Nandurbar, a tribal and hilly district in Maharashtra with a population of 20 lakh, is an unlikely contender for setting a precedent for the rest of India, but under the leadership of district collector Dr Rajendra Bharud, it took several measures to augment medical oxygen supply ahead of the second wave of Covid-19. Now that Delhi and several other cities are running short of oxygen for critical patients, this district is well equipped to meet the challenge.

This is surprising for a district whose human development index is 0.604. Nandurbar is far away from big cities. It has limited private health facilities and resources – there are only two government doctors with an MD degree. There are no medical colleges. When there are no testing facilities, it would be too much to expect a liquid oxygen plant.

When infections had started coming down in September last year, and most administrators were getting relaxed, Dr Bharud thought ahead and knew oxygen could be a critical factor in future. He read how the US and Brazil were struggling in the second surge and wanted to be prepared for the future. So, he set up an in-house oxygen generation plant, with 600 liters per minute capacity, at the district hospital. In February a second plant was set up and by end-March a third plant came up. Each plant has been set up at a cost of Rs 85 lakh, the funds for which have come from the district planning and development and state disaster relief fund. In addition, two private firms were contracted for more supply. Now with oxygen supply coming from a total of five generators, two more oxygen gas plants and a liquid plant are being set up.

With the country facing a shortage of oxygen supplies, the centre and states are in overdrive to set up oxygen generation units. But Dr Bharud – a native of the same district, born into a poor family and raised in a hut by a single mother – has already set an example of anticipatory governance with innovative thinking.

“We now have five running PSA [pressure swing absorption] medical oxygen generation plants. About 60-70% of our own internal demands are met through our own plants while and 30% is being met through our liquid oxygen suppliers. In the future, we will not have to depend on anybody for our oxygen needs. We are also planning now for third wave and to ensure how oxygen beds can be provided at every rural hospital or PHCs [primary health centres],” says Dr Bharud.

Moreover, now 100 oxygen concentrators are available in Nandurbar and the administration is purchasing 300 more. Nandurbar is also the first district to have ‘oxygen nurses’ who monitor the use of oxygen by patients and prevent any wastage.   
    
Dr Bharud, who holds an MBBS degree, says as a medical student he had seen how the technology works and knew there were two or three such plants in Mumbai. So, when the pandemic came, he thought of having a similar plant in Nandurbar too.

The administration has been successful in bringing down the number of cases from 1,200 a day to 286 by April 28. The guidelines issued by central authorities from time to time were followed, and Dr Bharud and his team of administrators, frontline workers and volunteers have ensured that cases are directed through control rooms and for those from villages swabs are collected at home. In case of positive test results, the gram sevaks immediately isolate such patients and test their family members.

In the first wave, an RT-PCR laboratory was set up with a capacity of testing 1,000 samples a day. During the second wave, an additional device was installed, taking the total capacity to 2,000 tests daily. As many as 29 mobile teams travelled through remote villages to create awareness about the virus. A district control room was set up with four helpline numbers (02564 – 210123 /210234/210345/210006). All information on beds, RT-PCR reports and ambulances is displayed on the district’s own, dedicated website, https://ndbcovidinfo.com. Now an app provides real-time information on the number of vacant beds in individual hospitals, available ambulances and drivers along with their telephone numbers, information on vaccination centres and test results.

Thirty ambulances were procured through corporate social responsibility (CSR) funds of corporates at a cost of around Rs 3.28 crore. Jeeps were converted into ambulances for far-off tribal areas. This gave them 100 additional ambulances.

A three-layer treatment was made operational with the DCH for critical patients, DCHC for mild and moderate cases and rural CCC especially for remote villages. Over 286 contractual persons were appointed in DH, SDH and RH, CC. For vaccination, 16 vaccination mobile teams are working in remote areas.  

For villagers with mild symptoms, various community places, likes student hostels, Samaj Mandir and Mangal Karyalaye, where beds, bathrooms and toilets are available, are used as isolation wards, overseen by teachers and auxiliary nurse and midwives (ANMs). Those in need of oxygen are admitted to rural hospitals and those requiring further treatment are sent to the district hospital.

Newly appointed BAMS and BUMS doctors are being given training regularly. A dedicated hospital for female Covid patients, with 250 beds, has been set up. Another CCC with 100 beds especially for women has been set up by the Nandurbar municipal corporation. As many as 378 beds have also been set up at Railway DCHC with the help of Indian Railways

“These systemic methods helped us bring down the case load from 1,200 to 240-250. We are now working to bring down the number of cases below 200 and we are also preparing for a third wave,” says Dr Bahrud.

There is no rocket science to handle a pandemic: you devise ways to handle it and you must follow it. With proper implementation of SOPs, pulling of resources, manpower training and management, building up testing facilities and strengthening of health infrastructure, quarantine and isolation up to village level, awareness generation and with participation of society, Nandurbar has managed to keep its infection levels low.  

Due to porous borders, 15% of Nandurbar’s case load is because of the patients from neighbouring districts – and the neighbouring states of Gujarat and Madhya Pradesh – coming in for treatment.

Meanwhile, the vaccination drive is running successfully, and 1.3 lakh doses have been administered so far. As vaccination for 18+ opened from May 1, 12 lakh more people are eligible for inoculation. The district has 25,000-28,000 doses available with daily dose administration of 5,000-6,000.

“The government has shown special concern for Nandurbar. There is no shortage of vaccine so far,” says Dr Bhurud. Some people were reluctant to come forward for vaccination, he adds, but teachers and ANMs have set up camps in villages for registration and inoculation.

Dr Bharud has now been asked by the Supreme Court and the National Human Rights Commission to share his SOP which includes oxygen generation, setting up of ICU, ventilators and oxygen beds, swab collection, RT-PCR machines, website registration, control room, isolation facilities, nurses and doctors training, monitoring of nurses, recruitments, vaccination movement and vehicle movement, among other matters.