personal protection equipment

COVID-19: At Delhi Hospital Where Nurse Died, Others Say They Were Made to Reuse PPE

While nurses at Kalra hospital said they have not been provided sufficient equipment, the hospital’s owner has denied the allegation.

New Delhi: Nurses at Kalra Hospital in Delhi’s Safdarjung Hospital, where 46-year-old nurse Ambika P.K. had recently died due to COVID-19, have alleged that they were asked to reuse personal protective equipment (PPE), including gloves and masks, for the past two months.

“While the doctors were given fresh PPE, the nurses were asked to reuse PPE. If we raised objections, we were told that since this is not a designated COVID-19 hospital, we are at little risk, and can reuse PPE,” a senior nurse at the Kalra Hospital told the Indian Express.

Another nurse close to Ambika disclosed that on her last day on duty a week ago, she had raised the issue of non-availability of “fresh PPE and masks” with the nursing in-charge.

On May 18, after finishing her morning shift, she complained of fever, bad throat and body ache and didn’t come for the night shift. On May 21, after she developed difficulty in breathing, she was taken to Safdarjung Hospital.

Ambika succumbed to COVID-19 on the afternoon of May 24. She had been working at the Kalra hospital’s neonatal wing for the past ten years and was recently deputed at the ICU. She lived in Delhi along with her 16-year-old daughter. Her husband resides in Malaysia and her son in Kerala.

“My mother’s condition deteriorated so rapidly. I couldn’t understand how to get here sooner. Over a week ago, she mentioned that the hospital was making her reuse PPE and charging money for masks. I got agitated and told her to just stay at home, but she didn’t listen to me. She continued working, and now she is dead,” Ambika’s 22-year-old son Akhil told the Indian Express.

Doctors at the hospital had also objected to nurses wearing used PPE. “The doctor said he won’t allow us in, and tore the discarded PPE. He said it wasn’t safe for us or the staff or patients. So, we have been wearing the OT gown instead. Instead of N95 masks, we have been given washable cloth masks,” said a senior nurse at the hospital.

Also read: Low Wages, Poor PPE: Contractual Healthcare Workers Face the Worst of the Pandemic

Meanwhile, nurses at Kalra Hospital have decided not to go to work until adequate safety arrangements were instituted. “Today it’s Ambika, tomorrow it can be me. I have not reported to work since Ambika’s death. Our neighbours aren’t happy about having a nurse next door,” a senior nurse said.

A nurse at the hospital said her parents “pleaded with her to skip work after they read about Ambika’s death”.

The hospital owner, R.N. Kalra, has denied the allegations saying that adequate PPE and hand sanitisers were being provided to all employees. “I have not received a single complaint from any staffer. If there is a single discrepancy, I will investigate and take strict action,” he said.

Similarly, nurses in-charge S. Wilson and Anita Soni, also denied the allegations and said, “PPE, gloves and sanitisers are available in bulk.”

Following Ambika’s death, the MP from her native place of Kerala’s Pathanamthitta, Anto Antony wrote to Prime Minister Narendra Modi requesting the release of insurance cover of Rs 50 lakh to Ambika’s family. He even alleged that private hospitals were not providing any kind of protective material, including N95 masks, to staff employed in their hospitals.

He has also written to Delhi chief minister Arvind Kejriwal, asking for Rs one crore compensation for Ambika’s family.

Kalra Hospital in Delhi’s Kirti Nagar. Photo: kalrahospital/Facebook

“She is the first nurse in India who lost her life due to COVID-19. There are reports that nurses and healthcare workers in several hospitals in Delhi are forced to work without protective equipment even now. It is also requested to take urgent measures to ensure that hospitals are taking all mandatory measures to ensure safety of health workers,” Rajya Sabha MP K.K. Ragesh wrote to Kejriwal.

