The Supreme Court of India recently praised “The Mumbai Model” in responding to the second wave of covid-19 and asked other Indian states to draw from its experience.
In early to mid-April, the state of Maharashtra and its capital Mumbai were at the epicentre of the covid-19 pandemic contributing nearly 30-50% of all cases across India. The number of cases has now dipped even as the disease has spread more widely across the country. Lockdown measures were enforced from mid-April with cases peaking at over 11,000 each day in Mumbai. Hospitals were quickly overwhelmed. The public had to source everything themselves including treatments for covid-19, oxygen cylinders, and hospital beds. Most people in the city will have received a distress call from a covid-affected family.
In a matter of a few days however, single-point helpline numbers were being circulated for any covid-related query or requirement. The city is administratively divided into wards. The Mumbai Model focused on decentralising the covid-19 response with ward-level triage, supervision, and contact tracing. Each ward has a covid “war room” and response team with a single helpline number to respond to queries. The ward control room is equipped with dashboards for live tracking and allocation of hospital beds. These became the first point of contact for patients trying to find an available hospital bed near their residence without having to shuttle between hospitals. This helped avoid delay, deterioration, and further transmission. Patients are triaged over the phone based on severity so only patients with moderate or severe disease were hospitalized. After a brief oxygen shortage crisis, prompt guidelines were issued to hospitals across the state on when to use oxygen and when to avoid using high flow nasal oxygen. This was backed by continuous audit of oxygen consumption and identifying sources for oxygen supply. Hospital bed turnaround times were closely managed with decisions on discharge or transfer to covid care centres once the patient had stabilised. Strict guidelines were enforced for labs to issue covid-19 test reports within 24 – 48 hours for early detection and isolation. Covid positive reports were not handed directly to the patient, rather these were routed through the municipal office who contacted the patient to discuss next steps.
Early on a Saturday morning, we received a phone call from the local ward office informing us that one in our family had tested positive. The caller did a risk assessment asking for exposure, symptoms, age, and comorbidities and accordingly advised hospital admission. We assured them that we would be able to manage our relative at home under medical supervision and that we have enough space for isolation. They agreed to let us proceed. Within an hour, we had a local ward official at our door. She inquired about symptoms in all family members and put stamps on our hand declaring dates until when we would be under quarantine. She checked and documented the pulse oximeter reading for the patient. In another hour we had a garbage cleaner wearing personal protective equipment (PPE) at our door to collect our garbage in a biomedical waste bag separate from the rest of the building. He handed us bags for the next day and this continued for the entire quarantine period. He was followed shortly by a team to sanitize the entire premises. Home-based testing was available with prompt online reporting of test results by labs.
Annual work performance reviews have a rating for going “above and beyond” the objectives of the role. Each one of the people who helped us went above and beyond their duties. Fellow doctors have mentioned how the municipal ward offices have responded promptly to requests to transfer covid patients to designated public hospitals. At a children’s shelter that I oversee, after the first covid case was detected, the local ward arranged testing for all staff and kids and sanitization of the premises the very next day. The centre was quarantined and further cases have been smoothly transferred for testing and admission at designated covid care centres. If you have ever lived in India, you would know that not much moves without multiple calls and appeals. We are mighty impressed by the change and the seriousness of action. No one is cutting corners.
The response system put in place has merits, but is certainly not foolproof. There have been shortages, lapses, delays, and needless loss of life. As more cities in India adopt the Mumbai Model for the covid-19 response, quicker sharing of lessons and resources will help put up a unified front to continue to counter the pandemic in the country. The state of Kerala has done well to reduce vaccine wastage. Boosting the vaccination drive is a crucial priority over the coming months as well as disease surveillance and response as lockdown restrictions are eased.
Honest, responsive, and forthright leadership at each level will be critical. Not a day goes by without people questioning whether this second wave could have been prevented, or the impact reduced by earlier and more responsive action. There is still more to be done and a long way to go.
Anita Jain is a family doctor in Mumbai and clinical editor with The BMJ.
Competing interests: none declared.