Maharashtra, one of the worst-affected states by the COVID-19 pandemic, has been hit by a double-whammy of shortages over the past month.
After running short of resources such as ventilator beds, liquid oxygen, and drugs like remdesivir in April, the state is currently battling a shortage of the anti-fungal drug liposomal amphotericin B (Ampho-B).
Ampho-B is crucial in the treatment of mucormycosis or the ‘black fungus’ infection which has been declared as a notifiable disease under the Epidemic Diseases Act, 1897 by at least 20 states since 22 May. The disease is largely being detected in COVID-19 patients.
Maharashtra is one of the worst-affected states by mucormycosis, having reported 2,200 of the national tally of 11,717 cases as of 26 May.
Announcing that all black fungus patients will be treated under the state government’s health insurance scheme, state health minister Rajesh Tope has said that the shortage of ampho-B in Maharashtra is a cause for worry.
Appealing to the Centre for more doses Tope said, “The state needs 1.50 lakh vials of the drug but has only received 16,000 vials from the Centre.”
The requirement of the medicine has risen sharply across the state in the past two weeks.
Rohit Karpe, treasurer of the Association of Chemists in the Pune district, was quoted by Indian Express as saying, “Usually, in any hospital, there would be a requirement of up to 100 vials per month prior to COVID-19. Now the consumption per patient is up to 120 vials. Presently, the demand has shot up to 1,000 to 1,500 vials from hospitals to various distributors in Pune district.”
Ravi Chavan, a resident doctor in a government hospital in Pune district’s Baramati, spoke about the black fungus situation at the taluka-level. He said that the taluka-level healthcare infrastructure faces limitations in treating black fungus cases and that the patients are almost always referred directly to the district hospitals.
“The treatment of black fungus cases needs a combined effort. A specialist team comprising a neurosurgeon, ophthalmologist, ENT surgeon, and an MD is required to correctly treat a patient. But in the Baramati taluka, there are only two hospitals equipped with all these specialists. Such is the case in largely all talukas in Maharashtra,” Chavan told Firstpost.
Doctors and healthcare experts based in Palghar, Amravati, and Gadchiroli districts also said that local infrastructure was ill-equipped.
A regulatory policy to boost the availability of ampho-B is yet to be implemented in the state.
However, Dr Subhash Salunkhe, the technical adviser on COVID-19 to the Maharashtra government, stated that the administration is working to bolster its stocks and streamline the process in the next two weeks.
“The state government will follow the same protocol for ampho-B as was followed for remdesivir. Patients and hospitals will be able to procure the medicine from the respective district collectors’ offices,” Salunkhe said.
‘Had to pick and choose whom to help’
The shortage of the anti-fungal drug comes on the heels of an unprecedented overburdening of hospitals battling the second wave of COVID-19. For almost a month since 22 April, social media platforms such as Twitter, Facebook, and Instagram have been inundated with requests for oxygen cylinders and beds, ventilator and ICU beds, plasma, and remdesivir.
Countless citizens have stepped up with efforts to finds and verify leads for resources.
Among the ‘COVID-19 volunteers’ is a group of 20 second-year MBBS students from the Dr VM Government Medical College in Solapur, who formed a network in 21 of Maharashtra’s districts: Washim, Nanded, Satara, Solapur, Parbhani, Dhule, Nandurbar, Raigad, Ahmednagar, Kolhapur, Pune, Hingoli, Nashik, Amravati, Yavatmal, Akola, Buldhana, Jalna, Pimpri Chinchwad, Jalgaon, and Aurangabad.
The students, who are now flagging the deepening shortage of the Ampho-B drug, were unanimous in sounding the alarm about the shortcomings of rural healthcare infrastructure in 13 districts.
Firstpost spoke to them about the situation they faced, as citizen volunteers, in helping COVID-19 patients secure life-saving resources at the peak of the crisis in April.
“The shortage of COVID-19 resources like oxygen and ventilator beds or remdesivir and plasma was so bad that we had to pick and choose whom to help,” said Girish Kothale, the volunteer group in-charge of Maharashtra’s Akola district.
