ven as images of endless burning pyres are flashed across the globe accompanied by desperate social media messages, frantically seeking hospital beds in Delhi, Gujarat and Uttar Pradesh, Mumbai is relatively calm. After a few stressful days in mid-April, there is no mindless panic, shortage of hospital beds or oxygen or queues to cremate the dead.
That Mumbai, with over 324,000 cases, has handled the second COVID-19 wave well, is not a matter of chance. It is the result of careful planning, quick action to fix emerging situations, a powerful feedback loop, smart information dissemination and the willingness to spend money to deal with a once-in-a-century crisis.
All this worked because of strong political support and, to a great extent, the gutsy and dynamic leadership of Mumbai’s municipal commissioner Iqbal Singh Chahal.
That the main Opposition party has worked overtime to find faults and trip up the government was, probably, a blessing in disguise, especially since the high-stakes election for India’s richest municipal corporation (with a budget larger than most state governments) is around the corner. It has ensured that the ruling coalition fully supported the all-out war to keep Mumbaikars alive.
It supported Mr Chahal’s bold decision to ensure that Mumbai had an adequate stock of Remdesivir and other medicines (especially in civic hospitals and facilities) and the struggle to ensure adequate oxygen allocation by the Centre after a harrowing situation on 17 April 2021, when 168 patients were shifted overnight to hospitals with adequate oxygen without a single death.
Mumbai has halved its COVID cases in the past 20 days, even as the numbers across India are rising steadily.
What is glaringly obvious, in contrast to the tragic mishandling of Delhi and other cities, is that Mumbaikars don’t need to run from pillar-to-post for hospital beds or in search of oxygen and ICU (intensive care unit) beds on receiving COVID test results.
Mumbai’s excellent handling has come in for praise by the Supreme Court of India as well as the Nagpur bench of Bombay High Court. On 4th May, justice DY Chandrachud of the Supreme Court, while hearing a petition, advised the Central government and the Union health secretary to speak to the Mumbai municipal commissioner Mr Chahal and draw on the (BMC)’s experience of dealing with COVID BrihanMumbai Municipal Corporation.
On 2nd May, an order of the Nagpur bench of the Bombay High Court asked the district collector and the Nagpur municipal commissioner to set up a 24×7 control room and to “adopt the model devised by the BMC under the leadership of its Commissioner IS Chahal.”
The ‘Mumbai Model’
What exactly is the Mumbai model and can it be replicated across the country? Mr Chahal says a ‘decentralised fight is the key’, even while he is clearly in control and works with a core team of dedicated people that is accessible and quick to respond.
At a time when retired generals are asking for the army to fight the virus, it is interesting that Iqbal Chahal, a marathoner, and engineer, who comes from a defence services background, has worked through ‘war rooms’ to control the virus.
Mr Chahal was appointed at the height of the crisis in May last year, when Mumbai was making news with terrifying videos of bodies wrapped in garbage bags lying next to COVID patients in government hospital wards.
Almost everything was in short supply — from PPE kits to gloves, sanitisers, specialised oxygen masks, face shields, disposable bed-sheets and even body-bags.
Moneylife Foundation’s COVID relief work showed us how desperate doctors were forced to divide their time between treating patients and contacting donors for basic supplies. The first wave largely affected over 300,000 people living in the slums of Mumbai. The second wave, more virulent, has primarily affected the middle class and the privileged and Mumbai has been reporting around 1,500 COVID positive cases every day.
On taking charge, visiting hospitals and COVID hotspots like Dharavi, Mr Chahal worked on three strategies: 1) eliminate the panic; 2) decentralise war rooms to cut response time; 3) build adequate infrastructure. Here’s how each of these was rolled out with precision and discipline.
Eliminate Panic: A major reason for panic was that COVID test results were directly shared by testing laboratories with patients. Reports of tests conducted during the day were usually shared by evening. Although the BrihanMumbai Municipal Corporation (BMC) had a central control room, a flood of calls after the results began to overwhelm the helpline by 8pm causing chaos and panic as nearly 10,000 people tried to find hospital beds. One of Mr Chahal’s first decisions was to abolish the central control room and order each of the COVID testing laboratories not to share test results directly with patients. They had to be shared with the BMC only.
