Let me make it clear at the outset that I greatly appreciate the tireless hard work and extreme risk that ground workers and administrative officials of the Brihanmumbai Mahanagarpalika (BMC)) have undergone during this pandemic. This article is an attempt at a genuine critique of the so-called “Mumbai Model” insofar as its hits and misses are concerned. There is very little doubt on the efforts put in by governmental agencies for a difficult battle against a raging monster. But surely there are legitimate reasons to doubt whether the resolution of the second wave of the COVID pandemic in Mumbai was due to a “Mumbai model”, or the vagaries of nature itself. After all, Pune, Nagpur, Delhi, Lucknow, Bengaluru, Ahmedabad and several other cities did not have a “Mumbai model” but the second wave resolved in these cities just as quickly as it did in Mumbai. Some cities did better than Mumbai and some worse. Before the “Mumbai model”, we had the “Kerala model” and we all know how that narrative fell apart during the second wave with the state being one of the worst affected.
Hence, it is important to assess whether the approach Mumbai had taken was unique in some respects, and whether it can be successfully replicated to reduce spread of disease, admissions and mortality in other places.
“Mumbai Model”: Details
In an interview to Shekhar Gupta, Municipal Commissioner Iqbal Chahal explained this “Mumbai model” that was implemented. Broadly, the major talk points are:
- “Chase the virus” strategy: Contact tracing, tracking, testing and isolation and treatment of patients (four T’s)
- “Chase the patient” strategy: Setting up 24 war rooms, one in each ward of the city, equipped with manpower, nurses, doctors and ambulances to visit patients at their home and decide need for admission
- Blocking 80% of beds in private hospitals for COVID treatment and capping the rates for treatment in those hospitals
- Large field hospitals (“Jumbo COVID centers”) for treatment of large number of patients simultaneously
- Oxygen control rooms for procurement of oxygen in adequate amounts to manage the city’s requirements
- Procurement of oxygen from industries of neighbouring states, setting up liquid oxygen tanks
- Mass vaccination on a large scale to pre-empt a third wave
While all of these strategies are absolutely sound, the reality is most of them are hardly unique. All of them have been implemented across several states with minor modifications based on local requirements. For example, Uttar Pradesh excelled at door-to-door screening. Kerala did very well in testing and isolation. Almost all states capped hospital tariffs and blocked beds in private hospitals, procured oxygen from large industries and opened large temporary hospitals. Let us take a closer look at these strategies and their on-ground implementation in some more detail.
War rooms have been set up by almost all states as well as central government since early 2020, and are based broadly on models provided by WHO. Considering the high volumes of patients needing hospital beds in Mumbai, decentralisation of control room and organisation of ward wise control rooms was a good move to reduce chaos related to hospital admissions. However, ward wise control rooms in the BMC are not a new concept and date back to at least 2013, having been originally set up for management of monsoon related problems. All admissions at government and private hospitals were to be routed through the control room. While the young and enthusiastic volunteers and staff manning these control rooms did their best to get patients the beds they desperately needed, they too were overwhelmed by the sheer number of patients around the peak of the second wave. The online dashboard showing bed availability status at various hospitals in real time was supposed to be a game changer. However, while the status showed beds available at some hospitals, in reality no beds could be obtained at those hospitals and patients continued struggling to get beds while the government kept insisting that they had enough beds.
Tariff Capping & Bill Audits
The decisions taken by Maharashtra government for capping of hospital tariffs and blocking of 50-80% of beds in private hospitals for COVID treatment are also not unique and have been implemented by almost all states. This was done under the guise of “rampant over-charging and looting by hospitals”, despite the fact that hardly a couple of dozen complaints had been received on this account across several thousand patients treated by private hospitals. While other states held meetings with private hospital owners before taking decisions on capping, Maharashtra did this extremely high handedly, without any discussions with private hospitals. The packages fixed were ridiculously low (less than half of the packages recommended by Niti Aayog) and covered not only COVID treatment but also non-COVID treatments. To make matters worse, the government sent teams of auditors to all hospitals to enforce those tariffs. Private hospitals, already struggling with staff and oxygen shortages and huge work loads, were harassed and pushed to the extent that many hospitals were forced to approach the Court for relief. The Nagpur bench of Bombay High Court set aside non-COVID tariff capping and observed that COVID tariff capping too may not be legally sound. The matter continues to be subjudice.
It is really not a badge of honour to be worn by any bureaucrat that his teams are harassing healthcare workers at the time that they are most stressed. The state government continues to push this severely flawed policy further, and on 1st June 2021 has actually capped COVID treatment packages at even lower tariffs, despite vehement objections and representations by various doctors’ bodies.
