"Authors do not choose a story to write, The story chooses us." Richard P. Denny, Author1
Once in a while, I get a phone call from my old students, asking about my welfare in this pandemic. News reports in the media on escalation of SARS-COV-2 infection among healthcare workers could be a reason.2,15 The concern expressed by them gives me a warm feeling. It also allows me a peek into the mind of this generation.
Long back, GD and RS, were students in the same batch of MD Medicine course. Both were brilliant. Contrary to what one expects, they were great friends too. They covered up for each other in all their mischievous acts. It did not not stop them from being fierce competitors for the gold medal, reserved for the person who stands first in MD in the university. Even examiners could not determine who was better. Consequently, they had shared the medal.
Within a few years of passing, both decided to take premature retirement from the Armed Services and joined the civvy street. After leaving service they set to charter widely different career paths. Both went in first for super specialisation in different branches of medicine. Thereafter GD joined a newly commissioned corporate hospital and soon became a very sought after specialist in his field.
RS chose to join an apex government teaching institute and excelled in research work. He published a series of papers in his field to establish himself as an authority. Both of them were in their respective state capitals. Once in a while they took holidays together with their families.
They remembered me once every couple of years. Especially when they wanted to share a major event in their lives. That would give me a gist of all the happenings in their world. I was happy to note that both were doing exceedingly well.
A phone call
It was a coincidence that I got a call from both of them during last fortnight. Later, when I pondered over what they had told me, I felt very disturbed.
GD called first and appeared depressed. It was unusual to find him in this state. He sounded very disconcerted with COVID-19 situation. “Sir, it’s a disaster out here!” And that is what his phone call was all about.
“The Government had asked us to reserve 80% of our beds for COVID-19 patients. It has literally converted us into a COVID-19 hospital. No patient now wants to come to this hospital for a non-COVID-19 disease.”
“Oh, What about your superspeciality work?”
“It’s zero, absolutely zilch.”
Make it affordable
I was aware that earlier this year, on March 11, the government had invoked the Disaster Management Act, thus declaring the outbreak of the epidemic COVID-19 as a disaster. Disaster Management act of 2005 gave the Government sweeping powers over all medical facilities.
GD was saying, “As long as beds are available, the hospital cannot refuse admission to any COVID-19 patient. Nearly 65% of the hospital staff has either contracted COVID-19 or are in quarantine for having served in COVID Hospital. Doctors have been looking after all the beds with grossly depleted staff.”
“What about you?” I cared for his health.
He just went on, “The cost of treatment has gone up due to increased PPE requirements. On one hand the Government is fast tracking approval of new and expensive drugs for COVID-19, and on the other, it has capped the amount one can charge the patient for treatment.”
I was aware that he worked in a famous corporate hospital that had very good facilities. I enquired,”What are you charging your patients?”
“Sir, before COVID-19, the hospital used to charge Rs 14000 per day for an ICU bed. They separately billed the patient for the consumables and services (usually the total used to go over Rs 50000/day). Government has capped it at Rs 12000/day. This amount includes the cost of all ancillary expenses, services and medicines. Some of the medicines alone cost more than this.”
He continued, “The charges for ICU bed with ventilator are capped at Rs 13000/- per day (previous cost was around 80000/- per day).3 The cost of COVID-19 test is also being progressively brought down from Rs 4000 to 2200 and now 1200 under Government orders.16
I asked,”Do you think, earlier high charges were justified?”
He replied,”Sir, the hospital provides an international standard of care with multiple layers of safety checks. Our hospital has hired a highly trained staff that needs to be paid well. Surely, there was also an element of profit as it is supposed to be a private hospital. Our costs are less than a third of what is being charged abroad for similar class of services!”
“How does the costs capping affect you?” I was curious.
“Sir, my hospital administrators tell us that it is way below the cost of maintaining the infrastructure. They feel that the Government does not intend that we should genuinely treat patients. They only want us to be appearing to treat the patients! Hospital authorities are finding it difficult to cope and want to close down the hospital. The administration is already discussing with lawyers about how to bring an end to all operations!”
“What about you?” I repeated my question.
“Sir, the hospital has stopped paying salaries to the super specialists for 3 months now. The exceptions are those who work with COVID-19 patients. This includes house officers, residents, general physicians, critical care staff and respiratory physicians. They asked me last month to work as a general physician in COVID-19 ‘suspect’ ward (Patients admitted after negative for Rapid antigen test and awaiting results of PCR test)!”
“GD, Are you safe?” His tone of voice was now worrying me.
