India should continue increase its medical capacity and resources to be better prepared for a third wave of the COVID-19 pandemic even when the number of cases go down, according to Dr Nandakumar Jairam.
Dr Jairam, who is an advisor to the Manipal Group and served under various capacities at IRDA, FICCI and National Accreditation Board for the Hospitals and Healthcare Providers, also believes that the third wave will affect children the most leading to a need for healthcare facilities to be set up which would cater to them.
"You have to build idle capacity. You have to be able to open such idle capacities at such short notice. You will have to be prepared for a different kind of disease in the coming months, and you will have to vaccinate, vaccinate and vaccinate.
"Now while we do that, it is important that we put in ventilators that work for adults and children. Because what science tells us is that the next wave is likely to affect children. So, if the infrastructure you put in is not going to be enough for the population that is going to be affected, then we are in trouble," Dr Jairam told BOOM Live.
Apart from increasing capacity, Dr Jairam stated that there also has to be plans in place to increase the medical manpower available to tackle COVID-19.
"Create manpower, very much like the Home Guard force, which is trained and even if they are not nurses, they could be other. They could be non-allopathic doctors, they could be physiotherapists, they could be others who could pitch in when the time comes. But their training should be carried on during this period," Dr Jairam Said.
Edited excerpts follow
Govindraj Ethiraj: Columbia Asia, which until recently you were Chairman of, has 11 hospitals, across Bangalore, Gurugram near New Delhi, Kolkata and many other places. From a facilities infrastructure point of view, what you have been seeing and how have you been coping?
Dr Nandakumar Jairam: So, we have principally our presence in Bangalore, where we have five hospitals and just to correct what you said, we have another hospital in Pune, which is the only hospital in Maharashtra. Well to tell you about COVID, it caught us by surprise last year. We were unprepared and had a disease that was not known to us, a disease that was probably new to mankind and nowhere in the globe did we have protocols for treatment.
So, the initial part was a lot of, kind of discussions, managing it, understanding the kind of virus it is, and hoping that the protocols that we have set, and of course with the help of Government of India and the ICMR, were appropriate for the patients.
Let me classify what we did into three buckets. Firstly, the non-medical infrastructure. What was very clear was that the circulating air in the hospital had to be completely separated for COVID patients compared to non-covid patients. And we had to have a green channel for the movement of patients, which did not allow contamination of those who were not infected.
This is one of the many changes that we had to do in order that we took care of this pandemic. Then there was the issue of the medical and nursing personnel who last year were not immunised and therefore highly susceptible. The lack of PPEs and other protective equipment and an understanding of how these should be worn, how one has to manage and so on and so forth. This set us thinking and not only that, we had to quickly improvise and manage earlier with less resources. Fortunately, they were quickly manufactured in large numbers in India and I compliment those that had done this substantially.
The third and most significant was to handle the morale of the medical staff. Not just the medical staff but every single person who was in the hospital--from fear and also to push them, and egg them on to continue to work. The number of people who had COVID at that time amongst the hospital staff was quite high and we had to manage them as well. But the situation is completely different this year. And perhaps I will talk about it as we continue our discussions.
So, to say, one was the psychological requirements of the staff that we had to handle. Secondly, was the medical protocol. And third was the infrastructure that we had to quickly address last year because the enemy, unknown and unseen had struck with swiftness and severity.
GE: What were April and May 2021 like, particularly in terms of the sheer demands for beds and what you have been able to manage?
NJ: Well, if last year was difficult, this year was more difficult in terms of managing beds. The situation was very different because over the year, two important things happened. Firstly, globally, clear protocols came into being. So, patients could be treated with better protocols, better understanding of the disease, and the way it manifests and so on and therefore standard of care became much clearer and it was easy to follow this at all levels, whether it was primary care, in the ICU or outside of the ICU.
The second was the fact that frontline workers, particularly the hospital staff, were immunised. And therefore, the risk of infections and the number of infections, in all fairness, has been significantly less this year. However, the tsunami that hit us in terms of requiring beds was something unimaginable.
Of course, we are not over the curve yet, but I believe that we have hit the top and are on the way down and hopefully it will stay that way. But several things had to be handled. Firstly, there were patients who did not need to be admitted, who sought hospital care, who pleaded to be admitted and who had to be spoken to and sent to Covid Care Centres which came up quickly.
The second, was to rapidly increase the number of beds available. Simply stated, the volume of people walking into the emergency room was so huge that we needed to do and help mankind. I must and very frankly admit, and I am sure I speak for the entire healthcare fraternity here, that the demand and supply was inadequate. There were heart-rendering situations where we had to see people wait and suffer for the want of ventilator and oxygen beds.
