Surajit Nundy describes the scene working in an intensive care unit in Delhi

As India experiences a devastating second covid-19 wave, in Delhi there is so much suffering everywhere one looks that it feels like doing anything will be some help. I spend most of my time working in artificial intelligence for health, but because I was trained in Internal Medicine and there are so many patients in a critical state, I have volunteered to run a covid-19 intensive care unit (ICU) along with colleagues from paediatric surgery, laparoscopic surgery, and dermatology. We are all worried about our own safety and our family’s safety, but being out of our depth treating patients is less scary than staying at home and feeling helpless.

Two weeks ago, covid-19 was a smouldering problem, but today in Delhi it is like a war zone. The hospital corridors have been rejigged to have oxygen lifelines snaking out at regular intervals so that patients in stretchers can be lined up alongside them. They can only be given minimal medical attention, but they do at least have life-preserving oxygen. However, this is not nearly enough. People are driving up to the hospital in ambulances from faraway states, with loved ones in the back of personal cars, only to be turned away because there is no oxygen, and there are no beds. Some of them are dying outside as they arrive, or as they get to the wards, or while they are waiting for a bed.

We try to triage by medical need, but other considerations often dominate. A person in a politician’s uniform is threatening the Emergency physician with a call from a minister unless he gets a bed. There are videos [from other states] of how oxygen cylinders are being taken away from people by the authorities so they can be used by “VIPs.” Patients who are admitted don’t want to leave in case they get sick again and can’t then get a bed, as is likely. It is hard to treat the people who have beds, but don’t need them as much as others outside, but it is even harder to ask them to leave knowing they could relapse.

The toll this is taking on healthcare professionals is evident. We hear of a young doctor assigned to another hospital’s ICU who kills himself from the stress and pressure. Healthcare personnel are getting sick from the virus, both physically and mentally. There isn’t much hope. India had 40,000 ventilators for its 1.3 billion population at the start of the pandemic and 1 doctor per 1500 people. [1,2] So, when this wave arrived, it quickly overwhelmed the existing healthcare infrastructure. Similar to the disaster scenarios invoked by Imperial College scientists in the UK, but in this case all the beds, and all the ventilators actually did quickly get occupied. [3] It seems to make sense that in a poorer country like ours, ventilators and the human resources to run them would be limiting, but what has turned out to be limiting is the distribution of oxygen in the ventilator and tubes. India makes a huge amount of oxygen for its heavy industries, which is stored and can be used for medical care, but this wave has overwhelmed the mechanisms for its distribution. 

Most hospitals don’t produce their own oxygen, but place oxygen in reservoirs that are supplied by tankers. These aren’t being supplied enough oxygen. There are reports that a hospital lost oxygen and 25 people died; another lost oxygen for 1 hour and 12 peopledied. [4,5] Our hospital has come close, but hasn’t yet run out of oxygen. In our ICUs we sometimes have to manually Ambu-bag because the ventilators stop working when the reservoir supplying oxygen depletes so much that its partial pressure becomes too low for these machines. These have been designed in developed countries and detect this as a malfunction. They aren’t designed to adapt and continue under oxygen scarcity as might now be expected in India. 

Oxygen is on everyone’s lips. Relatives of patients tell me how some people are creating new mobile numbers and deluging platforms with messages saying that they have oxygen available in cylinders or concentrators at oxygen prices and if an advance digital payment is made, they can supply it to them. The people who do make contact on behalf of their loved ones are deluged with messages saying that the cylinders are disappearing, last chance, that the death of their parent will be on their heads. After the payment is made, the number is deactivated. 

In an attempt to spread equity, the private-sector hospitals have been mandated by the State to treat covid-19 at capped prices. These hospitals form the majority of hospitals in India and charge fees for their services which they set themselves. The capped fees are affordable for a few more patients, but are still out of the reach of the majority of people here who would have to pay a month’s salary for a day’s hospitalisation, even at these price caps. Those who could pay for them before these caps are finding it hard to get into these hospitals, but the system still has ways of profiting using experimental therapies, for example etolizumab, a high-priced psoriasis drug whose emergency use authorisation (EUA) in India was hastily granted for a trial with 10 patients in the treatment arm vs 20 in the control arm. [6,7] 

I ask one of my patients  if he’d like to know what is going on outside and what he has missed, but then I think that might be dangerous. He might suffer if he really understood the scale of what is going on, so it is better if he stays in the dark. It flashes briefly across my mind that I might like to join him, but the next patient calls. 

Surajit Nundy, founder/CEO, Raxa Health and visiting consultant, Department of Internal Medicine, Sir GangaRam Hospital.

Competing interests: none declared.

References:

1. As coronavirus cases surge in India, 40,000 ventilators for 1.3bn people a worry [Internet]. Hindustan Times. 2020 [cited 2021 May 3];Available from: https://www.hindustantimes.com/india-news/as-coronavirus-cases-surge-in-india-40-000-ve ntilators-for-1-3bn-people-a-worry/story-2My7VOoMuqHpGmvosK3tvN.html
2. India has one doctor for every 1,457 citizens: Govt | India News – Times of India [Internet]. Times India. 2019 [cited 2021 May 3];Available from: https://timesofindia.indiatimes.com/india/india-has-one-doctor-for-every-1457-citizens-govt/a rticleshow/70077266.cms
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5. Delhi’s Batra hospital says 12 in ICU, including doctor, dead during oxygen shortage [Internet]. Indian Express. 2021 [cited 2021 May 3];Available from: https://indianexpress.com/article/cities/delhi/delhi-batra-hospital-oxygen-shortage-deaths-72 97942/
6. DCGI gives Nod for Restricted Emergency Use to Itolizumab for moderate to severe COVID-19 patients [Internet]. 2020 [cited 2021 May 3];Available from: pib.gov.in/Pressreleaseshare.aspx?PRID=1637926
7. Atal S, Fatima Z, Balakrishnan S. Approval of Itolizumab for COVID-19: A Premature Decision or Need of The Hour? Biodrugs 2020;1–7.