AIIMS Delhi’s senior sanitation supervisor passes away

On Monday, COVID-19 claimed the life of another worker who was working without protective gear at AIIMS, New Delhi. Senior sanitation supervisor Heera Lal had developed symptoms of COVID-19 last Tuesday. He was asked to rest at home after the hospital conducted his blood test but after a few days, his condition deteriorated. He was rushed to the emergency ward where he tested positive and died within a week.

“People whose roles need them to engage with all kinds of potential infection sources should get priority in protective gear. We have hundreds of sanitation staffers who are constantly on the job and at risk,” said Kuldip Singh, General Secretary of AIIMS’ SC-ST Association.

Ironically, on Thursday, the Union government claimed that it had become the world’s second-largest manufacturer of personal protective equipment (PPE), after China.

Low Wages, Poor PPE: Contractual Healthcare Workers Face the Worst of the Pandemic

Similar to a large section of the unorganised working class, health workers are fatigued but are left to fend for themselves during the COVID-19 pandemic.

Several reports from different states in India have highlighted the risk that health workers have been exposed to as they treat COVID-19 patients.

These risks can be attributed to the virulence of the infection and the lack of preparedness of hospitals in dealing with the pandemic. There are several important aspects for preparedness of hospitals and these include creating isolation wards and intensive care facilities, ventilators and other supportive equipment, protocols for treatment and infection control and personal protective equipment for health personnel.

The availability of these inputs has been varied across both public and private hospitals in India. But the weakest link has been the availability of PPEs – that includes sanitisers, masks, gloves and gowns – for health workers. Shortage of such essential protective gear has affected doctors, nurses, technicians, and sanitary workers in hospitals and frontline workers in the community.

Personnel in the public and private hospitals have faced a shortage of PPEs. Several nurses and doctors have tested positive for COVID-19 even in internationally accredited tertiary private hospitals in Mumbai and Delhi. In early April, we did not have the required machinery to stitch PPEs and had to depend on China for its supply. The PPEs imported from China fell short of the prescribed standards so they had to be dumped. A great deal of time was lost in getting the required number of PPEs because of import dependency for a range of medical equipment.

Also read: No Food, Water, Toilets: Life After Testing Positive for Delhi Health Care Workers

A significant number of doctors and nurses have already contracted COVID-19 from patients during the lockdown. This directly raises questions about the availability and accessibility of Personal Protective Equipment (PPE) for healthcare personnel. If PPEs are in short supply, then its availability for the lower rungs of health workers in an institutional and community setting is compromised.

While doctors and nurses were vocal in raising concern about the shortage, equally at risk of acquiring the infection were the technicians, nursing orderlies, cleaning staff and security personnel in a hospital. Although the government claims that the problem of availability has been alleviated with the production of PPEs ramped up to two lakhs per day, there have been questions about its quality and distribution.

Many nurses and doctors have reportedly had to share, and reuse their PPEs owing to limited supply, even though PPEs are made for one-time use. In Maharashtra, which has the highest number of COVID-19 cases, the shortage of PPEs at the secondary and tertiary hospitals may have possibly been alleviated, however as shared by health activists, at the primary level the shortage of PPEs continues.

The public health workforce today is highly differentiated in terms of job security, wages, entitlements and privileges owing to extensive contractualisation in the public sector. As a result, a mix of permanent, contract and outsourced workers work side by side in the same institution. The outsourced workers, owing to the temporary nature of their engagement, do not have a voice at the decision-making table and their predicament goes unheard.

Health workers dispose of medical waste in open at a government hospital, during the ongoing nationwide COVID-19 lockdown, in New Delhi, Thursday, May 14, 2020. Photo: PTI/Kamal Kishore

Since these workers are on a contract, the government is not accountable for their vulnerabilities and risk of exposure to COVID-19. What this epidemic has highlighted is the callous attitude of the government and the public towards even the doctors and nurses in hospitals. Evoking the National Disaster Management Act means that all public sector employees in hospitals are forced to work irrespective of the risks and dangers that they are exposed to. As a consequence, several private hospitals shut down when their health workers contracted the infection.

