WE WILL NEVER FORGET

Three friends spoke to me about the second Covid wave in New Delhi. Their experience with India’s health care system, weighted heavily towards the rich, has a message for all.

Early in April, our friend in India’s Gurugram, Lavindra de Silva (Lavi), contracted Covid-19 from a visiting relative. For days afterward, Ritu Chhatwal, his wife—she was slammed by Covid a few days before Lavi himself felt the first onslaught of the virus—didn’t know if her husband would return home. Lavi was discharged on May 8th, however, after eighteen days at Fortis Memorial Research Institute (FMRI), a top research hospital in Gurugram.

FMRI describes itself in superlatives on its website. A “multi-super specialty” institution set on “a spacious 11-acre campus with a potential to grow to 1000 beds”, Fortis is also a “quaternary care” hospital. Quaternary care institutions offer advanced levels of medicine and highly specialized skills. On many days last month, however, this “Next Generation Hospital” was no more of a hospital than our tiny apartment in Singapore. As Covid cases mounted in Delhi and the suburbs, FMRI had few beds available. It was also short on oxygen.  

On Tuesday, April 19, one week after testing positive for Covid, Lavi was admitted into the Covid ward at FMRI after three hours of waiting, during which time his temperature had spiked to 103 F (39.4 C). Fifteen minutes after he was on the gurney in the Covid ward with 30 people, his oxygen cylinder was yanked out from him because another patient’s vitals took a nosedive. Lavi realized he had entered a war zone. Among them was an 8-year-old whose mother slept by her side, attired in full PPE.

I dedicate this week’s post to the story of Lavi and Ritu. Their struggle this spring points to how health care systems—that are shoddy and already under duress—collapse for reasons within the control of a leader. Despite their affluence and their connections, Lavi and Ritu felt the full brunt of not just Covid but also the latency of a government whose expertise lay in power-mongering, zero transparency, skepticism towards science, and, above all, mixed messaging.

We met Lavi and Ritu for the first time in Sri Lanka in May 2015 when we were on a family trip to celebrate my husband’s 60th birthday. I had no idea then that we would meet them again on a few more occasions in Gurugram, or that, thanks to their hospitality, we would experience the new hyperconnected India where high tech had altered Indian life. Inside Gurugram I often forgot I was in a nation where 800 million people lived on less than half a dollar a day. The Gurugram skyline resembles that of Manhattan in parts; the city is the headquarters of many of India's largest companies. It is  home to scores of startup ventures, with local offices for more than 250 Fortune 500 companies. Gurugram is India's second largest information technology hub and its third largest financial and banking hub. It turns out that Gurugram is also home to India's largest medical tourism industry.  It’s clear now that a place that may be a haven for a medical tourist need not be one for the common man. The India that Ritu’s statesman father had once helped build now neither cushioned the rich nor comforted the poor.

By the time Delhi and its suburbs were sucked into the second vortex of Covid in April, the only specialty that anyone prayed for was often the most basic one offered in primary care, an act of care that nurses could probably do in their sleep—that of fitting a nasal cannula to a patient. Many times for the first couple of days inside the Covid ward of 30 people, Lavi wanted merely to get a chance to take a deep breath. 

The day he found a bed at FMRI, he was wheeled away so quickly he couldn’t say more than a hasty goodbye to Ritu. Inside the Covid ward, with patients at all levels of distress, the struggle for an oxygen cylinder was constant. The staff gave him enough oxygen to “maintain” him—just one liter per minute—to ensure that the oxygen lasted and could be amortized across many patients. By morning, however, the cylinder would be spent; Lavi would have to wait. One day he remembers waiting for six hours. “I was gasping for most of those six hours, but I didn’t tell Ritu how I was feeling,” he says. “At one point I walked to nurses’ station a hundred feet away and stuck my finger out.” Unable to muster the breath to speak, he hoped they would realize that his blood oxygen needed to be checked. A quick check made the nurses yell out for an oxygen cylinder. His reading showed 70. A few days later, Lavi was moved to his own semi-private room which had a constant supply of oxygen. There would, however, be other challenges to his health over the next few days.

The day after Lavi was released he wrote a post on social media about the excellence of the nursing staff in the Covid ward. Doctors only consulted with patients through video; they did not physically visit patients because it was the only way for the medical community to scale, especially as the number of patients rose exponentially during the Covid outbreak. The absence of doctors put an enormous burden on the nursing staff. Lavi believes that the Almighty worked in the guise of four nurses who, in twelve-hour shifts, serviced thirty people who had all manner of complications. But the nurses soldiered on. “They kept smiling even when patients yelled at them asking why they did not come when they called,” he says. The only time Lavi saw a doctor in person was when he needed an invasive procedure.

Ritu and Lavi’s story is the tale of the multitudes in India blindsided by the second Covid conflagration. But it’s also the tale of India’s affluent. It’s the story of those of us who hope that money will assure us a modicum of comfort until we too discover that it really doesn’t work for the rich or the poor. Naturally, Ritu is bitter and angry. “We’ve seen our country burn. And it will continue burning because these people do not acknowledge there is a problem. If people don’t see the problem how can you fix it?” She is appalled by the hoarding of supplies and the racketeering around medical supplies as corpses grew on pyres.  “If there was oxygen, how did Lavi not have oxygen? How did he not have medicines? How did it take me a week to find him a bed in a ward—and this is with connections?”

