PPE gear

AIIMS Medic Who Criticised Quality of PPE Now Faces Disciplinary Action

“I stand by what I said, everything I said is based on facts. Every letter we wrote to the media raised important issues, we want a change in the condition of healthcare workers at AIIMS,” Dr Srinivas Rajkumar told The Wire.

New Delhi: Dr Srinivas Rajkumar T., the All India Institute of Medical Sciences (AIIMS) whistle-blower who told the media that the N95 masks provided by the hospital for its medical staff don’t meet the safety standards set by the health ministry has been expelled from the Resident Doctors Association (RDA) and now faces disciplinary action from the hospital’s administration as well.

Dr Srinivas, who was general secretary of the RDA, received a show cause notice from the AIIMS registrar for his May 25 tweet in which he said there were quality issues with the N-95 masks made in Indian and that the statistic issued by the health ministry and the Indian Council of Medical Research (ICMR) were false. According to the notice, he must provide the AIIMS administration with a reply by June 3 or face punitive action.

For the past two weeks, Dr Srinivas has been providing information to the media on this issue via Twitter and WhatsApp. He was quoted in the press on May 29, when 50 more healthcare workers and other staff members at AIIMS tested positive for the novel coronavirus over a 48-hour period, bringing the number of cases at India’s premier healthcare research institute on that date to 195. Two members of the AIIMS staff also died due to COVID-19. On May 30, Dr Srinivas spoke to The Wire about the PPE via a video call.

Masking the masks

“Yes, I have been expelled from the RDA and this is the result of continuous pressure from the administration,” Dr Srinivas told The Wire on Monday. “I stand by what I said and everything I said is verifiable and based on facts. Every letter we wrote to the media raised important issues and we want a change in the condition of healthcare workers at AIIMS.”

He added, “Last Saturday (May 23) we [RDA] had a very heated meeting where I was questioned about my statements in the media and I spoke for 30 minutes about the quality of masks and other equipment. I asked them why we have not got a response from the administration even to the letters we sent months ago.”

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

He continued, “If this was their [the administration’s] way to address our query, we were not left with any option but to approach the media and put pressure on the administration. I am targeted because of my active participation in meetings, drafting letters and seeking responses. I didn’t dilute these issues…the number of cases in AIIMS is now above 200. Despite our statements in the media, the condition of the health workers has not at all improved.”

The Wire has been given access to screenshots of WhatsApp conversations between doctors and also the minutes of the meeting where Dr Srinivas was expelled from the RDA.

Screenshots of the WhatsApp conversations on the masks. The doctors’ names and numbers have been covered.

One WhatsApp conversation includes images of at least four doctors sharing photos of the masks they had been provided with and complaining about their quality. The photos show broken straps on the masks. One doctor wrote, “The straps given way. Evidence of me trying to staple it! Happened the first time I wore it (sic)!!”

Another doctor wrote, “Why is there the difference in the types of N95 masks between departments?”

In another screenshot, a doctor shared a photo of his mask with the straps stapled on and wrote, “Stapled.” Another doctor wrote: “Had to punch a hole and tie the strap and use it… this is a fresh mask… similar thing happened with another such mask on the 2nd image (sic).”

Image vs reality

The minutes of the meeting of the RDA’s executive committee on May 29 recorded the statements of at least 13 doctors, including Dr Srinivas. The meeting concluded with the removal of Dr Srinivas as general secretary.

Some of the pages bearing the minutes of the RDA meeting. The doctors’ names have been covered to protect their identities.

In the minutes, one doctor was recorded as having said that Dr Srinivas should not have said anything against AIIMS in the media and, even if he had been threatened with legal action by the administration for talking to the media about the quality of the PPE, the issue should have been resolved on campus and amongst the resident doctors.

Also read: When a News Article Vanishes, We Have More Than Just a Pandemic to Worry About

Another doctor claimed: “There is already an enquiry against Srinivas by a fellow resident for physical assault. This is not the first time that he is giving baseless statements against the administration without the confidence of the panel. PPE provided by AIIMs administration is of fine quality now. Things have improved a lot… We shouldn’t fight regarding PPE now, we have to fight together rather than fight among ourselves (sic).”

The majority of the doctors who attended this meeting said that Dr Srinivas should not have “maligned the image of AIIMS” in the media, at least without consulting other members of the executive committee.

But the decision to expel Dr Srinivas from the RDA was not unanimous. At least three doctors said he should be allowed to make a statement in his defence and issue an apology rather than be expelled.

One doctor in this meeting said: “Defaming AIIMS was wrong on the part of Dr Srinivas. Different varieties of PPE are supplied by AIIMS to different areas of the hospital. In some places, low quality PPE was given, especially in the emergency department, and no action was taken against it. The quality of the masks is also not up to level… (sic).”

In the minutes of the meeting, Dr Srinivas was reported as having said, “The statement given by me was right but the context was different. I was under the impression that [the administration] threatening me […] was known to all executives. I am ready to give a public apology and clarification regarding the statement given by me in the media and also personally to the whole resident fraternity. I am of the opinion that 2/3rd majority of executives should be there to expel any executive from the panel (sic).”