Also read: India Urgently Needs Quarantine Guidelines for Its Health Care Workers

The COVID-19 epidemic has exposed the manifold layers of vulnerability that health workers face in hospitals. Those who occupy the lower rungs in the work hierarchy face additional risks – low wages, job insecurity, poor protective measures and increased susceptibility to infection. The community-level workers like ASHAs workers face a similar predicament. They are given the task of creating awareness and identifying potential COVID-19 cases but are not being remunerated adequately for the risks that they have to face on a daily basis.

The COVID-19 pandemic has demonstrated the need for strengthening the public health systems. It is an opportunity for the Indian government to reimagine public health by increasing investments and also to correct some of the anomalies that have become entrenched.

An important aspect that requires attention is investment in human resources for health. Outsourcing, contracting, and other precarious employment mechanisms have created divides within the workforce, where one lot is privileged with access to government benefits, and others are grappling with job insecurity and poor wages.

Standing at the juncture of relaxing the lockdown, and resuming economic activity, as we move ahead dealing with COVID 19, the concerns of health care workers spanning across the hierarchy need to be addressed. The recent case where government doctors in the national capital did not receive their salaries for the last three months exemplifies the callousness of the government.

Political gimmickry is employed to ‘honour corona warriors’ while basic protective equipment is not being provided! If this is the reality for government doctors who have secure employment then one can only imagine the plight of contract workers in the health sector. Similar to a large section of the unorganised working class, health workers are fatigued but are left to fend for themselves during the COVID-19 pandemic.

Rama V. Baru is a professor and Seemi Zafar is a research scholar at the Centre of Social Medicine and Community, Jawaharlal Nehru University, New Delhi.

The Government Must Stop Appeasing the Private Healthcare Sector

The private sector is more focused on seeking support for itself, rather than volunteering to partner with the government in dealing with a public health crisis.

The central government has shown immense ‘political will’ by imposing severe lockdown measures to contain the COVID-19 pandemic. While various arms of the state have been summoned to ensure that the ‘lockdown’ is successful, there seems to be no such urgency to ‘lock-in’ private hospitals to address what has been declared as a national emergency.

In a recent column, Indu Bhushan, the CEO of Ayushman Bharat, approached the private sector with kid gloves, seeking cooperation, but not requisitioning it. During this period of acute crisis, one would have thought that the central government would have been far more proactive in requisitioning the private sector to provide emergency services, rather than merely plead and urge.

The National Disaster Management Act, in fact, has provisions for the state to requisition required services to handle precisely such emergencies. In the case of the COVID-19 pandemic, private hospitals should play an important role in dealing with the moderate and severe cases that require hospitalisation, making their ICU facilities and isolation wards available. Some state governments have in fact requisitioned private hospitals to supplement the public sector. However, the experience so far has been mixed.

The preparedness of private hospitals in dealing with the COVID-19 epidemic and the extremely variable quality of services in the poorly regulated private sector is now becoming apparent. Even internationally accredited hospitals in Mumbai and Delhi were ill-prepared to deal with the outbreak of coronavirus.

A large number of health workers in these hospitals tested positive since they did not have adequate Personal Protection Equipment (PPEs) for doctors, nurses and other staff members. Once the positive cases were identified, some of these hospitals shut down. While there are reports of a few corporate hospitals offering treatment for COVID-19 cases, this does not amount to a systemic strategy for engaging a highly differentiated private sector.

Also read: COVID-19: The Government Needs to Incentivise Private Sector Participation

The lack of PPEs affects both private and public hospitals and a large number of doctors and nurses in the latter have also tested positive. The difference, of course, has been that while private sector hospitals simply shut shop claiming inadequate capacity and capability, public sector hospitals have to plod on, exposed to all the risks. All public sector hospitals continue to provide services despite the multiple challenges and constraints they face. In several states, retired government doctors and nurses have been re-employed to meet staff shortages.

