in government hospitals during this period, many people preferred private hospitals. The process of going from hospital to hospital began to create panic among patients; and via social media in the public-at-large. Bed capacity was immediately expanded in private hospitals. An order was passed by the Kejriwal government whereby all private hospitals with more than 50 beds had to reserve 40 per cent of beds for treating COVID patients. Not only did this mean that the number of COVID beds in private hospitals increased from 700 to 5,000, it also meant that COVID facilities were now available in all parts of the city. In addition to this, hotels were linked to private hospitals thereby increasing bed capacity of hospitals. With this hotel linkage, the number of beds in private hospitals went up from 5,000 to 7,000. Today, there are over 15,000 COVID beds in Delhi. While much of this increased capacity is still vacant — with only 38 per cent of 15,000-plus COVID beds being occupied — it has meant that the people of Delhi feel a sense of confidence that if they need a hospital bed, it would be easily available in a hospital of their choice.
Accessible Information on Bed Availability
When several cases came to light of patients going from one hospital to another, the government realised that the problem was also the availability of information. More than a 1,000 beds were available even in the first week of June, but the patients and their families did not know which were the hospitals where these beds were available. It was then that the Kejriwal government became the first in the country to launch ‘Delhi Corona App’ that displayed real-time availability of beds in every hospital of the city.
Yes, there were hiccups in the first few days of app launch with some disparities in the numbers that hospital staff keyed in to the app, and the actual number of available beds. But as hospitals got into the rhythm of using the app, bed availability started being displayed on a real time basis. So now every Delhiite had the information about the nearest hospital, how many beds they had available as well as a 24x7 dedicated helpline number for each hospital. And it was this transparency of information that ended the panic of patients running from one hospital to another.
Counselling of Covid-19 Patients by Doctors
The list of COVID positive patients is provided by the testing labs to ICMR which gives it to Delhi government’s health department; and from the health department to the district surveillance teams that reach out to patients and assign them to home isolation, quarantine centres or move them to hospitals depending upon their condition. However, this transfer of information and reaching out to the increasing number of patients meant that there was a gap of 24-36 hours between when the patient received their COVID report from the lab and when they received a communication from the government about next steps. And it was in these 24-36 hours that patients, their families and neighbourhoods often panicked.
Many of them rushed to hospitals, even though their symptoms were mild and they did not need hospitalisation. In response to this, Delhi government collaborated with a network of NGOs and doctor-volunteers who started real-time calling and counselling of COVID-positive patients, as soon as their lab reports got uploaded. This meant that a COVID-positive patient was able to get medical advice and counselling within hours of getting their lab reports. When doctors counselled them and explained how most corona patients do not need hospitalisation, patients were able to cope with the psychological and emotional trauma of their COVID-positive status, without panicking.
COVID-19 has a 2to 5 percent mortality rate across the world. In the absence of a vaccine for this virus, it may not be possible to bring the mortality rate down to zero, but proper patient and facility management can lead to reduction of mortality and this is exactly the strategy that has been followed in Delhi. The focus of the Delhi government was on ensuring that the patients who had mild symptoms could recover at home, so that hospital facilities remained available for serious and critical patients. Close watch was also kept on patients to ensure a swift transition to hospitals in case of escalating symptoms. The objective was to reduce deaths by preventing mild and moderate patients from becoming severe and preventing severe patients from getting into critical condition.
Oximeters and Oxygen Concentrators
One of the causes of mortality in COVID is reduction in oxygen levels in the blood, hypoxia. Unlike other ailments where this hypoxia is accompanied with breathlessness, in COVID we witness a phenomenon of ‘Happy Hypoxia’, wherein a patient may have dangerously low levels of oxygen but may not have any awareness about it. Monitoring oxygen levels and having accessible supply of oxygen was crucial to prevent mortality of patients in Home Isolation. The Arvind Kejriwal government provided oximeters to all patients recovering in home isolation so they could monitor their oxygen levels to prevent any sudden falls. The government purchased 59,600 oximeters and 58,974 are in use today by patients in home isolation. Oxygen concentrators were provided to local dispensaries who could immediately take these to a patient’s home and provide oxygen support, if their oxygen levels began to dip. The government purchased 2,750 oxygen concentrators. Most beds in Delhi government hospitals today have oxygen facility.