However, the president of the RDA, in the minutes of the meeting which was held on May 29 and released on June 1, said that Dr Srinivas should be expelled for his “irresponsible and undemocratic behaviour.”

He stated: “Despite the release of his expulsion notice dated 29.05.2020, he still gave a media statement as an office bearer of RDA, which is apparently an unauthorised and illegal act in court of law (sic).”

Criticism not allowed

On May 31, News18 published a report on the poor quality of masks and PPE kits, based on Dr Srinivas’s statement. The story was completely changed after 48 hours, and was replaced with a denial from the AIIMS administration, as Newslaundry pointed out. A tweet by a News18 reporter showing ‘low-grade N95 masks’ in use at AIIMS was shared by many opposition leaders, but has now been deleted.

Also read: At AIIMS, Confusion as Healthcare Workers Asked to Reuse N-95 Masks

The original headline, “’Not Worried About Virus But Govt Apathy’: Lack of PPEs Makes AIIMS Healthcare Staff Target for Covid” has been changed to, “AIIMS Dismisses Allegations Around Quality of PPE Kits and Masks, Says Specified Standards Being Met.”

This is not the first time that stories criticising the government have been removed by big media organisations.

In mid-May, it was reported that the New Indian Express, one of India’s major English language newspapers, had pulled down an article that was heavily critical of the Centre’s response to COVID-19. The article, entitled ‘Centre’s COVID-19 Communication Plan: hold back data, gag agencies and scientists,’ was published on the New Indian Express’s website at 7:09 pm on May 8 and disappeared within a day without an explanation.

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.

Fighting Covid Will Be a Long Haul but Normal Life Does Not Need to be Kept on Hold

Before it is eradicated, the novel coronavirus can be tamed, but this will require the rapid implementation of an action plan that is humane, rational – and unafraid of the fiscal beancounters.

It’s too late. The COVID-19 horse has bolted and closing the barn doors now will not bring it back. Despite Narendra Modi’s all-India lockdown, the number of people testing positive for the virus has risen sharply during the past 10 days, from 200 in three days to 200 in a single day.

Much of this increase is the result of more intensive testing following the discovery of COVID-19 “hotspots” such as the Tablighi Jamaat centre in Nizamuddin, where a large number of preachers (including at least 250 persons from abroad) had gathered in the first two weeks of March when even foreign travel restrictions had not yet been announced.

But the real nightmare is only just beginning. For one, crucial failure of planning and foresight in the lockdown has already sent tens of thousands of migrant workers struggling back to their home villages. This marked the failure of both the Central and state governments to understand that to keep the workers in the cities throughout the duration of the lockdown, their employers needed to be compensated for the near total loss of business they would suffer. Only then would the government have acquire the moral right to prosecute those employers and landlords who failed, or refused, to keep their workers housed and fed during this time of trial.

Today, migrant workers who have been thrown to the wolves in the towns are streaming into their home villages and hamlets by the tens of thousands every day. State governments are scrambling to regulate their return, testing and then clearing or quarantining them. But the tests they are using, mainly the temperature test, can only catch those who already have the symptoms. As many more will still be in the asymptomatic stage. Since social distancing is almost impossible within a family, those carrying the virus of them will unknowingly infect others.

In his NDTV Town Hall Programme on COVID-19 some days ago, Prannoy Roy had pointed out that the infection ratio can vary from as low as four or five to 1, with rigorous social distancing, to as high as 400 to 1 without it. The cases of the Sikh preacher who visited Anandpur sahib and at least 15 villages after returning from Europe, and the Tablighi Jamaat gathering in Nizamuddin show that the infection rate from those whom the government is not able to identify and quarantine could average between 100 and 200 to 1.

Mobilising more health workers, such as doctors and nurses in training, and creating more and more monitoring centres, can only take us so far. This is for a reason that we haven’t factored in as yet – the absence of biohazard suits, or kits for them to work with. While the state governments have given a great deal of encouragement to increasing the supply of beds and ventilators for patients, they have said very little about the need to increase the supply of biohazard suits and kits.

But as the experience of other countries is showing, doctors and nurses are the people in greatest danger of infection. If they start falling sick and dying, the stream of health volunteers will dry up. Finance minister Nirmala Sitharaman has announced a massively generous insurance policy for health workers. But that only guarantees good treatment after they have contracted the disease, and does nothing to prevent them from doing so.

It is therefore time to face the fact squarely that there is now no way of preventing India from entering stage three of the spread of COVID-19 —community transmission — in which the health establishment will lose track of the spread of the disease. In fact, Dr Girdhar Gyani, the convenor of a task force on COVID-19 hospitals, said as much on March 28, barely four days into the 21 day lockdown. So today, even as health workers continue the fight to contain its spread, the government must start fashioning its response to stage 3.

The very first thing needed is a shift in the goal of strategy from the eradication of the virus, to taming it. The standard way of doing this – through vaccination – is not available because no vaccine has been developed as yet. The alternative – in fact the only strategy that remains – is to tame it. Fortunately, COVID-19 has characteristics that make this possible.