One way in which the private sector can be requisitioned to help the public sector would be through the redeployment of staff from the former to the latter. Another way in which private hospitals can step in and help would be by providing routine care and addressing special needs that arise out of the epidemic and the lockdown.

Bhushan has appealed to the private sector for its wholehearted participation in the fight against COVID-19. This was premised on the 71st round of the National Sample Survey that shows that a large section of the population is dependent on the private sector for outpatient and in-patient care. Data regarding this has been available to the government for a while now.

Hospital staff is seen outside the Special Isolation Ward set up to provide treatment to any suspected case of the coronavirus (CoV) at the Rajiv Gandhi Government General Hospital, in Chennai, Tuesday, Jan. 28, 2020. Photo: PTI

It is surprising that such information was not used in health care planning by NITI Aayog. Or does this demonstrate a lack of communication between multiple authorities – the NITI Aayog, the Ministry of Health and the Ayushman Bharat that are addressing the COVID-19 pandemic? Is the second week into the lockdown not a little late for prescriptive suggestions from a government institution that administers a public insurance scheme?

Those administering Ayushman Bharat ought to have drawn up plans for including the private sector as part of a broader strategy of public-private partnership in the management of COVID-19. The lockdown has affected livelihoods of millions in the unorganised sector, small, medium and large businesses. They are being forced to bear the losses imposed on them by the government’s policy of a lockdown. By the same logic, the government ought to have demanded that the private sector also chip in and show its commitment to the national effort.

Also read: Why India’s Founders Championed a State-Dominated Healthcare System

In the midst of a humanitarian crisis and a national effort to address the same, the hospital committee of a premier business organisation, FICCI, and a private consulting firm, Ernst and Young, have only sought to promote the interests of the private hospital sector. The FICCI report highlights the financial distress that private hospitals face due to a drop in patient footfall.

This distress is minuscule compared to the distress of those who have lost their livelihood due to the lockdown. The demands being made include indirect tax reliefs, exemptions, waivers like recoup amounts equivalent to ineligible GST credits paid on procurements for a stipulated period; customs duty or GST exemption on essential medicines, consumables and devices for treatment of COVID patients; waiver or reduction of health cess on medical devices, extension of time under the EPCG scheme etc. income tax benefits and deferment of statutory liability payments without interest, the penalty for a stipulated period (3-6 months) and a rebate on the commercial rate of power for a stipulated period.

The private healthcare sector is more focused on seeking government support for itself, rather than volunteering to partner with the government in dealing with a public health crisis.

Rama. V. Baru and Ramila Bisht are professors at the Centre for Social Medicine and Community Health, JNU.

Andhra Pradesh: As COVID-19 Cases Rise, so Do Concerns About Lack of Equipment

Many districts also do not have testing laboratories, while doctors have complained about lack of PPE.

Vijayawada: The government of Andhra Pradesh has gone full steam to combat the COVID-19 pandemic, as K.S. Jawahar Reddy, special chief secretary of the Department of Medical and Health on Tuesday confirmed that the state is now in the “initial stages” of community transmission.

Up to April 1, only 44 positive cases were reported in the state but the numbers surged to 348 with four fatal cases as on April 10, according to the government’s media bulletin. Initially, only persons with foreign travel history tested positive for the virus, after which some of their family members got infected.

After more than half a dozen people who had no history of foreign travel were found to have the viral infection, the government started looking at the possibility of stage-III transmission. If the Centre decides to lift the lockdown, the Andhra Pradesh government is planning to continue restrictions on movement in identified and potential hotspots.

The lack of sufficient labs for testing suspected COVID-19 cases stares at the nearly 1 lakh doctors, paramedics, nurses and the other health workers engaged in containing the virus. Kurnool in Rayalaseema region, is one of the hotspots in the state and witnessed a sudden rise of cases in the span of a week. It does not have a virology lab for testing COVID-19 cases. The samples are collected and referred either to the Sri Venkateswara Institute of Medical Sciences (SVIMS) in Tirupati or to Anantapur district for confirmation.

