Code red: the uphill struggle in Gujarat and Bengal with the highest Covid-19 case mortality in the country

Vegetable sellers, considered “superpassors”, are testing themselves at Shahpur in Ahmedabad. (Express photo: Javed Raja)

On May 6, Gujarat sent a request to the Center to send experts from Delhi and Mumbai to help it combat the coronavirus. Consequently, it put two of its largest cities, Ahmedabad and Surat, under full curfew, stopping everything except the supply of milk and medicine, the two-month culmination of a Covid-19 situation that is progressively worsening in the state.

Almost two months after its first case on March 19, Gujarat has the highest number of cases and deaths after Maharashtra, the second highest death rate in the country after West Bengal and, worryingly, a large proportion of young people that die. This despite the fact that only 1% of deaths in the state, which has a large diaspora, have been attributed to infections abroad.

Under pressure from the Center, which named Gujarat and West Bengal as states of concern in a May 6 statement, authorities sought answers: from patients who arrived late to hospitals, to a different strain, to Tablighi Jamaat (although only 14 of the 130 who returned to Gujarat from the organization’s Delhi meeting, which became a group, tested positive, with one death.)

Neither reason has been maintained so far. Meanwhile, even when the Union Home Office attacks West Bengal for lack of transparency about the coronavirus, as of May 5 (when it reported the highest single-day deaths, 49), Gujarat ruled by BJP he has stopped giving details on the age and comorbidity of his dead. Ahmedabad now also has a new team of officials, led by Additional Chief Secretary Rajiv Gupta, who led the Statue of Unity project, to handle the capital city’s coronavirus strategy.

THE TIMELINE

Gujarat, who began screening at airports in February, obtained his first Covid-19 case on March 19. By then, nearly half of the states had already reported cases and the count across the country had crossed 100.

The first case was a 32-year-old Rajkot resident, who had returned from Umrah in Saudi Arabia. While recovering rapidly, the first Ahmedabad patient, a 21-year-old man who had returned from New York on March 14 and had mild symptoms, took 32 days to return home. Doctors said the younger woman’s longest recovery may be due to the fact that she has asthma.

After the first two cases, the curve began to climb. While it took 17 days for cases to cross 100 across the state, 90 new cases were reported on April 9 alone, 57 from Ahmedabad. The first death, that of a 62-year-old businessman from Surat, occurred within three days after the first case was reported.

Authorities admit that while Gujarat was on guard quickly enough, the tests were delayed. For a long time, a large number of samples were sent to the National Institute of Virology (NIV), Pune, and the Kasturba Hospital in Mumbai. The daily average, even in mid-March, was just 15 tests, reaching 200 or more by the end of the month. At the end of April, when Delhi was testing 1,492 per million and Tamil Nadu 930 per million, Gujarat was testing 721 per million.

In an interaction with the media at the time, Chief Minister Vijay Rupani said: “Certain states that have a smaller number (of cases) obtained authorization for laboratory tests before. If we had obtained the authorization earlier, we could have been able to control the situation. ”

The state now has 24 laboratories that test. With group testing, the state is testing more than 5,500 samples a day.

But Ahmedabad, which comprises more than 70% of Gujarat’s cases and deaths (4,991 of 7,013 cases; 321 of 425 deaths), only performs 21% of its daily tests. In fact, tests actually fell in the Ahmedabad Municipal Corporation (AMC) areas after April 23, when more than 2,400 samples were analyzed in a 24-hour cycle, to approximately 1,300 on May 1 and 1,072 on 5 May. may.

A senior AMC official alleges two main reasons. “When we tested over 2,400, we had the luxury of accommodating multiple positive patients in our hospitals. With each day, capacity is reduced, and therefore we have to test in a phased manner as we develop more capacity. ” The second reason, according to the official, is that the increase in cases also means a reduced capacity for new samples. “For a patient to be discharged, we have to perform at least three tests, as a result of which our capacity in the field is reduced.”

That argument is difficult to digest given the state’s increasing case fatality rate. With 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).

By contrast, Maharashtra (the state with the highest amount of coronavirus) increased its tests as cases and deaths increased.

THE PROFILE OF DEATH

On April 23, a 16-year-old boy died in the Dani Limda area, an access point in Ahmedabad. While the Covid-19 bulletin showed no comorbidities in her case, Dr. Jaiprakash V Modi, superintendent in charge of the Ahmedabad Civil Hospital where she died, told this newspaper that the teenager had an autoimmune disease Lupus.