The contact tracing policy of Maharashtra is very much in line with the guidelines issued by the Indian Council of Medical Research (ICMR) and has been implemented by several other states as well. Contact tracing in Maharashtra and especially in Mumbai was poor compared to other states in June 2020, and continued to be quite poor for several months thereafter. During the second wave, contact tracing almost fell apart due to extremely high volumes of cases. It was not uncommon for tracing to begin as much as a week after diagnosis, rendering the entire purpose meaningless. My sympathies are with the ground staff of the BMC who toiled relentlessly against all odds and at great personal risk.
During the first wave, the BMC won plaudits from WHO for their work in Dharavi using the “chase the virus” 4T approach. It helped that a large chunk of population of Dharavi had migrated back to their native places due to the lockdown. Nevertheless it was still a daunting task and BMC did reasonably well. However, there is one confounding factor. Sero-surveys of Dharavi showed that up to 57% of the slum’s population had developed antibodies, indicating exposure to the virus and asymptomatic infection. While the efforts that ground staff and officials put in are remarkable and commendable, it cannot be said for sure that the control was due to a unique model for tracking and tracing cases if over half the slum population still got exposed to the virus.
It must also be noted that things started falling apart as the first wave died down. In mid-March 2021, with number of cases rising again, a central government team visited Maharashtra to check the state’s preparedness for the second wave and found that tracking, tracing and testing across the state had faltered significantly. The report submitted by the team found that field staff had not understood the concept of contact tracing and were listing the immediate family and neighborhood contacts without identifying the high-risk contacts in workplace, social and family settings.
During the second wave, some disastrous missteps brought RTPCR testing for COVID across the state to a virtual standstill. The state government issued directives that all workers, from domestic helps to corporate employees, had to get their RTPCR test done every fortnight. This was apparently done without any consultation with the laboratories or confirming their capacities, or checking whether enough kits were available. Industries protested, calling it without any scientific basis, but were overruled. Within days the labs were swamped with lakhs of samples of completely normal people. Test results started getting more and more delayed, and at one point laboratories simply stopped accepting samples for testing as they were unable to manage. A farcical situation resulted, with those genuinely ill not being able to get tested for days together and thousands of normal persons being forced for tests. A new industry suddenly sprang up: fake RTPCR certificates. The error was soon realized and the order modified to allow Rapid Antigen Test and when even that did not help, the order was withdrawn, but the damage had already been done. It took several days for the backlog to be cleared and tests to be delivered within the mandated 24 hour window again.
Jumbo COVID Centers
Jumbo COVID centers (field hospitals) are again not a unique idea and several states have set up such centers in their cities and affected areas. Field hospitals have been used in pandemics for at least two centuries. China set up a 1000-bed temporary hospital within two weeks in April 2020. Several other countries used field hospitals during this pandemic. While such field hospitals take the load off existing medical infrastructure, staffing and equipment issues at the temporary hospitals are historically known to act as factors leading to higher mortality. Mumbai was no exception. The mortality in BKC jumbo COVID center ICU was found to be an unacceptably high 37% in August 2020. In spite of such a high mortality, the Dean of the center went on to make an audacious claim of zero mortality from 10,000 patients treated at the center upto October 2020. Staffing and patient care at the centers was not up to the mark (but then this is nothing new for public hospitals), prompting the Chief Minister to request private hospitals to adopt the jumbo centers. The central government also stepped in to provide additional training and handholding to these centers for reducing their mortality. I am all for augmenting capacity of public healthcare and believe that the “jumbo” model if done well can be a good solution for India’s healthcare needs. However, the government must desist from making patently false claims that can ruin their own credibility.
As if this were not enough, the BMC did not pay frontline warriors working in jumbo centres their salaries in time. The 40-member medical team from Kerala apparently quit due to non payment of salary and returned to their native state. The admission criteria to these hospitals too left a lot to be desired. Patients from one district were refused admission in jumbo centres of another district even if no beds were available at the patients’ own district. This was done keeping in mind local requirements, but nevertheless it is quite a cruel thing to do, and should not have happened.
I have written and spoken extensively on India’s oxygen crisis. The “Mumbai model” has been touted as a solution for this. However, if we look dispassionately, the municipal corporation’s oxygen management in Mumbai has been anything but good. In any other state, six major public hospitals running out of oxygen in one night would have been a scandal of humongous proportions. But shockingly, in Mumbai, the shifting of patients from these hospitals to other municipal hospitals in the dead of night was tom-tommed as efficient management. An existing defunct oxygen plant at KEM Hospital was not restarted, nor were additional plants installed at any major public hospital despite funds being available. Several private hospitals also ran out of oxygen and patients died as the supply chain broke down completely in the city, but the Health Minister continued insisting that there were no deaths due to lack of oxygen. As a large number of oxygen plants are in Thane district, the BMC requirements were by and large met through these plants as there are no large oxygen plants in Mumbai. Only towards the third week of April 2021 did the authorities start publicly saying that 16 PSA plants would be set up at municipal hospitals. As requirements skyrocketed and plants ran out of supplies, the BMC turned to corporate giants such as Reliance Industries for help. RIL responded by rushing in hundreds of metric tonnes of oxygen to the city from their industrial plant in Gujarat, solving the shortage until the second wave passed.
