Kolkata: As the Indian medical fraternity’s fight against the new coronavirus takes newer turns and faces dire challenges, healthcare professionals have been discovering that when it comes to protective equipment, some are more equal than others. Doctors who should have been resting when they’re not attending to severely ill patients have instead been occupied with organising protests, drawing up petitions and attending meetings – all of which demand that those on the frontlines be given personal protective equipment actually capable of ensuring the disease does not spread to them.
Much has already been written on India’s curious response to the personal protective equipment or ‘PPE’ crisis. As The Wire’s Dheeraj Mishra noted in his report on March 25:
The first case of COVID-19 was reported in India on January 30, 2020. The very next day, i.e. on January 31, the Union Ministry of Commerce and Industry issued a notification banning the export of all sorts of PPE like surgical masks, gloves, ventilators, etc.
However, the Centre amended this decision a few days later. The commerce ministry issued an order on February 8, 2020 allowing the export of all types of gloves except NBR gloves as well as surgical masks.
On February 25, India inexplicably added eight more items to its list of PPE allowed for export. On February 27, the WHO issued a clear order asking countries to stockpile PPE. India was, even then, feeding other countries. It was only between March 19 and March 24 that the government took decisions to ban PPE items, raw materials required to make them and other related goods.
A report in The Caravan noted how manufacturers were gobsmacked by the dissonance in government estimates of requirement (experts held the daily requirement of coveralls, gloves and masks at 5 lakh a day – the government estimated 7.25 lakh would be needed in total until May).
Even with reports of insufficient testing, COVID-19 has had over 1,071 patients in India until now. In Kolkata, the Calcutta Medical College has been transformed exclusively into a COVID-19 healthcare centre. Evacuation of other patients was followed by training sessions with healthcare staff, nurses and doctors, during which they were shown the kind of PPE they will be given. The suits have “rainwear” written on them.
In additional photos that The Wire received of the PPE, there is also a clear absence of eye protection, which WHO lists as a must for patient room healthcare workers.
“We went in groups to ask the hospital authorities these raincoats are the ones that will be given to us on the field. He said that that was merely for demonstration and kits made in accordance with WHO guidelines will be given to us,” said a doctor of the hospital. By Monday, March 30, when the hospital threw doors open to suspected COVID-19 patients, no such alternative kits had arrived.
The doctor who The Wire spoke to said professionals would have no alternative but to protest under the circumstances. “Please write about this, this is a suicide mission,” she said.
A medical officer at Mumbai’s Kasturba hospital, which has also been treating COVID-19 patients, said the PPE they were given is traditionally an HIV PPE.
“It can do very little to prevent the transmission of the coronavirus,” she said, pointing to a Facebook video that shows a medical professional putting on the requisite PPE that can ensure protection against the spread of the disease.
It is noteworthy that doctors in Bihar, Chhattisgarh, Bengal and Uttar Pradesh all said that an HIV kit was as good as could be hoped for under the circumstances.
Across the cross section of government hospital medical professionals that The Wire spoke to, the consensus was that while nurses and doctors were ready to serve at a time like this, authorities would do well to recognise that them falling ill would not just harm the medical response to the pandemic but also put their patients at increased risk.
The Mumbai doctor, therefore, has decided along with many of her colleagues, to not return home while this phase lasts, thanks to the lack of PPE. Doctors at Patna’s Nalanda Medical College and Hospital – another centre treating COVID-19 patients where the lack of administrative empathy has made news – have not been able to stay in the hospital as no arrangements have been made for them.
“I am a senior resident and my wife is a doctor too, but we only have surgical masks in the isolation wards. As a result, I have not been going home,” said a doctor at the hospital. When two doctors’ associations went to the authorities to speak on the fact that treating patients without PPE would be “equal to suicide,” the authorities threatened them with FIRs and cases under the Epidemic Diseases Act.
At North Bengal Medical College and Hospital, the doctors have had to function with raincoats, cloth masks and absolutely no sanitisers. A patient died at the hospital on Monday, fuelling outrage among doctors who asked to be given better PPE. The authorities told them to stop working if they had a problem.
On Sunday, a News18 report shone light on the fact that 11% of those tested due to severe acute respiratory illness hospitalisations have been positive despite no travel history abroad. Not only does this indicate that the statistics available on the spread is insufficient, it also points to the particular risk doctors, nurses and ward staff attending to such patients are.
In Tamil Nadu, doctors and nurses reacted to chief minister Edappadi K. Palaniswami’s promise of an additional month’s salary as bonus with the plea that all they want is PPE. At a government hospital in Chikalthana of Maharashtra’s Aurangabad, where swab samples of suspected coronavirus patients are collected, a memorandum was submitted by the Maharashtra State Nurses Association, demanding basic protection gear.
“These things [protective gear and facilities] are available in only few wards. In view of the present situation, they should be provided in every ward,” said Jana Munde, secretary of the Aurangabad chapter of the Association.
Class and role-driven hierarchies are also prevalent here. The WHO guidelines prescribe the most number of protective layers (medical mask, gown, heavy duty gloves, eye protection (if risk of splash from organic material or chemicals and boots or closed work shoes) for cleaners. However, in at least two hospitals exclusively catering to COVID-19 patients, cleaners were in no way better off than their colleagues.
SOS messages from medical healthcare professionals are abound on social media.
Donning and doffing #PPE requires time, diligence and patience. Every hospital has to have a #checklist to ensure that healthcare workers do not miss crucial steps. Not sure how many and how often HCWs correctly practice this ritual? #COVID @Atul_Gawande
— SP Kalantri (@spkalantri) March 27, 2020
In at least two government hospitals in Uttar Pradesh, repeated meetings between resident doctors and nurses and hospital administrators, resulted in promises of PPE. In some hospitals, authorities have cited the low number of cases in the region to justify the lack of PPE. A doctor in Bengal’s Rampurhat Medical College and Hospital attested to this line of reasoning.
“My colleagues in the fever clinic have been wearing helmets to work. We have been told that the number of cases could rise, but because we are not in a big town – although the situation is dire in big cities too – we are not being taken seriously despite repeated requests,” she said.
While the WHO guidelines mention that healthcare professionals outside of the triage do not need PPE, two senior doctors The Wire spoke to differed, while fully recognising that a hierarchy did need to be established in the absence of availability.
One of the authority figures of the Bangalore Medical College and Research Institute said the PPE is the only step that can prevent the outbreak from reaching an even worse stage in India. “Every single medical healthcare professional attending to a patient at an OPD needs PPE. You have no idea who can be infected,” she said. Another, an oncologist in Chhattisgarh’s Raipur, cited the hypothetical situation of operating on patients who are themselves not aware that they have the virus.
Both, however, recognised that protests for basic protective gearing during a health crisis was not a good use of doctors’ time.
An indicator of the acute pressure and circumstantial awareness that the doctors are under can perhaps be found from the fact that all of the professionals that The Wire spoke to requested anonymity.
On Sunday, 24 hours after the publishing of a detailed report by The Wire’s Sukanya Shantha, on two hospitals in Thane where doctors were forced to work without PPE and under tenuous conditions, the doctors received PPE from the corporation.