“Still alive, sir! The hospital did not think of providing PPE in the suspect ward as patients were Rapid antigen negative. But many of these patients later turned out to be PCR positive. I too, caught COVID-19 about 3 weeks back. My period of quarantine is over. But I still get palpitations and breathlessness on walking. So I have taken leave and am sitting at home.”
“Have they done your CT chest?” I was concerned.
“Yes I got a CT done. It shows mild changes. I took steroids and LMWH.” He said
“Terrible!” I sympathised with him.
“Sir, I am worried about you. You fall in the high risk group. I suggest you stop going to hospital and stay at home.” He sounded genuinely worried.
In my team of eight Gastroenterologists, five had already contracted COVID-19. Two of them were having persistent post COVID-19 symptoms. But I reassured him.“Don’t worry, GD. I have cut down my work quite a bit.”
Then we talked about his family and the conversation ended. I was wondering if the Government was doing a wise thing by pushing private hospitals to the brink. The investment required to build and run a modern hospital was humongous. It takes several years for hospitals to ‘break even’ in terms of business. Many technologies become obsolete quickly, so one is forced to invest more in newer technologies. The very thing, our Government could not do in most public sector hospitals leaving them doddering with aging technology and poor infrastructure.
A view from the other side
As luck would have it, within a week I got a call from RS too. He appeared very upbeat. “Sir, how are you doing in COVID-19 times?”
I was happy to hear his voice and I told him so.
“Sir, please take care, the situation is deteriorating out there!”
I replied, “Yes, the numbers are increasing in most places. I find the news very vexing these days and therefore I stick to the firestick. How are you doing, RS?”
“I am fine sir! And, I have been inducted into the central COVID-19 think tank!”
I was surprised,”But your superspeciality has nothing to do with infectious diseases, immunology or public health?”
He laughed,”But I am also basically a physician!”
“I know you are, and a real good one too. I was just wondering!” My eyebrows went up when he replied.
“Actually sir, I was treating this Mantriji (he uttered a name) and had become very close to him. Almost like a family. He insisted that I should be a part of the think tank!”
“It’s a big honour! But what do you all do?” I asked.
Privileged in Pandemic
“Sir, we are detailed as an inspection team to see that the private hospitals are following the instructions given to them by the Government. Then every other day we have strategic meetings with the Department of Health to plan how the state should tackle the COVID-19 situation. In our spare time we conduct webinars for educating the practitioners.”
He seemed happy in what he was doing. I couldn’t understand the last part, “But is that your mandate? Doing webinars for practitioners?”
“No sir, most webinars are actually organised by professional societies with the help of the pharmaceutical industry. They invite us to be the faculty.”
I enquired further, “Doesn’t that take you away from your patients? Your hospital must be full of COVID-19 cases?”.
“No, sir. Whatever gave you that idea?” He looked surprised.
I replied, “With numbers rising so rapidly, I thought the hospitals would be full.”
“Sir we had converted our infectious diseases (ID) block into COVID-19 hospital. But the main hospital is nearly empty! And then in ID block too, three of our junior doctors got infected. Since then, we have closed it down. We have now asked for enhanced facilities from the Government, which normally takes years to materialise. Till such facilities materialise, we are not seeing any COVID-19 cases ”
I found it difficult to digest. “Your ID block has only 110 beds! The main hospital has 1140 beds. How have you managed to keep away from COVID-19 patients in the main hospital building?”
Give us the moon
RS was quiet for some time. “Our director communicated to the CM’s office that till additional facilities, equipment and consumables are provided we have decided to postpone seeing COVID-19 cases. One exception is our ‘Cardio-thoracic ICU’ which has been converted into a VIP ward, just in case a VIP4 gets COVID-19.”
I was not expecting this answer. “What about your hospital that used to be teeming with patients.?”
He reluctantly answered,“We have drastically restricted our hospital admissions. Currently the wards are nearly empty. We are only admitting cold non-COVID-19 cases when recommended by the VIPs. And that too after they are proven PCR negative. We want to preserve our facilities.”
I asked,”Preserve your facilities for VIPs? And who are these VIPs?”
RS answered with a chuckle and I could sense the sarcasm in his reply, “Sir, you must be joking. When you were in the Army, wasn’t GOC-in-C your VIP?”
This was an attack on the Army culture. Therefore I had to give a rebuttal to him.
“Yes, GOC-in-C was a VIP, but not for reserving essential services. A GOC-in-C’s time was given more importance over others. But no one has ever kept a hospital empty ‘just in case’ he fell ill! He would have been furious to learn if anyone did! Does your VIP know?”