Today, I believe that the oxygen bed issue is much better but the ventilator bed issue still persists. Because there are sick patients for more than two weeks and until they get better this situation is going to continue. We also had to work with very very restricted staff numbers. You must understand a hospital, for example, that normally has 75 inpatients, had to manage and accommodate a 115, which was a stupendous task, with the stated, the same kind of manpower that we had before because you cannot produce doctors and nurses from thin air, they are in short supply.
However, my compliments to the entire nursing fraternity and medical fraternity. The way they have stood up tells me…. that there is hope for the future of mankind. They are indeed the angels of today.
GE: When you said 75 patients going up to 115, is this one hospital that you are specifically referring to. Is this the proportion that you would have seen across the hospitals across the country?
NJ: Yes and no. The demand in certain cities was very high. In our hospital in Gurgaon, it was high. In our hospitals in Bangalore, it was huge. It was also high in Pune, definitely. But I do not believe that the pressure was much in our Kolkata hospital or perhaps we are going to see that in the coming weeks. But the maximum impact because of our larger presence was in the city of Bangalore.
GE: Tell us about how you were or are distributing infrastructure. Now we are seeing the arrival of more oxygen concentrators, liquid oxygen cylinders and so on. But at the point when you were at the peak how were you allocating resources and how was that different?
NJ: Yes, so we did very many innovative things. For example, I just have to deviate here and say that the way in which our hospitals are planned, our single rooms are very large. It can easily accommodate two beds and then there are multi-bedded rooms where additional beds could be put in.
So simply what we did was to increase the bed capacity. There is another thing, and it is fortunately so that some of our hospitals were not fully occupied. We had idle space, which we quickly ramped up and of course we converted the single rooms into double rooms. That reduced the privacy no doubt. But let us look at it fairly. If between saving lives and giving privacy you have to choose. The choice is very easy.
Now there are other things that I should really say that I am thankful for. When we started the first hospital in Bangalore, we decided that every single bed will have an oxygen portal. We also invested in liquid oxygen in almost all our hospitals. This paid off very richly. We were fortunate in that we hardly had a serious issue of oxygen in our Bangalore hospitals.
We did have an issue in our Gurugram Hospitals but by and large it was not as bad as what my other healthcare fraternity have suffered during this period. And I must say that the lessons learnt will stand in good stead for the coming months and years
GE: What are the takeaways in the way you were achieving greater efficiency with existing machines and manpower?
NJ: I think there are several lessons. Firstly, I know a lot of finger pointing is going on as to why this wave was not anticipated and so on and so forth but let us be honest. I believe that many of us as human beings relaxed as the numbers of the first wave came down.
We did not anticipate the second wave, the ferociousness with which it hit us and certainly we did not anticipate that we would be faced with a situation that was worse than what it was in the first wave. There is another thing that we are clear about--the pattern of the disease and the kind of people who are affected is not going to be the same.
In the initial wave elderly people were the biggest sufferers, youngsters were relatively spared and most of them had very mild illness. This time there were others who were much younger, who suffered fairly severely and unfortunate deaths of younger bread-winners and so on and so forth has really been a very tragic instance this time. What it tells us is as follows.
You cannot sit back. You have to build idle capacity. You have to be able to open such idle capacities at such short notice. You will have to be prepared for a different kind of disease in the coming months, and you will have to vaccinate, vaccinate and vaccinate. So, every hospital infrastructure and every available opportunity must be taken to achieve each of the mentioned because that is the way for the future.
For example, now, among social initiatives which I am also a part of, there is an attempt to set up modular ICU beds in government hospitals to increase capacity rapidly. Now while we do that, it is important that we put in ventilators that work for adults and children. Because all of us have been told, and we do not know, but this is what science tells us, the next wave is likely to affect children. So, if the infrastructure you put in is not going to be enough for the population that is going to be affected, then we are in trouble.
So, if I can put my priorities, I would say do not stop creating capacity even if it is likely to stay idle for some time. Create the correct kind of capacity based on the evidence available to you. Create manpower, very much like the Home Guard force, which is trained and even if they are not nurses, they could be other.
So, they could be non-allopathic doctors, they could be physiotherapists, they could be others who could pitch in when the time comes. But their training should be carried on during this period. And of course, vaccinate.