One needs to seriously introspect whether this is actually a successful management model. But then the comparison is being drawn with Delhi, which is a spectacular case of mismanagement. If that is the standard to be taken, then Mumbai has certainly managed much better.
Oxygen control rooms were set up by some municipal corporations such as NMMC and Panvel Municipal Corporation, and these corporations did a good job in ensuring hospitals in their jurisdiction did not run out of supplies, albeit at a much higher cost. In that sense, other municipal corporations managed oxygen supplies more efficiently than Mumbai and their model should be studied in detail.
Black marketing of medicines
A successful “model” should not allow for any black marketing of medicines necessary for treatment of COVID. But it is now common knowledge that people and hospitals faced extreme problems on this account. Remdesivir, tocilizumab, baricitinib, bevacizumab and other drugs rapidly disappeared from the shelves and appeared on the black market at several times the price. There were a few raids on black marketeers but this was extremely inadequate. Eventually, the drugs went off even the black market and hospitals had to somehow manage without them. Sale into the private market was completely stopped by the government and distribution could thereafter be done only through the Collector’s office. But here too, the number of doses being supplied to hospitals was highly inadequate. To top this, if hospitals prescribed the medicines and asked the relatives to procure, they were threatened and booked. It may be noted that the concerned medicines were part of the protocols issued by both central and state governments. It was the government’s responsibility to make sure that they were available, and hospitals should not been penalized for following the protocols. Eventually these drugs started becoming available again late in the second wave when falling numbers made it easy to procure them. Of course, Mumbai was not alone in facing this situation and it was also rampant in large parts of the country.
As the second COVID wave increased in Mumbai, the state government introduced fresh restrictions that were serially increased, culminating in a complete lockdown on 15th April 2021. The government then claimed that the sharp fall in numbers was due to lockdown. But is this true? Did this lockdown work, and is its continuation to 15th June 21 and beyond justified? The numbers certainly do not support this claim.
The number of fresh cases in Mumbai had already started dropping by 12th April 21, three days before the complete lockdown was introduced. The number of fresh cases in the week from 12-18 April had decreased by approximately 20% as compared to the number of fresh cases from 5-11 April 2021. This makes it amply clear that the sharp decrease in numbers was not due to strict lockdown. The lockdown has been devastating for the state’s poor and there is no respite for them as it still continues. Chief Minister Uddhav Thackeray indirectly admitted that the lockdown was ineffective when he pointed out that there was heavy traffic on the streets in his address to the state on 30th May 2021. Other states such as Gujarat did not implement a strict lockdown and their numbers do not indicate that they did any worse than Maharashtra or Mumbai. Gujarat Deputy CM Nitin Patel categorically stated that there is no proof that strict lockdowns are effective in “breaking the chain”. By first imposing, and then continuing, yet another unnecessary and devastating lockdown, all that has been achieved by the Maharashtra government is that migrant labour has once again been driven out of the city. This is another massive blow to already struggling industries, as once laborers go home, they generally do not return for several months.
Mumbai has been one of the worst affected cities in both the first and second waves, and therefore any claims to being a star performer whose model of management is ideal, must be taken with a pinch of salt. The “Mumbai model” is not very different from those implemented by other states and broadly follows the guidelines issued by ICMR and central government from time to time. It has certain good features, such as decentralized ward-wise control rooms, reliance on jumbo COVID centers for preventing overburdening of key hospitals and, at least early on, good management of disease control in densely populated slums. However, Mumbai has done poorly on various issues outlined above including the testing disaster, oxygen mismanagement, unnecessary lockdown and failure in preventing black marketeers from having a free run in the state. An added problem is the propensity for top officials to utter downright falsehoods to impress the people via friendly media houses. This will create credibility issues and must be avoided at all costs.
The “Mumbai model” has some good and easily replicable features, but overall fails to live up to the hype. The bottomline is that there is no single successful model anywhere in the world at present, and Mumbai is no exception to this rule. The best practices from various other cities can be adopted by Mumbai and vice versa, and implemented with some local modifications to prepare for future waves of the pandemic.