BMC additional municipal commissioner (health), Suresh Kakani, has been at the heart of Covid management in Mumbai since the start of the pandemic, helming the health infrastructure and planning of the country’s financial capital. On field, going from one slum and hospital to another, Kakani worked overtime to ensure the situation was kept under control. In a chat with Geetanjali Minhas of Governance Now, the bureaucrat narrates the BMC’s Covid management story and the path ahead:

After the central government’s alert to states on resurgence of Covid-19 in China, Europe and other regions, how are you preparing to tackle a possible 4th wave in Mumbai?
We have been able to successfully tackle the third wave and now we are getting 50 or fewer daily cases. While we are on alert for a possible fourth wave after the predictions by researchers from IIT Kanpur and other agencies, we are prepared.

We have decided to keep our Jumbo Covid facilities on standby for at least a month after which we will be able to take further call. All our oxygen supply systems, ventilators, ICU facilities will be on standby mode. While there is a maintenance cost to this, dismantling them and again putting them in place will be time and resource consuming and so we will continue with these facilities for now. We have adequate stock of medicines and that should not be a problem.
 
We are focussing more on giving booster doses to the eligible population like those in the 60+ age group and those who have completed nine months after the second dose, so they can be vaccinated with preventive or booster dose.

We are also creating awareness among people though IEC activities to follow Covid appropriate behaviour (CAB). If we follow all these strategies, there will be nothing to worry. As of now we are ready and if required we will upgrade our facilities.

There is a general belief now that after the court order, it is not necessary to wear mask.No, the hon’ble court has not said that. Whoever is communicating this should provide a copy of the court order. Someone is creating a mischief. Of course, the court case is going on in that matter but as of now there is no ban and there is no order by the hon’ble court.

According to scientists, as antibodies wane, the virus can re-infect. Does that mean vaccination and CAB will be a continuous process as potential new variants emerge?
Covid-appropriate behaviour should be the new normal. Just as you wear a helmet while riding, similarly wearing a mask is for your own safety. It may not be mandatory, but it is a directive. If you come in contact with an infected person, for no fault of yours you may get infection.

You have been at the heart of Covid management during all the three waves in Mumbai. Please take us through your experience and journey of handling the unprecedented situation.
Yes, during the first wave, the situation was challenging. Subsequently after we upgraded our capabilities, capacities, facilities … though challenging, we could successfully handle it. Our fatality rate during the first wave was 3.57%. During the second wave we could bring it down to 1.14 % and during the third wave it was 0.15% or less than 0.2%. While there should not be a single fatality for that matter, initially Mumbai had a high fatality rate as compared to the rest of the country. Subsequently we could bring it down to less than the national average or other states’ average.

It was certainly challenging because we were not certain about treatment protocols, how to manage patients, how to segregate symptomatic patients from community, how to separate high-risk and low-risk close contacts and house them and provide necessary support, attach them, vaccinate them… everything was challenging … but because of team effort and a systematic plan we could take care of all the three waves without issues.
 
Since I was personally moving from one hospital and slum in the field to another, we were in the process learning and getting information to come out with better and implementable policies. Usually there is a gap between polices and their implementation and subsequently governance. But on all three fronts because of close contact in the field situation, we could come out with better policies and take care of Covid positive patients in a systematic manner. This also reduced the fear level substantially.

Economic activities during the third wave were almost operational except some social restrictions. This too helped us build confidence among citizens. It is very satisfying for us that public faith in MCGM operated public facilities has gone up like anything.

Did you notice any gaps in the system?
Of course, gaps are always there, as no system is perfect. It cannot be an idealistic situation. As our teams were connected closely with the field situation and feedback channels were open 24x7, we were able to come out with required implementable policies during the second and third waves and the situation now is much better.
   
Can you tell us about challenges you faced during the first and second waves?
During the first wave everything was a challenge. Treatment protocols, management of patients, beds, ICU beds, ventilators, oxygen supply… everything was a challenge. But we could come out with better solutions within a month or two thereafter.
 
During the second wave when the death rate was mounting everywhere, that was not the case in Mumbai. As the situation was alarming in other parts of the country, it stressed us out too and we started to plan our regular oxygen supply. During the first wave when we had patients with breathlessness, it was decided to have our own consistent oxygen supply and we shifted from cylinder based supply to a centralised oxygen supply system connecting tanks to pipelines. We set up our own oxygen generation and refilling plants in collaboration with Bharat Petroleum and Hindustan Petroleum. During the second wave there was no incidence of any fatality due to shortage or improper supply of oxygen which was not the case elsewhere.               