In the 13 districts, the common refrain is that the hospitals – both government and private – in the headquarter cities were massively overburdened. Additionally, the most challenging resources to get leads on were ventilator beds and remdesivir.
While the number of active cases has reduced across Maharashtra this week, the student volunteers were wary of stating that the situation has stabilised in hospitals in the districts and talukas that they have been handling.
'Availability of ventilator beds boosted in Akola, but situation far from stable'
The biggest obstacle is to find ventilator beds, the students said.
Districts such as Solapur, Pune, Nanded, Satara, Nashik, Yavatmal, and Amravati are seeing comparatively better availability of ventilator beds since the second week of May.
Kothale, the student handling patient requests in Akola, said that the load of COVID-19 patients under treatment in the district’s hospitals had not decreased as of 29 May.
“The hospitals in Akola are still dealing with the same number of COVID-19 patients, many of whom are severe. The availability of ventilator beds has been boosted slightly but the situation is far from stable,” he said.
Rushikesh Kholghadge, the student responsible for the Washim district, summarised the general challenges faced by the students in all districts.
“When we started our initiative, we were venturing into a ‘zero’ situation. There were zero ventilator beds and zero oxygen beds available because of the sudden spike in cases. All hospital facilities were completely overburdened in the last week of April. It was simply impossible to find a ventilator. Now the situation is manageable but not better,” Kholghadge said.
Resident doctor Chavan, in the Baramati taluka, echoed Kholghadge’s statement and illustrated the severity of the shortage.
“It was simply impossible to get a ventilator bed anywhere in the taluka or the district. In April, despite getting 10 to 12 additional ventilators, our hospital was overburdened. In some cases, the delay in procuring a ventilator resulted in the patient’s death,” he said.
Chavan also said that the hospital was hard-pressed to provide beds and accommodate all the patients seeking admission. “There was absolute chaos. Our hospital has a capacity of 92 but there were 200 patients admitted. The management had set up cots in the verandah, in the corridors, in every available space. Somehow, we tried to admit every patient possible,” he said.
The lack of awareness about COVID-19 testing and treatment in rural areas compounded the problem because families delayed treatment and hospitalisation till the patient’s condition was severe, Chavan added.
“In such a situation, the patient directly needs a ventilator because his or her oxygen saturation is rapidly falling. With few ventilator beds to start with, a high number of severe patients made the situation worse,” he explained.
In Nandurbar, student Vishal Pawara shared an unusual insight. He said that contrary to the situation in almost all other districts, the hospitals in Nandurbar were not at full capacity because people were refusing to get tested and/or admitted “out of fear”.
The COVID-19 adviser to the Maharashtra government, Salunkhe, also admitted that the state machinery’s communication strategy fell short in its purpose of raising awareness about the benefits of timely reporting, and alleviating the fear and mistrust.
He added, “It has to be a joint effort between various state agencies, citizens, youth groups, NGOs to disseminate information so that people are less fearful of entering the healthcare system.”
Student volunteers in all the 13 districts reported that they received at least 25 to 30 calls daily from families of COVID-19 patients requiring ventilators on an urgent basis.
Unfortunately, they said, their success rate was abysmal.
“Of the around 30 calls that I got every day for ventilators I was able to fulfil only 3 to 4 requests. The shortage was such that there was absolutely no gap between the discharges and admissions for ventilator beds. Both government and private hospitals had very limited beds,” said Shubhadeep Turkane, the volunteer group in-charge of Yavatmal and Amravati districts.
Shriya Shah, the student handling requests in the Solapur district, spoke of an instance when she received a call for a ventilator bed and managed to secure a bed relatively quickly.
But by then the patient had already passed away.
The few patients who received ventilators or oxygen beds had to face waiting periods from ten hours upto a whole day. This, at the risk of the patient’s deteriorating condition, said Gaju Nana, a bureaucrat posted in a government hospital in Washim.
