Breathless

 Yesterday was a day of desperate messages on our neighbourhood e-group:

13:50: "Does anybody know where oxygen cylinders can be purchased right now? "

19:02: "Mr. B needs a ventilator immediately...his hospital does not have one to spare.."

01:14: "Very, very sorry to inform you that Mr. B is no more..."

The same tragic sequence of events is being played out in thousands of places across the country now. As the "Second Wave" of Covid-19 infections sweeps across India a major crisis of medical supply-chain inefficiencies has hit India. There has been such a sharp spike in Covid cases that 54.5% of patients during second wave required supplemental oxygen during treatment - a 13.4% increase from the peak during September and November 2020.

The irony of the situation is that there is no shortage of O2 production in the country - India has a total production capacity of more than 100,000 tons/day (7,100 tpd of medical O2 as per HT), of which over 80% goes for steel-making. According to HL Meghnani, an industry veteran, industrial O2 has to be 99.5% pure while medical O2 needs to be only 93% pure, and less than 1% of O2 produced is used for medical purposes. Yet the scale of crisis currently unfolding is mind-boggling.

India's clinical management protocol recommends oxygen therapy as the primary form of treatment: the target is to achieve 92-96% SpO2, or 88-92% in patients with COPD. While proportion of those requiring oxygen beds is still hovering around under 10%, this number is at an all time high with India's active caseload crossing 26 lakh (2.6 million). The demand for medical oxygen has increased by 18% over the last 6 days across 12 states which account for 83% of India's active cases.

Where did we go wrong? What will it take to bring this situation under control? 

One of the points made by Meghnani brings out the nature of the complexities involved rather nicely - "The current crisis arises because of a shortage of road tankers, storage tanks and cylinders... each tanker costs INR 4.5 million and a cylinder costs INR 10,000 in which you sell O2 worth just INR 300" (!) Add to this the location of the O2 plants -  mostly in Western  and Eastern India -  and the decision taken by major hospitals to outsource O2 supply instead of having captive plants, and you begin to understand why the supply-chains collapsed last week.

We are now in the process of rushing in extra cryogenic O2 tankers from abroad, and penalising those who have been profiteering during this crisis by hoarding O2, and driving up the prices.

What remains unclear is a more granular picture of O2 demand and consumption in our hospitals. How many O2 tankers are needed every day to service all the hospitals in our cities and towns? Can some of the shortage be handled by portable O2 concentrators? 

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REFERENCES & LINKS

* 28Apr21 - Gurumurthy S, New Indian Express - Missing Facts, Misdirected Course - https://www.hindustantimes.com/india-news/why-india-is-facing-an-oxygen-crisis-as-covid-19-cases-mount-101619268862048.html

* 25Apr21 IEexplained - What changed in the second wave? - https://indianexpress.com/article/explained/explained-whats-changed-in-second-wave-7289002/

* 25Apr21 IESunday - Falling Short O2 - https://indianexpress.com/article/opinion/editorials/nirmala-sitharaman-economic-package-migrant-workers-one-nation-one-ration-card-coronavirus-6410303/

* 24Apr21 - HT - Why India is facing an oxygen crisis - https://www.hindustantimes.com/india-news/why-india-is-facing-an-oxygen-crisis-as-covid-19-cases-mount-101619268862048.html

Mucous Cyst Rx

"Its just a local trauma..."
"No, its a bacterial wart! be careful, it infectious...certainly needs a surgery and biopsy..."
"Oh, just a simple mucous cyst!"

Two months, four doctors and three hospitals and many thousand rupees later, we have gained a few insights into the way in which our medical system works. It give you a glimpse of how private medical care is designed to make a mountain out of a molehill, to scare and fleece the gullible.

Two months ago, our son Aki got a cut on his upper lip which, instead of healing, developed into an eruption. Flesh etruded out of the cut which bled profusely from time to time. One day it would seem to be healing with a black scab but return to a a fleshy, bleeding nodule the very next. About 10 days after it showed no signs of healing, we took him to a doctor at the nearby Jaypee Hosptital. The pediatrician said it was just a "local trauma" and prescribed a  an anti-inflamatory syrup.

Aki found the syrup tasty but it nothing to reduce the eruption, or the bleeding. So off we went for a second opinion, to pediatrician at Patparganj, one strongly recommended by doctor-friends. The clinic was crowded and, from the number of vaccine adverts on the walls, quite popular with pharma companies as well. The doctor here came through a fair, honest, consciencious physician. "This looks like a wart", he said, "It needs to be surgically excised...it is just an Out Patient (OP) procedure in any government hospital, but given the crowds, you won't be seen unless you know somebody personally. If you go to any private hosptial, make sure you get the estimates clearly, in writing, before you get the child admitted". He also graciously returned - to our amazement - his consultancy fees (INR500) because, in his words, "I only advised you to go elsewhere." 