The following day, among the victims was a 17-year-old boy from Behrampura, another access point in Ahmedabad. Once again, the official note listed it as a Covid-19 death (without comorbidity). Her mother, who is in quarantine with her other two children, told this newspaper that she had no other conditions apart from a mental disability. “On April 22, she was unable to sleep through the night. She was unable to communicate and could not understand what was happening. The next day I had a high fever. Within hours, she had difficulty breathing, ”says the mother, who took her to the Sardar Vallabhbhai Patel Hospital (SVP) administered by AMC.

She says doctors told her that her daughter was taking epilepsy medication. “But no doctor told us anything else. I never saw her have an epileptic fit, “says the mother, who was unable to be present at the 17-year-old’s funeral. Deputy city commissioner Om Prakash Machra, who oversees operations at SVP, told The Sunday Express:” She had pre-existing conditions and had been taking medications since birth. “

Since then, however, explanations have been more difficult. As of April 30, 40 (nearly 18%) of the 214 deaths in the state had no major underlying health conditions. By May 6, this number was 109 (27% of 396 dead). In addition, by then, 31 of the 319 dead (almost 10%) were under the age of 41.

Dr. Atul Patel, an infectious disease specialist who has been working with the state government on the coronavirus, said last week: “Gujarat has many patients, even otherwise, with (hypertensive) blood pressure and diabetes. With the coronavirus, these conditions deteriorate further. Many patients come to the hospital after a long delay, with little functionality of their lungs, and we see them die in approximately six hours. “

The last report

Among the dead is the body of Behrampura, Badruddin Shaikh, 67, who succumbed on the twelfth day of the positive tests. His colleague, Jamalpur-Khadia Congress MLA Imran Khedawala, 53, was released on April 27, a day after Badruddin’s death.

The two are believed to have captured the coronavirus while moving between Ahmedabad minority-dominated areas such as Behrampura, Jamalpur and Dariapur, trying to convince people to come forward if they had symptoms. Of the 4,649 AMC cases as of May 7, 1,587 or 34% had been reported in the Walled City areas, including Jamalpur, Shahpur, Dariapur and Khadia. The four rooms comprise four of the 10 red zones.

Karnataka Panel Report: Late Admission, Age Behind Most Deaths

Khedawala believes that the inherent mistrust of government medical facilities among minority-dominated areas is a reason for late testing. Most of these areas are ghettos, where Muslims have settled through successive communal riots, including 2002. An AMC official admits to a lax presence here, both in terms of sanitation and health.

The Tablighi connection, reiterated by CM Rupani, deputy CM Nitin Patel, and virtually all BJP senior leaders, has only reinforced mistrust.

Prime Minister Vijay Rupani and his deputy Nitin Patel inspected the “Dhaman-1” ventilator at Ahmedabad Civil Hospital for crown treatment worth Rs 1 lakh prepared by CNC in just 10 days. (Source: CMO Gujarat / Twitter)

“I have been trying to tell the community to see a doctor right away, even at the slightest sign. Instead, people take medicine when they have a fever or cough. They believe that if they go to a hospital, there is no return, “he says, adding that recovering their case should be a positive example.

Indore, which once had the highest death rate among critical points, managed to turn the corner in a similar fashion with positive reinforcements among its minority areas, from where many cases were reported (its death rate has dropped from 15% to less 5%). In Ujjain in Madhya Pradesh, authorities changed the protocol to home quarantine for those asymptomatic, to establish trust. In Maharashtra, an approach in Urdu was started.

Deputy city commissioner Machra gives the example of a 35-year-old man from Jamalpur who died on April 29. “While there was no comorbidity, the patient was tested six days after the onset of symptoms,” says Machra, adding he was serious when admitted. However, he reiterates that the majority of deaths are from patients with underlying conditions, some of whom may not have been aware of the same until admission.

Another patient, a 66-year-old retired bank employee who lived in the Shah-e-Alam area, did not see a doctor until three days after he developed a fever, followed by a cough and chest pain. Although 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 being taken to the hospital on April 29.
The son says his father enthusiastically followed the Covid-19 news and was therefore aware of the symptoms, but “did not go to the doctor for fear the family would get into trouble.”

Workers of the service civic corps in Kolkata. (Express photo / Partha Paul)

Khedawala says: “I was tested to create a sense of trust towards the authorities … (But) the kind of atmosphere that is being created will not help. This could lead to a serious situation. “

Former BJP MLA Bhushan Bhatt, for example, has a clear logic as to why Khadia, a Hindu pocket in the containment zone in Ahmedabad Walled City, has 440 strange cases (like May 7). “The biggest mistake we made was not to restrict movement to and from Khadia,” he says.