The third wave was comparatively less fatal…
Critical patients or hospital requirements were very less because of two counts; vaccination – as by then 90% people had been vaccinated with double dose and also the following of CAB by the population. Our maximum count during the third wave was 20,000 but later in a week’s time our tally was manageable. In terms of tests, we were able to conduct between 55,000 and 72,000 tests per day and 95% patients were asymptomatic and not requiring medical or oxygen support and recovery was much faster as compared to the first and second waves.  

Earlier, you were instrumental in sourcing the genome sequencing equipment from Singapore. Now the BMC will be carrying out genome sequencing of sewage water samples for presence of the novel coronavirus. Can you please explain this concept and how this research will help?
In September 2021, we were able to start our own genome sequencing lab to know the circulation of variant for correct assessment and treatment protocol and to come out with policies that will work for such a situation. This is very good intervention as this facility is available in a very few cities. We have conducted 10 genome sequencings (350 samples each) so far. The last one indicates dominance of Omicron variant. BA.2 numbers were more but due to our interventions, we were able to control the third wave in minimum possible time.

Right now, the positivity rate has come down and our genome sequencing should not be underutilised and so we have decided to collect sewerage samples to study if the virus is present and if present what the variant is. Here we are collecting random sewerage samples and putting them to RTPCR tests. If the test is positive then the sample will undergo genome sequencing. This will tell us about the variant and the required necessary policy and planning for that. It will help us predict a possible fourth wave and its volume.  

What is the current status of vaccination in Mumbai?
We have been able to vaccinate 110% of the 18+ population (including people travelling in and out of Mumbai as well as the migrant population) with the first dose and 99% with the second dose. If we take the 15+ population (98 lakh) our vaccination is 108%-109% with the first dose and 95% (93 lakh-94 lakh) with the second dose and across the four metropolitan cities we may possibly be no. 1. Our aggressive vaccination strategy worked very well in our favour and helped us contain further onslaught of the third wave.

We are continuing with the same policies for vaccinating 12-14-year-olds (5 lakh plus population) in a decentralised manner. We may set up camps in schools and colleges, provided they allow us to do so.

For the booster dose, 60% of the eligible population has been covered, and the remaining will be covered as and when they are due as there is a gap of nine months after the second dose for taking the booster shot. Additionally, if a person is Covid-infected there is a gap of three months to be followed for taking the booster dose.

Under the sixth sero survey we are collecting samples of frontline and healthcare workers in three phases; on day 1, after 6 months and 9 months. Here we study the quantum of antibodies available in the person’s blood: if they are constant or going up or down over the period, which will help us decided on subsequent or booster doses. We will be sharing these results with the government of India to hopefully come out with a revised policy.              

How has Covid impacted the economy of the financial capital of the country? Which sectors and services have been severely impacted?
During the first wave, the economy was badly impacted but during the second wave we advocated that with some restrictions the economy should run as normal. During the third wave, except for a few social restrictions, everything else was open. The state government also has declared good growth.

There is no long-term permanent impact on any sector. In case there is a short-term impact it would be recovered in the long term.
            
Was lockdown essential, especially in the financial capital of the country?
During the first wave, the world over, there was no known protocol and to develop infrastructure it was necessary to lock down. Subsequently, as systems came into place a lockdown was not required but restrictions on some social activities were required. Unlike China, we opened up gradually reducing restrictions and vaccination and self-immunity were the three-pronged strategy for improving overall recovery rate and reducing the fatality rate.              

BMC has allocated around Rs 7,000 crore for health in the coming year. What are the steps being taken to strengthen healthcare in the city?
Our focus is on all sectors – tertiary, secondary and primary, with major thrust on primary care. Though our investment may not be enough at this point, we are strengthening and upgrading healthcare, so that load on secondary and tertiary centres will be reduced. We have decided to conduct pathological and radiological tests at primary health centres, so people do not have to travel long distance for getting their examinations done. Depending on local needs we are constructing peripheral hospitals. Definitely, the allocated funds would be utilised completely.

It is the success story of public health system that people have huge faith in public health system during and after the pandemic. Therefore, we are now trying to reduce load on the secondary and tertiary care by providing diagnostic facilities at the primary health level.                  

BMC has announced plans to set up a proton therapy facility. Please tell us more on that.
We have appointed a consultant and are having a series of meetings. After a final decision within 15 days or a month’s time, we may float a tender. With the number of cancer patients rising and a limited number of facilities available, we may collaborate with the Tata Memorial Hospital or set up our own facility.          

You are holding additional charge for elections. What is the current position on delimitation of ward boundaries and when are BMC elections likely to be held?
After our proposal was submitted to the State Election Commission, the appointed committee has heard the objections and suggestions and submitted its report to the EC. We are now awaiting further guidelines either from the government or the EC. We are keeping our preparations ready, so that we are not caught off guard in case elections are announced.