I sensed the same despair in texts I saw from another friend in Gurugram, Neha Garg, too. “It’s just been heartless, ruthless and relentless. No words are enough to capture the scale and magnitude of suffering. Putting it down on paper makes it sound trivial, for more stories are always left out than could ever be counted,” she says. An independent brand consultant, Neha began volunteering to help put people in touch when Covid surged. She has also been privy to how people scam those who are already in distress. “Those who want to make money are leaving no opportunity unexplored to do so. From hoarding oxygen cylinders and selling them at 20 times the price, to counterfeiting lifesaving medicines, to refusing medical claims and forcing patients’ families to pay in cash, to the usual bribes in getting anything arranged—it’s just chaos.” Going forward, Neha wants her country’s leaders to take stock of what is important and then take steps in order to tackle it all step-by-step. After all, there’s no dearth of resources in India, she says, just a lack of compassionate channelization of resource to those who need it. “We need accountability. We need concrete actions. We need infrastructure.”

I do hope, for all our sakes, that there is such an India in foment.  Things must plummet before anything will change. Some cities have learned and have put solid teams in place. I’ve been hearing from family members in Mumbai about the superior management of Mumbai’s second covid wave. It seems Iqbal Chahal, Brihanmumbai Municipal Corporation (BMC) commissioner, can teach a course on how facilities can be scaled in any city. While Aditya Thackeray, a 30-year-old minister in Maharashtra is looking at ways to get the entire population of Mumbai vaccinated within three weeks, Chahal has built a command center for the city of Mumbai (20 million population). In Mumbai, when someone contracts Covid, his case is funneled through call centers and a series of checks. Covid test results are not sent to the patients directly but forwarded, instead, to their command center so that qualified personnel can chase down the patient and then shepherd him through the system. The problems arise, Chahal says, when patients show up at hospitals, infecting others; instead, the hospital goes to them. “Jumbo” Covid centers with a capacity of more than 2,000 beds with state-of-the-art medical facilities, including intensive care units, and beds with oxygen and ventilators have been set up. In one month, Mumbai’s Covid cases dropped to less than half of what it was a month ago on April 14 when the city had 87,443 active cases with a recovery rate of 81%. The recovery rate in Mumbai now stands at 92%. Mumbai’s success is hard to clone in other parts. It’s the financial capital of the nation and the city’s work culture and its inherent efficiency may have a lot to do with it.

Across India, as the government lost its way, the responsibility has fallen to loose groups of people using social media, like the one my friend Neha Garg worked with, to build a support structure overnight. Citizens became both volunteer coordinators and grief counselors. My sister-in-law, Gayathri Chandrasekaran, told me about how T. R. Dhinakaran, an alumnus of her college in Coimbatore lived because of a WhatsApp post. Thanks to the efforts on social media by classmates spread across the globe, Dinakaran found a ventilator bed. Gayathri told me also about the efforts of a group from her high school at Vellore; they’ve been drumming up financial support to buy a slew of machines for a hospital in the state of Bihar: their shopping list included a ventilator, a defibrillator, several BPAP machines, infusion pumps, and oxygen unit extensions. These donations were being sent ahead to prepare for a third Covid wave that was expected to be particularly nasty for young children.

Indians in India and around the world were now building a virtual rolodex of names because no one trusts that their loved ones will be safe without a personal intervention of some sort. It’s clear how this breakdown of trust between people and their government happened. Disaster preparedness simply did not happen in any thoughtful way, even after the first wave. Neha points out that the government could have taken preparatory steps by vaccinating its own instead of securing favours with the international community by ‘donating’ vaccines.  It also began holding election rallies and large religious gatherings like Kumbh Mela, while the second wave was raging in the country. “And the false sense of assurance (and even pride) of having won over the deadly virus, when the second wave had already hit, seems to have led the whole population astray. Restrictions were lifted way before they should have been, declarations were made, and the victory flag was hoisted,” she says.

Sitting here in Singapore for the last six months, I’m learning lessons from another culture. Last night, my husband and I met a bright 50-year-old Singaporean urologist, Dr. Chong Kian Tai, who explained to us that young people in countries like China, South Korea and Singapore were taught early on in school about the notion of self, family, society and nation. Sometimes, this meant that people must suppress the self. While building oneself was obviously important, personal growth was always in relation to the goals of the nation. The compliance of a population does not happen overnight, he pointed out. School programs in civics incorporate this ideal early on into the curriculum, that the nation must be placed higher than a community and that the society was more important than the self. A system of shared values was dinned into them through their early years in school and through college. In 1991, civics and moral education were introduced into the school curriculum replacing religious lessons; Singapore is into recalibration, as I’ve said before.

I can see clearly how this system of shared goals is helping the combined fight against the pandemic in Singapore. Community cases have risen here steadily since April 13th and over the last week the Singaporean government introduced new measures to contain the virus. There are, of course, no guarantees that someone will not contract Covid. Still, with crystal-clear messaging and implementation, the government is trying to stagger the use of its resources and ensure it can save as many lives as possible and keep its fatalities low. Since I arrived last December in Singapore, there have been just two deaths to Covid; the number over an eighteen month period stands at 31.  

Lavi and Ritu know they are very lucky to be alive. Ritu says that the mission for her life has swum into sharp focus, despite the brain fog that’s such a big part of Covid recovery. The power-packed plant based product she had been building all along holds so much more meaning for her now: The only reason she thinks she got a second lease on life is to ensure that she brings her company’s product to the world, especially to the millions in Africa. Ritu still hasn’t fully regained her sense of smell, even after a month. She certainly hasn’t regained her faith in India. She cannot forget or forgive the country’s callous disregard for human life. “Every day we’re losing people, people we know,” Ritu says, “It’s heartrending. Lavi and I shed tears on a regular basis.”