Machra says people in the low-income groups also do not undergo the tests, fearing loss of income if they are quarantined. It is difficult to convince them, especially if they remain asymptomatic, adds the AMC official.

Some patients from the Khokra area of ​​Ahmedabad, admitted to the Ahmedabad Civil Hospital, say that. Natwarbhai Dabhi, 45, told The Sunday Express: “We are vegetable sellers, we were picked at random. Why this injustice? We were told that 24 of us are positive, but we don’t even have a fever. “

Even though sellers blame buyers, “who have cars so they never test positive,” the AMC has called sellers “super spreaders.” Almost 14,000 of them must be tested and consequently receive “health cards”.

AIIMS Director Dr. Randeep Guleria, among experts convened by the state from the Center, visited hospitals in Ahmedabad on Saturday. He also attributed the reasons for the state’s high mortality to the stigma associated with the disease. “There is still fear,” said Dr. Guleria, adding that a person may be mildly symptomatic but still have critically low levels of oxygen in the blood (a phenomenon known as happy hypoxia).

Now, establishments run by Muslim-majority trusts have offered spaces for Covid-19 facilities to fill the gap. The first such establishment, Haj House in Walled City, received a welcome response, as many Ramzan watchers see it as a more palatable space.

THE ILLNESS

Dr. Rajesh Mishra, an Ahmedabad-based critical care specialist, says that as a disease, Covid-19 is difficult to detect in the early stages. It directly attacks the lung, without necessarily appearing in the upper respiratory tract. “The data shows that 40% of the time a test can be negative. That is why, in suspicious cases, on the third or fourth attempt, a person can test positive, “says Dr. Mishra.

He calls for detecting low levels of oxygen in the blood through markers. “Consequently, patients can receive anticoagulants and anti-inflammatories … If we start this early, it improves a patient’s chances.” A clinical trial in this regard, the WHO Solidarity trial, which includes a comparative study of the administration of a cocktail of drugs versus standard care, is underway at BJ Medical College.

Dr. Atul Patel of Sterling Hospital, among the three hospitals designated for Covid-19 treatment in Ahmedabad, has suggested that Gujarat may be seeing the “virulent” L strain “of the coronavirus, as seen in China, that the “S-pressure.” However, there is little consensus on this, with the ICMR, as well as with Dr. MM Vegad, Head of Microbiology at BJ Medical College, saying that there is no evidence to support such a hypothesis.

The Chief Secretary, Gujarat Department of Health and Family Welfare, Jayanti Ravi, said that with almost 80% of asymptomatic coronavirus cases and another 15% with mild or moderate symptoms, her focus is “the nearly 5% who enter as critically ill patients. ” “It is not possible to assess the population of six million rupees in the state, but the main thing is adequate surveillance. Cases are expected to rise, “she says, speaking of” increased collective immunity. “

An AMC official says that more than deaths, they are concerned about “preventable deaths.” “In an 80 lakh city, even if less than 1% or around 80,000 are critical, we will not be able to handle it. This is a problem with the health system everywhere. So the focus is to slow down or stagger the disease, to create a rotation system in place. ”

That is the reason why the government has solved home insulation for people with mild symptoms now.

THE CURFEW

In addition to putting Ahmedabad and Surat under total blockade, the Gujarat government has pressured the BSF and CISF to patrol the containment areas. In the midst of talking that the Center was unhappy, a Gujarat government statement said the Interministerial Central Team dispatched to the two cities was “satisfied” with what it saw. “The team expressed satisfaction with the alertness and the administration’s success in detecting patients due to large-scale testing from the outset,” the statement said.

On Saturday, Ahmedabad began a massive sanitation campaign, which included fire-adapted vehicles, drones, and other equipment.

Meanwhile, Gujarat can already see a silver life: By May 5, the doubling rate was up to 12.6 in six days.

The many changes of course in Bengal

Even given the bitterness between West Bengal and the Center, few could have expected it to spread to efforts against the coronavirus. Now the numbers seem stacked against the Mamata Banerjee government: between 9.75% (the state estimate) and 13.2% (the Center), the state has the highest death rate in the country.

THE TIMELINE

There have been problems from the beginning. The first case, on March 18, was the son of a state government official who returned from London, tested positive, and was allowed to roam Kolkata for two days before he was finally admitted to a hospital. The first death occurred seven days later, from a 57-year-old man from Dumdum.