He replied in a bit feebler voice, “I don’t know. There are so many smaller VIPs under him. We don’t have direct access to the main boss.”
“So it is the smaller VIPs that are keeping your hospital as reserve?”
“I guess that may be the case.” He was less upbeat now.
“And who convinced them to do it? Was it you or people like you in the think-tank?” I was feeling the fumes inside.
Root of all evil
The content of his reply was chilling even in his feeble voice,“Sir, the suggestion came from one of them only. We did not object in the meeting. And they needed no convincing. Among our staff, we have seven spouses of these smaller VIPs as faculty. I am guessing they wanted their spouses to be safe. That was also the best way to keep themselves safe.”
“RS, I am aghast. What is it that you do in the think tank meeting?”
“Well sir, it is not the Army. The situation is different in civvy street. The hospital gets every facility from them. They can stop our equipment and supplies on a whim. We are totally dependent on them. If I want to develop my department, I have to keep them happy.”
“Do you know what you are saying?” I asked.
There was a tinge of doubt in his voice now, “I guess I do! I do want to upgrade my department to international standards. And therefore I need to keep them on my side. I give them what they want. But I am not doing anything wrong or unethical.”
“Have you sold your conscience too?” I asked
“Where is the question of selling my conscience? I have not suggested anything. I am just one of the members of the think tank. Decisions are taken by the bigwigs.” He replied.
I realised that our perspectives were very different. “If you had to decide, would you have taken this decision?”
He thought for some time,”Maybe not.”
I insisted,”Then why did you not object?”
He said,”Because no one was objecting!”
You too have a voice
I carried on,”But you had a voice as a member. You could put across your point of view. You could have insisted on inserting a note of dissent.”
“Why should I bother, when all my seniors were quiet. I did not want to be thought of as the odd man.” He was still persisting with his argument.
I could not help firing at him an old saying,”RS, remember, Each snowflake in an avalanche pleads not guilty.”5
And then, it suddenly dawned on him. He remained quiet for a few seconds. Then he said,”You feel I have done wrong by not objecting to what they proposed?”
I said,”I feel you have not given your true opinion where it was required. Now you are as guilty as others for depriving the poor people of your state, free medical facilities your hospital could have offered.”
He said,”Whatever I might have said, their decision was already made.”
I reiterated,”But now you are a party to that decision. You have failed the democracy. Your VIPs, I assure you, do not think that you are very intelligent. They think you are too much in awe of their power and therefore a convenient scapegoat. The minutes of meeting will later show that one of you had proposed the motion and another one had seconded, and finally it was unanimously agreed.”
He again paused for a long time. He concluded the conversation by saying,”Sir, you have given me a lot to think about.” And then he hung up.
The conversation had left me stunned. Was it really happening? Were Government officials in power keeping pockets of medical facilities reserved as a contingency and depriving the poor people for whom these facilities were originally meant? Or were some doctors in Government services sheltered from COVID-19 duties? Were these doctors working only as inspectors, to oversee that the private hospitals do what they were being forced to do? Were poor people being diverted to spend their own money in private hospitals while a huge reserve capacity was lying unused due to fear perception among VIPs?
I could not believe it at first. But I reasoned that both GD and RS had no reason to lie to me. And I knew that as a habit, they were truthful. Even as PG students, they had always come forward to take the blame when things went wrong. I respected them for that.