Yes, we can tame the virus

A strategy for taming the virus needs to be based upon the following four factual pillars:

First, COVID-19 is aerosol and spittle borne and not, like the Spanish ‘flu, airborne. So wearing a mask, frequently washing ones hands with soap, and avoiding touching one’s mouth, nose and eyes will go a long way towards checking its spread. Thanks to mobile telephony and the social media, this is now known to virtually every inhabitant of the country.

Second, the mortality rate is relatively low. According to the WHO, it began by being 2 percent in China and rose to 3.4 percent for the world as a whole at the end of last month. The organisation has cautioned, however, that this is almost certainly an inflated figure because most nations have not been able to track down and include the many who have contracted the disease and recovered without knowing they ever had it. In India, the current rate is 2.8%, but that too is almost certainly inflated for the same reason.

Third, COVID-19 is dangerous only to the old and very old. All, repeat all, the data gathered from more than more than three quarters of a million cases around the world, shows that very, very few people below the age of 60 have died if they have not already been suffering from a pre-disposing ailment. The death rate climbs to 8% for those between 60 and 70 and to 14% in those above 80. But the principal reason for this is again the much greater incidence of diabetes, hypertension and chronic gastro-intestinal and pulmonary diseases – the most obvious being smoking – among the older generation of the world’s inhabitants.

Fourth and last, 80% or more of those who contract the disease recover on their own, many without knowing they ever had it. Needless to say, the vast majority of those who do so are young and very young. This has enormously important implications for policy. The first and most important is that the migrant workers who are trekking homewards are all young. What is more, hard work has made them very fit. Thus, they may starve to death or die of heatstroke, but they shall not die of COVID-19.

However, since some of them may be carriers of the disease, and their parents are old, it is imperative that they maintain a substantial social distance from their families and others in the village for the required fortnight till the risk of their infecting others ends.

But social distancing does not mean that they cannot work and must sit, fretting, in their homes. Nowhere is safer in a village than the open fields, and that is where a bumper paddy crop and and a plethora of fruit and vegetables are waiting to be harvested. The returning migrants can not only help to bring these in more quickly, but earn some of the income they were forced to forego because of the lockdown.

Needed, a humane action plan for the countryside…

Here, therefore is the skeleton of a policy to contain the spread of COVID in the rural areas in a humane way:

1. Quarantine the returning migrants for 15 days, then encourage them to look for work;

2. Keep the mandis open, but allow access only those under 50 to work in, or even enter them, and let the returned migrants take their place while the government compensates them for their loss.

3. For those who begin to show signs of being infected, open camps where they can rest, and get the food, water and medicines that ease the symptoms and help them to conserve their strength.

4. As for intensive monitoring and medical care, it is not the returning migrant workers that require the sustained attention of the local government, but their parents, and in a limited number of cases their children, nephews and nieces. These are the vulnerable groups on whom every block, anchal and village administration, every primary health centre and every district hospital must focus its attention.

What are the numbers we are looking at? In 2016, the population above the age of 65 numbered just about 60 million. According to the 2001 census, there were 593,731 inhabited villages in the country. Assuming that the number is now a little over 600,000, the local authorities will need to keep a close watch on the health of around 100 persons in each village. That cannot be difficult to do.

… And an efficient plan for towns and cities

A similar program needs to be put in place in the towns and cities as well. When the present lockdown ends, shops should be allowed to open provided all of them maintain a ‘social’ distance between staff and customers, as shops selling food and medicines are doing today.

Small and medium sized enterprises in the manufacturing and service sectors, capital-intensive enterprises such as airlines, bus transport companies and centrally air conditioned shopping malls, theatres and hotels, will need to be kept closed for a good bit longer as the risk of transmission in them is particularly high. To make sure that they don’t become insolvent and incapable of revival when the threat from COVID wanes, they will need to have their fixed costs – interest and amortisation of debt, rent and maintenance costs – reimbursed.

The money for this will have to come from public funds just as the money for rehabilitation after an earthquake, a cyclone or a tsunami does. The Central and state governments will need to keep this expenditure out of their regular budgets for its purpose will not be to add to the purchasing power in the economy but prevent the existing purchasing power and therefore the economy itself from evaporating. What the bean counter in the government must remember is that if the government fails to do so, its revenues will shrink drastically in the next accounting period and the budget deficit will increase dramatically instead of remaining contained or growing smaller.

Stop the panic

All things considered, it is difficult to see life returning to normal for many months, possibly for as long as a year. By that time, COVID-19 will have worked its way through much of the working population, and immunized a large part of it to future attacks. A year is also the time it might take to develop and mass produce the vaccine against it that every pharmaceutical company is straining every nerve to do.

To sum up, therefore, there is no need for the panic that relentless media reporting has thrown much of the country into, but there is also no silver bullet for ending the threat from the coronavirus . All we can do is resume our normal lives as soon as the government has geared up the nation’s health infrastructure to facilitate early detection and treatment, and to exercise an extra amount of care and vigilance against exposing ourselves to the disease in our daily lives.