Within days, the state became the first in the country to establish a “death audit committee,” which would certify whether victims can be attributed to the virus or not. This sparked allegations of forged numbers. Exactly one month later, the gap remained marked when Chief Secretary Rajiva Sinha gave the first numbers, saying that while there were 57 deaths of people “with” Covid-19 in the state, he considered only 18 “due to” Covid-19 )

Incidentally, with the increase in deaths, several states have begun to make that distinction, including the seriously affected Mumbai, while West Bengal has practically dissolved the audit committee under pressure from the Center. Addressing the media on April 29, CM Mamata Banerjee said: “We have to correct ourselves because we make mistakes. I don’t know everything because I’m not an expert. “On May 4, the chief secretary said the administration had found” missing data “and acknowledged the gaps in the numbers.

Consequently, the increase in cases in Bengal has been rapid. On May 7, the number was 1,548, with 151 deaths. West Bengal has also amended its health bulletin to return to the original, again reporting the total number of cases rather than just “positive active cases”.

THE PROOF

On April 21, the Union Ministry of the Interior sent two central inter-ministerial teams to the state, to verify their Covid-19 efforts. Almost overnight, the state made another course change: from 400 to 450 tests per day, to 2,500. West Bengal has said it would not be able to increase testing earlier due to unavailability of kits from the Center. Random testing is yet to begin. A state official said: “Initially, the Center did not supply enough kits, now we have purchased them from the market.”

Says Trinamool Rajya Sabha MP Shantanu Sen, a doctor himself, “We never tried to suppress any data. The Center was not prepared enough … Now, they are blaming the states.”

However, the director of the National Institute for Cholera and Enteric Diseases, Shanta Dutta, had previously told The Indian Express: “We have enough kits … We would like to receive more samples to analyze.”

In a letter to the state on May 6, after the IMCT presented its final report, the Union’s interior secretary, Ajay Bhalla, said: “The response to Covid-19 in West Bengal is characterized by a very low rate of tests in proportion to the population … “

Among those accusing the state government of “late response” are medical organizations, which have alleged a serious shortage of protective equipment. Health workers represent more than one hundred positive cases in the state. The secretary of the Health Service Physicians Association, Manas Gumta, said: “The confinement gave time to prepare. But the government did nothing. “

THE PROFILE OF DEATH

The perceived reluctance to share data also extends to deaths, be it age or comorbidity details. In his first comments on the matter after the announcement of the core teams, Chief Secretary Sinha said: “The maximum number of people who died was old. Therefore, we suggest that older people stay home … “Later, he suggested a uniform format for death certificates, with” the immediate cause of death, the antecedent cause of death, and the underlying cause of death”.

In its first report, before it calmed down, the death audit committee mentioned several comorbidities, including cardiomyopathy with chronic kidney disease, kidney failure, as well as heart conditions and hypertension.

The case of a 70-year-old woman, a patient with lung disease, is symptomatic of the lack of details. Her son says she fell ill on April 24 and the next morning took her to a private hospital, which denied her admission and referred her to the NRS Medical College State Hospital. According to him, when both the NRS and the SSKM state hospital rejected them, they returned home. “The next morning (April 26), my mother’s oxygen level dropped. I couldn’t get an ambulance until 5pm. With the help of friends, I switched her to NRS.” After the initial treatment, the authorities asked them to take her to the MR Bangur Hospital as they lacked the necessary equipment.

“We took her there. However, the doctor on call said they did not have the necessary medications or instruments. He suggested that we change it to NRS again, ”he says. This time she was admitted to an isolation room at the NRS Hospital; the son says he had to carry it himself. When he returned in the afternoon to visit her, they told her that she had died and that they would do a Covid-19 test. On April 28, the Health Department called to say that her mother had tested positive and that the family should remain in quarantine for 14 days and also be tested. He says, however, that no one “from the government came to collect our samples.” On May 2, the Kolkata Municipal Corporation called to tell her that her mother had been cremated on April 29. He says the saga continued, and on May 6, he received a call from the Health Department, asking, “How is your mother doing now? “

NRS Hospital superintendent Tarun Kumar Pathak says: “If a patient dies, we cannot do anything. The family may approach the Department of Health. But if a family files a complaint with us, we can investigate the matter. ”

MEASURES

Since the arrival of the core team, the state has not only made major changes to the Covid-19’s management, but also a tighter lockdown, especially in the containment areas. From April 7 to May 3, the state claims to have surveyed 5.57 crore households for severe acute respiratory illness and flu-like illness, and identified 872 and 91,515 respectively.

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