24 War Rooms: In order to handle these test results shared with the BMC, he set up 24 war rooms, one in each civic ward. The 24 war rooms would be sent test results of patients in their wards by 6am. Each war-room was a control centre equipped with 30 telephone lines; it had 10 telephone operators, 10 doctors with medical support staff and 10 ambulances.
They worked round the clock in three shifts. Interestingly, their work was further divided by creating 10 dashboards within each ward with information about availability of beds making a total of 240 decentralised dashboards for the city of Mumbai.
Hub-and-Spoke Operation: The BMC head office acted as the hub that received and sorted out nearly 10,000 reports coming in from 55 testing labs everyday and transmitted them to 24 wards. This reduced the load per ward to 400, or just 40 per dashboard within these.
The focus was on patients who tested positive and needed hospitalisation — usually less than five. By 8am each ward-war room would be delivering results to people even as doctors and medical staff fanned out to the homes of those who tested positive. The key to this was staff and infrastructure.
Medical Staff: BMC invited doctors and medical support staff specifically to handle the war rooms (especially fresh graduates from medical colleges and nursing schools across the state), provided them with a hefty stipend (Rs50,000 per month) and hotel accommodation at walking distance within the ward. It could hire over 900 doctors as well as 600 nursing students to accompany the ambulances in each ward.
Ambulances: Mr Chahal also requisitioned over 800 SUVs and refurbished them to separate the driver’s area with a glass partition. These became makeshift ambulances which were adequate to transfer patient with mild symptoms to hospital. He also asked Uber to help with its software platform to track and manage the 800 ambulances to create a well-streamlined and tech-savvy system.
Co-opting Hospitals: Very early in the pandemic, Maharashtra had decided to cap COVID treatment prices at all hospitals; this seems to be working well, after initial hiccups. Mr Chahal has a centralised dashboard of 172 hospitals and COVID facilities created by the BMC, including many jumbo centres set up in open grounds, government and private hospitals, including smaller hospitals. These have been told to admit patients only through the municipal war rooms (this is not strictly enforceable).
Each ward team meets patients, examines their condition and, where necessary, calls the dashboard to obtain a bed, as per their condition (ICU beds or oxygen beds, where necessary) and transfers patients directly to the hospital on confirmation. Those who can be home-quarantined are counselled with regular follow-up by the ward teams. This personal touch ensures that people do not block ICU beds when symptoms are mild enough to be taken care of by oxygen beds.
Intriguingly, the panic, if any, is created by entitled well-to-do patients insisting on a specific private hospital or refusing to get admitted to municipal facilities, despite the assurance that they are clean, well-maintained and air-conditioned. Those who have opted for the facilities have invariably complimented the BMC.
In addition, the BMC allowed patients to walk into any of the seven jumbo centres set up across the city to be tested or admitted directly, without waiting for swab tests and results. Mr Chahal says over 20,000 people have availed these facilities.
Crematoriums: It is notable that Mumbai had no images of long queues to cremate the dead. This too was a result of proper planning when fatalities increased. Mr Chahal tied up with the Indian Institute of Technology to create an online dashboard of Mumbai’s 47 crematoriums, which allots cremation slots to prevent crowding and allows people to bid their last farewell with dignity and relative privacy.
Future Ready: Apart from setting up multiple facilities and reviving those what were shut down after the first COVID wave, the BMC is preparing for a possible third COVID wave around July on a war footing. Mr Chahal says he has 5,500 beds including nearly 3,000 oxygen beds vacant and available today. These include nearly 2,000 ICU beds with oxygen and ventilators. Four more jumbo centres are being set up which will further enhance patient capacity by 2,000 beds including 200 ICU beds.
In effect, Mumbai has 22,000 beds today and that capacity will go up to 30,000 beds in three weeks. BMC plans to hand over each of these jumbo centres to be run by large private hospitals (five-star hospitals) so that patients who want to be treated with such facilities have no hesitation in being admitted there. This is expected to augment the capacity of beds for well-off Mumbaikars.
While this describes the nuts & bolts of the ‘Mumbai Model’ one must remember that effective implementation of a good plan is not about infrastructure and finances. It requires strong and uncompromising political leadership, and a livewire like Mr Chahal, that is able to motivate and take people along to be a step ahead of the virus.
(This article was first published in Moneylife)