In most districts, civil hospitals have a robust waiting system, the students said.
Some patients chose not to wait, but move to other towns or cities such as Mumbai and Pune.
Tejas Desai, the student entrusted with the Satara district, said that a COVID-19 positive senior citizen couple undertook a six-hour journey from Satara city to Mumbai.
“Both patients’ oxygen saturation was around 70 and needed ventilator beds at 11.30 pm. I called literally every private and government hospital in Pune, Kolhapur, and Karad but was unsuccessful. Eventually, they travelled 250 kilometres to Mumbai in an ambulance and were able to secure ventilator beds there,” Desai said, adding that such an option is only available to people who can afford inflated ambulance rates and expensive hospital bills.
Calling the situation “frustrating”, Chavan said that healthcare workers felt “helpless” at not being able to provide for patients.
Salunkhe added that the absence of skilled technicians to operate equipment like ventilators was just as alarming as the shortage of the resource itself. This gap was mentioned by all the doctors and health experts Firstpost spoke with.
A Palghar-based doctor who wished to remain anonymous said, “At the peak of shortages, the focus was on equipment but not on technical skill and manpower. This is majorly alarming.”
Gadchiroli-based public health expert Dr Yogesh Kalkonde also gave an idea of how overwhelmed the rural healthcare infrastructure was during the peak of the second wave.
“There was absolutely no preparation for the intensity of the second wave. The governments, both state and Centre, should have opted for a preventive approach rather than a reactive approach. Because the healthcare system on a whole is weak, the battle against COVID-19 ends up being fought in the ICU, which is a limited resource,” he said.
'Remdesivir hyped as treatment but efficacy conditional'
The drug remdesivir, used as an early treatment for moderate COVID-19 patients, was another resource that was challenging to procure, students across districts said.
“Remdesivir has been hyped as a treatment even though its efficacy is conditional and limited for the treatment of COVID-19. But because there was a lot of panic, patients were demanding that doctors prescribe it to them,” said Shriniwas Galshetwar, the volunteer group in-charge of Nanded district.
Health expert Kalkonde corroborated Galshetwar’s statement and said that remdesivir had become part of the “folklore” because people were considering it to be a “magic bullet”, which isv inaccurate.
On 22 May, reports emerged that remdesivir is likely to be dropped from the list of primary COVID-19 treatment protocols.
The Maharashtra government sought to clamp down on the rampant black marketing of the drug, as vials were being sold for over one lakh rupees. To counter the black market, the state government stipulated that remdesivir would only be available through the respective district collectors’ offices.
The strategy’s success or failure to curb black marketing is unclear but students said that it didn’t ease the process of procuring the drug.
Each patient who is prescribed remdesivir requires six vials to complete one course of the medicine.
The family of Piyush Patel, the volunteer group in-charge of Nashik district, runs its own hospital. Patel said that despite applying for remdesivir doses for 80 patients (which would be 480 vials), the DC’s office sent only five vials.
“Subsequently, when the patients visited the DC’s office individually to procure the medicine, officials said that doses were already given to the hospital. This was a major loophole in this system,” he said.
Government advisor Salunkhe stated that the system was bound to be flawed because of the sheer demand.
“When the demand is 5,000 vials and the supply is 500, it is natural to have some rationing and shortfalls in the process of procurement,” he said.
However, experts called the policy of routing the procurement of these drugs through the DC’s office as a “transparent and reasonable” strategy, which had its “pros and cons” in countering the black market.
'People largely dependent on facilities at govt hospitals'
Oxygen cylinders, which were in high demand in Delhi and other cities, were only an option for a few families who could afford the inflated rates on the black market, said Shubham Jadhav in Hingoli district.
People largely depended on the facilities available at government hospitals, Jadhav said
The students are now preparing for their second-year semester exams, set to be held in person in June. However, all the students are appealing to the college administration and the state government to promote them without the test, citing stress and the risk of COVID-19 in travelling to Solapur from their hometowns, Shah said.
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