Next stop, Max Hospital. Here we got to meet our first pediatric surgeon. One look at Aki's lip, and he declared that it was "mucous cyst". Pulling our a couple of blank sheets, he explained in detail how it developed. "Sometimes, the process of healing ends up blocking the flow of mucus cells...and instead of keeping the lip surface moist, they end up discharging mucus under the skin. This develops into a cyst which ruptures and bleeds easily." Surgery, apparently, was the only way to get the cyst removed.

How much would surgery cost? Well, the answer depends on whether or not you have a mediclaim insurance cover. If you do, then it would cost about INR 25,000 if you got it done at Max Hospital. The cost of booking an operation theatre, anaesthesia specialists and a days' stay at the hospital, we were told, made a relatively simple procedure expensive. 

Would this be defenitely covered under mediclaim? Guys at the billing office were not so sure. "Lets see", they said, "We will submit all the papers and then know in a couple of days". Not quite reassuring.

So now we went for fourth opinion with a surgeon at Kailash Hospital, Noida. The diagnosis at Max was reconfirmed. This certainly was a mucus cyst that needed to be 'surgically excised, or cauterized'. The cost was a couple of thousands less but, given the crowds at this hospital, nobody wanted to an operation date, or the insurance coverage.

Back at Jaypee Hospital, the feedback from the billing office was the same. The procedure would cost not less than INR 25,000, which included no less than INR 8000 for 'micellaneous consumables'! The cost of the biopsy, of course, would be extra.

Since none of the pediatric surgeons said that it was emergency procedure, we thought about it for a couple of days, checked with other hospital, and settled for a surgery at Felix Hospital. This was the only place were we met a pediatric surgeon who inspired confidence in us with his surgery-as-last-resort approach. This was the also only hospital that had an OT readily available, did not insist on conning insurance companies and came up with surgery cost estimates at INR 5500. The only down side at this hospital was that they charged thrice the amount for consultancy fees for pediatric surgeons, compared to far more reputed hospitals. 

Anyway, sometimes when all is not so well also ends well. A supposedly common medical condition was misdiagnosed, received inflated cost estimates for the surgery, and was finally sorted out for one-fifth the estimates. One thing is clear, the nexus between private private, medical insurance companies, and TPAs is designed to fleece patients - especially those who may not have the luxury of time to seek a fair deal.

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Postscript:
After the final follow-up visit, our doctor requested that we evaluate him online. I received three sites on WhatsApp -- Practo, Lybrate and JustDial. This is an interesting new trend - doctors want to create a reputation that is independent of the hospitals in which they serve. I am not sure if this is good for the patients because we now have one more broker in between, and the additional costs are built into the doctor's fees :(

* Practo: Verifies feedback with an OTP sent to mobile number, collects proof of visit (bill/prescription), and creates a login for you, on the sly. 
* Lybrate: Does not have a clear section for doctor feedback. Verified using OTP. No need to login.
* JustDial: Badly designed site. The doctor's review page forces you to post your comments on FaceBook and Twitter (default option). Crazy.

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LINKS:

- Oral mucocele - https://en.wikipedia.org/wiki/Oral_mucocele

The Apathy Chronicles

Science may have found a cure for mos evils; but it has no remedy for the worst of them all - the apathy of human beings." -- Helen Keller


Today's Indian Express has a telling cover story on the state of governance in India. It is a classic case of adopting the proverbial ostrich-like attitude: pretending that a problem does not exist, and hoping that, somehow, it will disappear on its own.

I just thought it would be interesting to list some of them to see if there is a pattern that could lead us to possible solutions.

First, the IE story today:

* AIR POLLUTION IN DELHI

The Central Pollution Control Board identifies a potential problem area and commissions an independent agency to examine the air quality in Delhi, through an exhaustive study involving 11,000 schoolchildren from 36 schools, across three years. Yet, despite detecting an alarming rise in pollution levels, everybody is still busy "studying the report".

