Need better containment strategy, ramping up of infra: Dharminder Nagar

The first wave of the Covid-19 pandemic began on a grim note for Paras Hospital founder Dharminder Nagar. The first employee to succumb in the pandemic was his tea boy who’d worked with him closely for almost a decade and was only in his early 30s. A daily presence, his passing felt like a personal loss to Nagar although they were a world apart in many ways.

At the time, the disease was a new, unknown and dreaded animal, and the hospital’s staff, nurses and even doctors were wary of treating patients. For a while Nagar found it difficult to “get anyone to the hospital to do anything”.

Nagar was sticking to the original plan — setting up hospitals across India — after the first wave when the second “tsunami” hit. In 2020 when the first wave struck, the Paras Hospitals group with a total of 1,000-plus beds cured 2,327 patients over 10 months. It also lost 280 patients to the virus during this period.

In the second wave, the hospital converted 559 beds, cured 2,459 and lost 363 patients in just one and a half months. His phone rang non-stop for many days and he barely slept four-five hours every night. Even as the second wave was yet to abate, Nagar spoke to Anjuli Bhargava and shared his lessons from the experience. Excerpts:

How was the second wave different from the first?

First, the sheer volume of cases. My phone rang day and night and cases were arriving every few minutes. We were overwhelmed. Second, unlike in the first wave, many patients were coming in needing oxygen and in a serious condition. In the first wave, many were cured after some treatment.

This wave hit us like a ton of bricks and there was no breathing room. One day you were planning surgeries and doing oncology and the next day, you had converted half the hospital into a Covid facility. Also, this time a majority of our cases were Delhi residents who were being admitted. I think this may be reflective of a slightly more aware, educated and risk-averse population living in Gurugram. Being “paranoid” paid off.

What, however, worked to our advantage was that the doctors, nurses and staff were not scared like last year and they led from the front. Last time, the virus was hardly known and everyone was very wary. This time, it was no longer an “alien animal”. Both doctors and nurses were on top of it, familiar with protocols and how to deal with patients while keeping themselves safe. So in that sense, we were fortunate that the surge hit when we were better prepared to deal with it. In the first wave, everyone was scared — for themselves, their families as they did not know what they were dealing with. It was merciful for us that the first wave was smaller and slowly rising for this reason. It allowed us to learn and breathe.

Second, this wave has travelled from the west to the east. Our first hospital to get hit this time was Udaipur and it was a second wave but not an avalanche. We had got an indication that it was coming. Then it hit NCR and this time it was like an avalanche. Patients were sicker, needing oxygen and ventilators. Further, we had many more female patients — almost 30 per cent unlike in the first wave where the female patients may have been barely 5 per cent of the total.

Also, this time we lost many patients in their mid-30s and early 40s too as there is a propensity for them to have many undiagnosed comorbidities. This is an age where many assume they are fine. You are usually pre-diabetic in the late 30s and then it may get diagnosed in the 40s. So many conditions that express themselves in your 40-50s lie dormant or undiagnosed in your mid to late 30s.

Do you think the Kumbh Mela worsened matters, since people travel through Delhi and Mumbai to reach Uttarakhand?

It may have made things worse in Uttarakhand but it doesn’t answer the main questions. This doesn’t really add up since the wave is coming from west to east. Post-facto, it’s easy to say anything. But at least our experience didn’t indicate this. As we saw it, the wave originated in the west, travelled from Udaipur to the east, hit NCR and Panchkula and then reached our facilities in Patna and Bihar almost two weeks later. South Mumbai residents or rich and upper middle income people from Delhi, for instance, didn’t travel to Haridwar for the mela but they were hit hard.

Do you think we went wrong somewhere with the vaccination drive?

I do think we should have handled this differently. In its bid to appear fair and as concerned about rural India, vaccine distribution has been botched up. In rural India, hesitancy was high too. Even in semi-urban areas, a majority was reluctant to get vaccinated.

The cities needed the vaccines above all, so instead of targeting the whole country a more carefully crafted distribution would have helped. I don’t think a clear assessment of where it was needed and where it wasn’t was done. The vaccination drive should have focussed on large metros, then the bigger cities (like Pune, Lucknow, Kanpur and so on) and then moved to remote parts. Perceptions instead of reality seem to have guided decision-making. Moreover, the private vaccine manufacturers could have been given whatever financial support they needed to ramp up production dramatically.

What problems did you face in dealing with authorities and what are the lessons from that?

In Gurugram, we had almost 320 beds dedicated to Covid (at any point, maybe 20-odd beds were for normal patients). ICU capacity was 80 beds. This time, 95 per cent of the patients needed oxygen. We had not ramped up our oxygen capacity as we did not anticipate this. Over and above, our Faridabad supplier was told to supply to Delhi first, due to the high court order. This was also very knee-jerk. Why Delhi first? You can’t say that a patient’s life in Gurugram is worth less than one in Delhi! We had to use strong arm tactics to augment supply of oxygen from our regular supplier. One Sunday I was in the hospital and we had less than one hour of oxygen left. I called up my supplier and persuaded him to comply. That was the scariest moment we had. In Bihar and other hospitals, we didn’t see the same severity. There was a need and a bit of panic but we were not overwhelmed. Also, Jharkhand supplied oxygen to our hospitals there.

What changes would you like to see so that private hospitals can contribute if there are future waves?

Less knee-jerk reactions would help, as would a better containment strategy and ramping up of facilities and personnel.

Let me give you an example. We have all been asked to invest in oxygen generators instead of the authorities managing the supply chain better. This doesn’t make much sense. What happens to these generators when we no longer have such a pressing need for oxygen? The same money can be invested to ramp up infrastructure — private or public — like adding ventilators or hiring more nurses and staff. There are unused ventilators in public hospitals — shortage of technical staff results in machines lying unused — which could have been utilised if there had been better partnership. Similarly, decisions or announcements like “testing hum Rs 100 mein karenge” (we will conduct tests at Rs 100) doesn’t help. Test more; it’s not about Rs 100.

Also, in my view, there is no clear or direct correlation between lockdowns and waves. A lockdown may reduce transmission but to stop a wave we need to test aggressively, isolate positive cases and vaccinate aggressively. Let those in power manage reality and focus less on perceptions.

A tsunami versus a wave

• First Wave – 194 beds, Patients cured: 2327 (data for 10 months), Deaths: 280
• Second Wave – 559 beds, Patients cured: 2459 (data for 1.5 months), Deaths: 363
• Paras Hospitals Group has 6 hospitals with 1000 Plus beds
• Cities: Gurugram, Patna, Panchkula, Udaipur, Darbhanga, Ranchi