War Room for Ambulance Management
It has been seen across the world that unnecessary mortality has been caused by an inability of the ambulance systems to keep pace with the spread of the pandemic. Delhi’s ambulance system has responded with speed to ensure that there is no shortage of ambulances as the city faced a surge of COVID cases and a dedicated war room was set up to ensure that every patient with escalating symptoms was able to reach the hospital in time. Starting with only 134 ambulances at the beginning of lockdown, Delhi government’s 102 CATS ambulance service currently operates a fleet of 602 vehicles, which includes 402 ambulances catering to both COVID and non-COVID cases, and 200 cabs that cater to non-emergency calls for ambulance service, example transfer of treated COVID patients back to their homes.
This was possible by expanding the in-house fleet of ambulances but also collaborating with private ambulance providers and cab providers leveraging technology to coordinate dispatch and manage the performance of ambulances. Protocols were worked out with each hospital so that COVID patients are admitted to hospitals within 15 minutes of arrival of ambulances. NGO partners were roped in to provide detailed training sessions to ambulance drivers, paramedics and CATS control room staff taking calls to ensure they fully understood various COVID symptoms and respond to each case as per need. So the ambulance system ensured that any patients with severe symptoms reach hospitals before they become critical.
The impact is visible in the performance of the ambulance system over the last two months. In the first week of May, the CATS ambulances catered to an average of 576 calls a day with patient handover time of 4 hr 28 min per COVID call. In the first week of July, the CATS ambulance service catered to an average of 890 calls per day with patient handover time of 2 hr 49 min per COVID call.
Convalescent plasma has shown encouraging results across the world in preventing mortality amongst critical patients, as it provides the patient with antibodies to fight the virus. Delhi was the first to start an experimental trial of plasma therapy in LNJP, the largest Delhi Government COVID-19 facility. Trial results were very encouraging. Plasma therapy could save some lives, till a vaccine was available. In a first, across the country, a ‘Plasma Bank’ has been set up by the Delhi government, so that patients can easily access convalescent plasma. An aggressive awareness campaign for plasma donation has been led by Kejriwal himself, so as to encourage recovered patients to come forward and donate their plasma.
PUBLIC ENGAGEMENT AND PARTICIPATION
Throughout the pandemic, Kejriwal kept a direct engagement with the people of Delhi - be it explaining home isolation, how oximeters work, why plasma should be donated, how hospitals beds are being increased. This engagement has meant that the people of Delhi have always been informed by a trusted voice about where the city stands in its ability to confront the coronavirus. This engagement has also been important because controlling a pandemic requires change in people’s behaviour; and change in behaviour comes from being informed of facts in a credible manner however difficult they may be.
Involving all Stakeholders
Instead of relying only on the government machinery to manage this pandemic, Kejriwal, aggressively reached out to different stakeholders to contribute in this fight. From central government that provided ventilators, masks, testing kits and medical staff, hotels that provided rooms, non-profit organisations that have helped run COVID Care centres, volunteer-doctors who helped man the helplines to counsel COVID-positive patients to civil defence volunteers who helped families in Home Isolation to buy groceries - all of these were brought together by the Chief Minister’s outreach efforts. It did not stop there; CM representatives were placed in every medical facility to ensure that public grievances were addressed promptly and with a human touch. Chief Minister Fellows and Delhi Legislative Assembly Fellows were pulled out of their offices and placed in district offices to support in the COVID-19 patient management process. Community volunteers were involved in the process of tracing and isolating patients. It was this public driven effort that helped stabilise the COVID-19 pandemic in Delhi The success of Delhi in overcoming the Coronavirus lies not just in its capacity to expand hospital infrastructure, increase testing or aggressively isolate; it lies in the ability of the government to understand the psychological and emotional challenges that this pandemic has created and the political will to resolve the public health crisis in a manner that take cognisance of the state-of-mind of the people of Delhi. Epidemiology, with a human touch.