Links:
- Landmark study lies buried - http://indianexpress.com/article/india/india-others/landmark-study-lies-buried-how-delhis-poisonous-air-is-damaging-its-children-for-life/
- Chatterjee, Pritha (31Mar'15), IE: Seven years ago, everyone saw Delhi’s air take a deadly U-turn but no one did a thing


* THE NEW (RE)EMERGING DISEASES

Over past two decades, hospitals across India have been witnessing a sharp rise in new and re-emerging diseases: Chikungunya, bird flu, swine flu, monkey flu, Ebola, MDR TB and Malaria, etc., This year along we have lost over 2000 lives to H1N1 swine flu.
What have we done about it? The health ministry had figured well in advance that our total dependence on imported diagnostics and medicines would hamper containment efforts. So it decided to develop indigenous technology and succeeded in getting entrepreneurs to produce test-kits for a tenth the cost (Rs. 400 vs. minimum of Rs.4500/test). And then, amazingly, after handing out the necessary regulatory clearances, it does nothing to encourage states to adopt cheaper, more affordable diagnostics and medicines.
Predictably MNCs like Applied Biosciences are quite pleased with the state of affairs. While low-income patients balk at the cost of getting reliable tests and drugs, the MNCs are laughing all the way to bank, happy to serve just those who can afford it.

Links:
- Nagarajan, Rema (18Mar'15), ToI: Two Indian firms develop cheap H1N1 test kits, but find few takers
- Singh, Jyotsna (31Mar'15), DTE: When flu turns fatal - http://www.downtoearth.org.in/content/when-flu-turns-fatal


* DELHI BUS RAPID TRANSPORT (BRT) SYSTEM

Inspired by Curitiba (Brazil) and Bogota (Colombia), and goaded by IITD academics, the Delhi government decided to ease the urban transport problem by building a BRT corridor in South Delhi. The first phase of construction (2008) was so haphazard and unplanned that vehicles kept crashing into unmarked barriers that had come up overnight, constriction of road space forced bikers on pedestrian pathways and VIPs appropriated the bus-lanes for themselves.
Now there is talk of just scrapping the whole project. So what if the project cost a few millions?

* PIPED WATER SUPPLY IN NCR DELHI

Why is it so rare to find 24x7 piped water supply in Indian cities? Because the amount of water that would be wasted from taps that are left open would leave us very little to supply the next day!
In suburbs like Noida, the municipality has fixed a "flat-rate" for monthly consumption of water. This amounts to a measly Rs. 25 to Rs.150 per month. Since there is no incentive or costs to careful use of this resource, enormous quantities of water overflow into the drains every day. Picture this: Everyday, Noida Jal processes and distributes about 100 cusecs (244 million litres/day) of water. Water is pumped from the holding stations to overhead waterttanks in each sector, and from here, it is supplied to users twice a day for about three hours.
Water quickly fills up the overhead tanks in all the buildings, and since the supply is not metered, most users have an overflow pipe that spills excess water into the drains. For at least an hour water just goes down the drains. Has there been any effort to calculate and control this huge, daily wastage of clean water? Who cares!

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LINKS:
- http://en.wikipedia.org/wiki/Delhi_Bus_Rapid_Transit_System
- BRT May be Scrapped - http://timesofindia.indiatimes.com/city/delhi/Delhis-BRT-may-finally-be-scrapped-as-MLAs-put-pressure-on-govt/articleshow/46569844.cms

Being Mortal in India

A peaceful, painless death is one of life's greatest blessings.

Atul Gawande's latest book is born out of experiences with those who, for most part, did not have this blessing. It discusses the way in which medical technology and social norms tend to mislead, dictate or overrule the options available to those who are terminally ill.

The book also brought back deeply disturbing memories of my father's last days at a hospital in Kerala. Much like a patient described in the book, he to was shuttling between hospitals and diagnostic labs, with an irreversible nervous system failure. Towards the end it was appalling to see somebody who stayed away from hospitals "drugged into oblivion and tubed in most natural orifices as well as a few artificial ones".

Gawande, with his focus on the prevailing healthcare system in USA, misses on some of the more disturbing aspects of what the urban elderly face in India. The fact that my father retired from the central government service prolonged his suffering in more ways than one. The first question they asked you at hospitals was - "He is fully insured under CGHS, isn't he?".

A comprehensive health insurance package seems to have prompted private hospital docs to prescribe drugs, diagnostics and procedures that were completely unnecessary. Towards the end, all the family members had to give a signed undertaking to get him out of the ICU, back into the pay-wards.

The priorities of the elderly, and the terminally ill in India may be the same as those in other countries -- to avoid suffering, strengthening relationships with family and friends, being mentally aware, not being a burden on others,

The challenge is trying to ensure that these priorities take precedence over those of the doctors, the healthcare service providers, pharma & diagnostic companies, as well as 'loving' family and friends.


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LINKS

Homepage - http://atulgawande.com/book/being-mortal/