Some things have worked… and yet way to go with Covid-19

-  Dr. Rama Shyam, Programme Director, Empowerment, Health & Sexuality of Adolescents (EHSAS), SNEHA

Up to the brim and spilling over

As Mumbai emerges as the leader in Covid-19 infections in India, it is significant to understand the situational context and the problem in all its complexity. According to the Census of India 2011, Mumbai city, as it falls under the jurisdiction of the Municipal Corporation of Greater Mumbai (MCGM), accommodates a population of 12.3 million. While MCGM is part of the larger Mumbai Metropolitan Region (MMR) comprising eight municipal corporations, the population density in Mumbai alone is 28575/sq.km. – highest in the country and six times denser than MMR (4765/sq.km.) [1]. Technically, the public health department of MCGM is responsible for the health of this population and one visit to any of the medical colleges attached to the four tertiary hospitals – Sion, KEM, Nair and R N Cooper as they are commonly known – is enough to overwhelm the visitor with the magnitude of health concerns MCGM caters to.

Whenever a health provider (doctor, nurse/other) tests COVID-19 positive, many associate health workers need to be quarantined as well…posing a huge human resource challenge in public health facilities!

Mumbai is no ordinary city and alluding back to the highest population density, we must reckon that very closely packed informal settlements make up for 41% of this island city. These are the colonies of dreams, where thousands of migrants from across the country employed in the unorganised sector live in duress with inadequate basic amenities. 208 MCGM primary health posts [2] – each catering to one lakh population – enumerate the health issues of this bulging human pool. In the current Covid-19 crisis, it is this skewed population and available health services ratio that has been thrown into sharp relief. 

What meets the eye…

It was 13th March 2020. The ultimate lockdown had not been announced yet, but schools had closed, offices were closing down and just a sweeping eye across the skyline would stare at preventive messages on Covid-19 mounted on each billboard that one could find! This was MCGM messaging at its aggressive best across the length and breadth of the city, capturing the otherwise colourful illusions of Bollywood blockbusters or Netflix and Hotstar releases!

While the first Covid-19 positive case in Mumbai was reported on 11th March, the police stations had already received instructions to disallow large gatherings since 6th March. We realised this first hand as all our International Women’s Day events had to be cancelled owing to these directives. The public health department had been able to anticipate the magnitude of the spread by the first week of March or may be much earlier and had swung into action. Our teams visiting the Kasturba hospital and in touch with the Nair hospital were alerted that health providers across public health facilities must be prepared for preventive interventions across their own geographies. Extensive thermal Scanning travellers at the airports continued, albeit with certain challenges and even slipped in some cases.

Mumbai unseen…responsiveness during Covid-19

As ordinary citizens, we obviously do not get to witness efforts made by the public health department. Friends have mentioned how institutions – hotels, guest houses, private offices, PWD set ups etc. – were identified for isolating contacts of COVID-19 patients by the first week of March 2020. The fact that right from Community health Volunteers (CHVs), ANMs and up to the Executive Health Officer (EHO) are standing up to the COVID-19 crisis management while running routine services is not something that we are likely to be aware of. This reassurance was affirmed when I witnessed an organised queue outside Gazdar Hall in Andheri West – people seeking routine services at the MCGM dispensary.

Our public health workers are standing up to the colossal challenge despite resource constraints of inadequate Personal Protective Equipment (PPE) kits, medicines and infrastructure. A retired doctor friend recounted how her husband, an elderly laboratory specialist has been fighting with the management of a hospital to ensure the safety of his team members. This specialist “lives like an untouchable in his own house, with no contact with family and owes it to his other peers who continue to stay at health facilities and do not get to return home for fear of contaminating others around”.

Amidst the multiplicity of efforts, citizens like me have continuously fallen back on the public institutions and the go to node has been 1916, the toll free helpline number set up by the Municipal Corporation of Greater Mumbai (MCGM) and now committed to all kinds of assistance related to the Covid-19 crisis. Any person at the other end of the helpline has been extremely proactive, directing people to Medical Officers at health posts, sharing phone numbers of police personnel or localized control rooms, connecting callers with municipal hospitals, maternity homes and Medical Officers of Health (MOH) or with helpline numbers meant to assist stranded daily wagers from other states. In one case, a caller who was seeking guidance for health workers assisting a terminally ill cancer patient who had returned from Saudi Arabia, felt comforted with the systematic response.