GE: You spoke about children. If you could throw light on why you say this based on your understanding? Some states like Rajasthan have declared 'black fungus' as an epidemic in itself under a pandemic. So now this is something perhaps was not anticipated, though black fungus was seen even in wave one. Would hospitals also need to be prepared for outcomes like this wherein patients may have got cured of COVID but they then face symptoms like black fungus which are deadly in themselves?
NJ: Yes, actually I have not mentioned one important fact and that is need to follow the standard of care. Among the doctor fraternity in the country there are people who follow what is advised as evidence-based, meaning there is a certain prescription that has to be followed and you follow it to a T, and then you are evidence based.
But if you do not and if you use some drugs indiscriminately--in this case it is steroids--and you land with this issue. And mucormycosis or black fungus, is an unfortunate sequence of Covid which has been probably overtreated with steroids. In the presence of mucormycotic course reduced immunity, fungus will definitely be there.
Now, we then go back to say that every single doctor must be spoken to, advised to follow protocols and not deviate from it for any reason.
Yes, the evidence points to children being more vulnerable in the coming wave. One of the strong reasons for that is they are the least vaccinated. Children have hardly been given vaccines because we do not know its safety in children. So, there is a need for us to develop a vaccine or support the development of vaccine that will work with efficiency among children and quickly vaccinate that category as well. Because the children are very likely to rapidly spread the condition.
Imagine if the schools open and if there is one child that is infected, the speed at which the virus can spread to the others is huge. So simply stated they are the most vulnerable section of the society today, globally.
GE: You talked about two areas, one is children as a potential future area of concern, the other the over prescription of steroids and doctors not following evidence-based approaches. What is it that we can do from a more macro policy point of view?
NJ: There are certain things that happen and I believe that the best method is to repetitively convey to the community that treats these patients the protocols that need to be followed and the problems of not doing so. No doctor in their rightful sense is likely to prescribe a drug, if they know it is likely to cause mucormycosis.
So, by repetitive information dispersing, which is easy today with social media, WhatsApp and bodies like the National Medical Council, various states should blast the protocol in WhatsApp to all the doctors to ensure that they are in knowledge.
The second thing we have to do is propagate the importance and safety of the vaccine much more than what we have done. I think we did a good job. We had the leaders themselves demonstrating that they were being vaccinated as proof that they were accepting it. But we need to do more.
We need to get others--cricketers, film stars, and various others to propagate among people and say that please vaccinate yourself, it is safe, that this vaccine is not made by any political party, it is made for you by the country.
GE: People who suffer or have suffered from other diseases, how have they managed in this period, particularly from your hospital point of view and their relationships with patients, especially with COVID being the major / or is going to consume most medical and hospital administration resources in?
NJ: Basically, what I would say is that the non-COVID work has come down in volume automatically. People have stopped going to hospitals for the fear of contracting COVID. But you must understand that there are several categories of people with non-Covid conditions. We have those who can wait.
I am sure all of us know of a condition called hernia, which is quite safe by and large unless it is complicated. And you can delay the surgery for hernia by several months without any worries. Many of these conditions have automatically taken the back burner.
There are others. Patients who have cancer for example. While it is not an emergency, the longer you wait to get treated, the less likely are you to be cured. So, in such a situation between the doctor and the patient a decision to take a risk or otherwise is taken and patients are taken care of.
The third category is emergency--where whatever it may be, it could be an intestine that is ruptured, an ulcer that is ruptured, bleeding there you have no choice. Just take the patient in and treat. In all fairness, I would say, when compared to the first wave when elective work came down tremendously, in the second wave there is a certain amount of confidence amongst people and they do seek attention for the latter two that I have mentioned.
GE: What is your advice to citizens, potential patients on when to approach a hospital or when not to approach a hospital in the coming months, or maybe years?
NJ: So, I will classify that into Covid-like and non-Covid. If you have Covid like systems, I would suggest that the first thing that you would do is what is already well known and advocated, mask yourself, isolate yourself wherever you are or seek tele consults with the doctor. If you have difficulty breathing, then you need to go to a centre. That is one symptom that you should be aware of that tells you that you are at risk. It is this symptom that should prompt you to seek physical medical attention at an appropriate place.
If you have a non-COVID condition please address it as far as you can through tele consultation. Tele-consults are becoming popular, doctors are becoming much more capable of understanding over a phone call or a video what your problem is and then decide. But if you have certain symptoms, obviously chest pain, all of us know that it could mean a heartache. Do not wait.
Wear a mask, preferably an N95 and reach a hospital, and I am sure you will be taken care of. It is difficult sometimes to predict which is an emergency and what is not, but then that is as far as we can go in terms of advice.