West Godavari, the native district of health minister Alla Kali Krishna Srinivas aka Nani, also does not have a testing lab. But officials recently declared a locality named Tangellamudi, on the suburbs of Eluru city as a “red zone” after it saw a spurt in COVID-19 cases. Samples are being sent to Vijayawada for confirmation. West Godavari registered 14 cases, six from Tangellamudi area alone.

Also Read: Rainwear, Cloth Masks: Across India, Doctors, Nurses Grow Restive in Absence of Basic Protective Gear

There is only one lab in Visakhapatnam for the whole north coastal region, which includes three backward districts. A doctor, Sudhakar, heading an area hospital at Narsipatnam in the Agency area of Visakhapatnam, raised his voice over the lack of basic facilities, including personal protective equipment (PPE), face masks and kits. He was later suspended by the government, citing violation of conduct rules.

Many instances of doctors contracting infection

While the government has denied his claims, doctors who are treating COVID-19 patients are increasingly facing the risk of exposure. An orthopaedic doctor in Nellore is reportedly in critical condition after he was infected with the virus. District medical and health officer Rajyalakshmi was quoted in the media as saying that he could have contracted the infection from a patient he treated.

The infected orthopaedic was taken to a corporate hospital in the town for treatment, where nearly two dozen doctors and nurses have now been quarantined. It all speaks of the risk the health personnel are facing for want of PPE such as N95 face masks.

Man with a mask. Photo: Reuters

Confirmed cases of the viral infection have been shooting up across the state, after more than 1,000 people who returned from a religious gathering in Delhi’s Nizamuddin area. This has multiplied the task of screening for health personnel, especially when concerns exist about the lack of PPE.

To meet the challenge, the state government aims to carry out 2 lakh tests in a stipulated timeline. In an attempt to accomplish the task, the government has placed an order for procurement of 3 lakh rapid test kits from private manufacturers. Jawahar Reddy said the government could at present make available 12,000 PPEs, 20,000 N95 masks, 40 lakh gloves and 12 lakh surgical masks for the frontline health workers. Chief minister Y.S. Jagan Mohan Reddy on April 8 released testing kits indigenously manufactured by the AP Med Tech Zone in Visakhapatnam. The tech zone is aiming to produce 25,000 kits per day to meet the demand.

Dr C.L. Venkata Rao, former chairman of the state-run Swachandhra Mission, said six of the state’s 13 districts do not have virology labs for confirmation of COVID-19 cases. The Indian Council of Medical Research (ICMR) offers Rs 2 crore to medical colleges/hospitals if they are willing to set up labs. But the government could not utilise the facility for six districts, Venkata Rao pointed out.

Also Read: In India, Microbiologists Are Suddenly in Demand. Where Were They Until Now?

Patients in isolation wards protest poor facilities

In an isolation ward in Prakasam district, patients went on a relay fast protesting the lack of basic facilities in the ward. Most isolation wards, it is complained, are bereft of cots, beds and bedsheets and toilets. Venkata Rao urged the government to rope in private companies to supply mobile toilets attached to the isolation wards.

Complaints like these are cause for concern when the state is in a position to mobilise many ideal locations for use as isolation wards. Engineering colleges, farm houses, resorts and cottages of the endowment department could be used as quarantine centres and COVID-19 treatment wards, Venkata Rao suggested. Fleets of RTC buses and vehicles run by private operators, colleges and schools could be converted into mobile health clinics, enabling them to roll into interior villages, he said.

According to the government, there are 1 lakh registered allopathic doctors, 1 lakh registered medical practitioners, 40,000 Ayurveda and Homeopathy doctors and 2 lakh nurses for deployment to handle the pandemic.