We do not have enough PPE kits. Once a suit (N-95 mask and all) is donned, the health provider cannot drink water, eat food or take even a toilet break for 6 hours, to ensure that this ONE KIT is utilised optimally!

Especially, on Covid-19, officials taking calls at 1916 have asked for travel history, symptoms and have accordingly guided with messages and steps to be taken. What remains with callers are, “…prompt response that soothed frayed nerves, asking us not to panic and seek help if needed”.

In densely packed informal settlements, demarcating containment zones emerged as one of the biggest limitations for Mumbai’s public health department. In a bid to tackle the novel coronavirus in a top down manner, the public health department had not paid much attention to training Community Health Volunteers (CHVs). Armed with incisive understanding about ‘plots’ in thickly populated settlements such as Malvani, Dharavi and Govandi, this potent army could have aggressively charged ahead with supporting the police and ward offices in mapping out containment zones or promoting preventive messages. They were brought in after much delay and that too with inadequate protective gear! With assistance from SNEHA, contact tracing was carried out and now the Health Post staff has asked CHVs and community members to refer symptomatic cases to a dispensary created as a first stop response center.

It’s been a hard stop… yet there are opportunities to be seized

Even as the Covid-19 tracker for Mumbai has been ticking fast and furious, the vulnerable and those stranded in the city have grappled with much more. Food crisis aggravated with delayed response from the Public Distribution System (PDS). Domestic violence crowned its ugly head amidst a lockdown where perpetrators and survivors are in the closest proximity. Delayed or no services for women in distress, especially with no access to medical termination of pregnancies is another cause for concern. A lack of coordination between the Municipal Corporation and the other executive departments in the state became conspicuous. By the time the PDS was getting streamlined, the MCGM had stepped in to distribute food grains in collaboration with civil society organisations and community networks.

Masks and hand sanitisers were arranged for health post workers; ASHA workers and MAS members were trained to deliver preventive messages on Covid-19; Our One Stop Crisis Centre at the KEM hospital and Palliative Services have been running their regular course

At SNEHA, it is this crisis that turned into a litmus test for the decades of relationship building with public health workers and professionals alike. While Medical Officers (MO) from health posts of different municipal corporations just poured their hearts out to our team members, their superiors requested PPE kits for their teams, even as senior decision makers relied on us, for volunteers who could step in to assist frontline public health workers. Besides Covid-19 support work, maternity referral reviews have been conducted together and AnteNatal Care (ANC) registrations have been monitored. Pregnant women from other states – from as far as Jharkhand in one instance – stranded in Mumbai have been assisted with registrations at MCGM maternity hospitals.

It was 9.30 pm in the night when a pregnant woman in her seventh month reached the Vasai Virar Municipal Corporation maternity home. Detecting alarmingly low heamoglobin levels (Hb less than 5 g/dl), the doctor at the maternity centre called up our team member and hours of coordination led to referral to Mumbai’s Nair Hospital. The doctor accompanied the woman to the hospital in an ambulance at 2.00 am in the night, but the patient passed away on the way. While Covid-19 crisis management continues, there are other essential health services to be taken care of and the going is tough indeed.

As we can only imagine what the post lockdown scenario would look like, there are certain changing patterns that can be discerned. Citizens from informal settlements have been repeatedly calling the 1916 helpline or reaching out to local municipal officials or elected representatives to get their localities disinfected or sanitised. Questions on hand hygiene and the significance of washing hands have featured continuously through online training sessions. Conversations mill around immunity boosting food and the relevance of Vitamin C. Coping with isolation crops up every now and then – across gender and age groups. Addressing domestic violence is fast gaining much needed vigour all around the globe.

Groups of people quarantined in various locations have started returning home – healthy and in high spirits! They wish to become ambassadors for preventive messages on HAND HYGIENE and maintaining social distancing

Though sustainable behaviour change is a long haul, it seems like an opportunity to be seized. The Covid-19 crisis has thrown us headlong into working with people and systems. Together, we can hope to institutionalise hand washing and respiratory hygiene, disciplined social distancing – some civility with forming queues without crushing each other – food security and access to better sanitation. One wonders if these could become ways of life in this crowded megapolis, even as we continue with support for mental health and intervene against gender based violence.

[1] M. G. Rao. (2018). Mumbai Metropolitan City Finances. Draft ESCAP Working paper. United Nations Economic and Social Commission for Asia and Pacific

[2] Health Services