I was aware that all orders for COVID-19 management were being issued under the terms of the Disaster Management Act, 2005 (DM Act). An authority on law had stated that the Constitution of India is silent on the subject of ‘disaster.’ The legal basis of the DM Act are (a) Entry 23, Concurrent List of the Constitution “Social security and social insurance”; and (b) Entry 29, Concurrent List “Prevention of the extension from one State to another of infectious or contagious diseases or pests affecting men, animals or plants.” These can be used for specific law making.6
The 2019 National Disaster Management Plan, deals extensively with Biological Disaster and Health Emergency. This is the broad legal framework within which activities to contain COVID-19 are being carried out by the Union and State governments.7
Power bestowed by DM Act on Central Government and NDMA are extensive. The Central Government, irrespective of any law in force (including overriding powers) can issue any directions to any authority anywhere in India to facilitate or assist in the disaster management (Ss 35, 62 and 72). Importantly, any such directions issued by Central Government and NDMA must necessarily be followed by the Union Ministries, State Governments and State Disaster Management Authorities (Ss 18 (2) (b); 24(1); 36; 38(1); 38(2)(b); 39(a);39(d) etc.17
State governments, in addition to DM Act, have used the Epidemic Diseases Act, 1897and the various state specific Public Health Acts (eg: Tamil Nadu Public Health Act, 1939) to deal with the crisis. Kerala, in addition to the above, invoked legislative power under Entry 6 (Public health and sanitation) of State List and issued ‘Kerala Epidemic Diseases Ordinance, 2020’. Overall, states have also enough legal power in dealing with this biological disaster, including punishments for disobeying order of a public servant and malignant act likely to spread infection of disease dangerous to life (Ss 188 & 270 IPC respectively).18
Pertinently, there is a bar on jurisdiction of courts (S 71) and there is no grievance redressal mechanism under DM Act. Having assumed the role of sentinel on the qui vive (State of Madras v. V G Row, 1952), it is obligatory on all the constitutional courts in the country to suo motu register PILs and closely monitor the implementation of DM Act, ensure rule of law and protection of human rights as guaranteed under the Constitution of India.8
You need to speak
GD and RS are imaginary characters, created to hide the identity of people who decided to speak. You can say that the evidence is hearsay. It is also possible that these are two isolated anomalies. But I do hear media reports suggesting that OPDs of so and so hospital have been closed.9,19,10 Or ICU beds in private hospitals are full while those in Government hospitals are not.11,12 The question remains, “Are private hospitals being browbeaten under the terms of DM Act to go into loss? Are some pockets of healthcare being protected as contingency while directing the poor public to private facilities?” I am aware that several Government hospitals are doing excellent service for COVID-19 patients. But I am also aware that several private hospitals have closed down.13 I had also raised some of these issues in my previous blog.14 I have no way of knowing the real truth. I will like it very much if you share your own knowledge and experience on this issue.
|↑3||There are various directives issued by the state Governments to cap the charges. I didn’t know the orders in GD’s state, but I believed him. In our own state, a similar letter has been issued to all hospitals. Government of Odisha, Health and Family Welfare Department letter no HFW-MWII-COVID-0020-2020/H&FW 18628 of 14 Aug 2020 refers. Within this amount, the charges for medicines are capped at Rs 7000/-, while the cost of some medicines specific for COVID-19 alone may be Rs 40000.|
|↑4||VIP stands for very important person|
|↑6, ↑8, ↑17, ↑18||https://www.theweek.in/news/india/2020/04/26/covid-19-and-the-ambit-of-the-disaster-management-act.html|
|↑7||The letter No. 40-3/2020-DM-I(A) Government of India Ministry of Home Affairs North Block, New Delhi-110001 Dated 17thMay, 2020 refers extensively to many of these authorities. It reads as follows: ORDER Whereas, the National Disaster Management Authority (NDMA) in exercise of their powers under section 6(2)(i) of the Disaster Management Act, 2005, vide their Orders dated 24.03.2020, 14.04.2020 and 01.05.2020 had directed the National Executive Committee (NEC) to take lockdown measures so as to contain the spread of COVID-19 in the country; Whereas, Chairperson NEC, in exercise of the powers conferred under Section 10(2)(1) of the Disaster Management Act, 2005, has issued Orders of even number on lockdown measures dated 24.03.2020, 29.03.2020, 14.04.2020, 15.04.2020 and 01.05.2020; Whereas, save as otherwise provided in the guidelines annexed to this Order, all Orders issued by NEC under Section 10(2)(1) of the Disaster Management Act, 2005, shall cease to have effect from 18.05.2020; Whereas, in exercise of the powers under section 6(2)(i) of the Disaster Management Act, 2005, NDMA has issued an Order number 1-29/2020 – PP dated 17.05.2020 directing the Chairperson, NEC that lockdown measures to contain the spread of COVID-19 be continued to be implemented in all parts of the Country, for a further period upto 31.05.2020; Now therefore, under directions of the aforesaid Order of NDMA dated 17.05.2020, and in exercise of the powers, conferred under Section 10(2)(1) of the Disaster Management Act, 2005, the undersigned, in his capacity as Chairperson, NEC, hereby issues directions for strict implementation, to all the Ministries/ Departments of Government of India, State/Union Territory Governments and State/ Union Territory Authorities that lockdown measures to contain the spread of COVID-19 will continue for a period of upto 31.05.2020, as per the guidelines annexed to this Order, which will come into effect from 18.05.2020. Signed by Union Home Secretary|
|↑15||And Nguyen LH, Drew DA, Joshi AD, et al. Risk of COVID-19 among frontline healthcare workers and the general community: a prospective cohort study. Preprint. medRxiv. 2020;2020.04.29.20084111. Published 2020 May 25. doi:10.1101/2020.04.29.20084111)|