Manpower shortages and bureaucratic tangles encumber Jammu’s COVID-19 hospitals

People wearing masks stand outside Government Medical College hospital in Jammu on 7 March 2020. Channi Anand/AP Photo
19 October, 2020

The Government Medical College—a premier hospital that caters to the whole of the Jammu division of Jammu and Kashmir—has been in disarray for the last few months. The hospital, located in Jammu city, has had severe deficiencies in infrastructure and manpower shortages even as COVID-19 cases in the division, which comprises ten districts, surged in September. The situation at the GMC is a reflection of the UT administration’s lack of preparedness for the novel coronavirus pandemic. 

According to official data, 35,246 people were infected and 457 people had died of COVID-19 in the Jammu division till 18 October. Of these, 26,710 cases and 394 deaths had occurred since the beginning of September. The region witnessed this sharp rise in infections after the UT’s lockdown was lifted in August and the surge left ill-equipped and understaffed government hospitals buckling under the patient load. For instance, many smaller hospitals have been unable to install ventilators. The GMC itself has had to deal with staff falling ill with the disease, doctors reluctant to treat COVID-19 patients, bureaucratic interference, inadequate oxygen storage and disruption in oxygen supply.  

Fifty-five-year old Bindi Bhat died at the GMC in the early hours of 23 September. According to her brother-in-law Ramesh Bhat, centralised oxygen supply suddenly stopped working in the hospital’s emergency ward. He said that he saw COVID-19 patients in beds near Bindi’s collapse within minutes of each other. Her family members ran to find doctors that could help. “It took us ten minutes to wake up a nursing orderly,” Ramesh said. “There was no other medical staff member around.” He said that Bindi died even as she watched her oxygen levels plummet on an oximeter and pleaded for someone to save her. 

The Bhat family, who live about twenty kilometres away from the hospital in Jagti township, had a hard time finding a hospital bed for Bindi. “We contacted Narayana Superspeciality Hospital, which is run by Shri Mata Vaishno Devi Shrine board, but they cited non-availability of beds,” Ramesh said. “Other private hospitals couldn’t assure us that oxygen support would be provided on arrival as her oxygen level was extremely low. We brought her to the GMC on the evening of 22 September.” He said that although her oxygen level was very low at the time, between 35 and 40 millimetres of mercury, the GMC did not give her a bed or oxygen support till late that night. Normal blood-oxygen levels measure between 75 and 100 millimetres.

Sixteen people died that night across hospitals in the Jammu division. Besides the Bhats, other families also alleged that they lost members because of the oxygen disruption at the GMC. The GMC set up an inquiry committee and the report on the incident “leading” to the “death of a patient” found that the disruption was due to a failure of coordination between the hospital administration and the mechanical-engineering wing. “There has been mismanagement on part of the hospital administration and the officers at the helm of affairs, who have been dealing with the situation in a very casual and unprofessional manner, thereby putting the things in disarray and the available resources have not been put to optimal use,” the committee’s report said. Rajiv Rai Bhatnagar, an advisor to the lieutenant governor of the UT, suspended the deputy medical superintendent and the executive engineer in charge of the mechanical department on the grounds that they were accountable for the shortage in oxygen supply. 

On 19 September, a two-member team from the National Centre for Disease Control in Delhi, including its director SK Singh, visited different COVID-19 hospitals in Jammu city. After meeting the principal and dean of the GMC, Nasib Chand Dingra, Singh told reporters that his team would take up the issues of availability of oxygen, intensive care beds and other facilities in various Jammu hospitals with the central government. The lieutenant governor Manoj Kumar Sinha also visited the GMC on 6 October to inspect its facilities.

Smaller hospitals in other districts of the division have also been finding it difficult to tend to COVID-19 patients who need oxygen. I spoke to administrators of several hospitals who said that they did not have space to install extra ventilators or technicians to run them. The majority of new ventilators provided to government hospitals in August remain unpacked, according to Balvinder Singh, an RTI activist. Manzoor Hussain, the block medical officer who heads the sub-district hospital at Sunderbani in Rajouri district, told me that the hospital had received five ventilators in August. But, he said, they were yet to be made operational due to lack of an oxygen plant at the hospital. 

Dingra lamented that medical colleges at Rajouri, Kathua and Doda and other district hospitals were referring many patients to the GMC. “Maximum patients coming to the GMC these days need oxygen,” he said. “The old oxygen plant at the hospital is not fulfilling our daily requirement whereas the cylinder system needs a lot of manpower.” The hospital, he said, had dedicated 200 beds for COVID-19 care, of which 80 need high-flow oxygen supply. The only other hospitals in Jammu with oxygen plants are the Shri Maharaja Ghulab Singh Hospital and the Gandhi Nagar Hospital, which, according to Dingra, cannot fulfil even 50 percent of the overall daily oxygen demand. In addition, Dingra said that the oxygen-saturation levels that the old plant could provide were lower than the oxygen saturation required by the new ventilators. 

With oxygen shortages hitting the Jammu division hard in September, the health and medical education department made a long overdue decision to approve 13 oxygen plants for 11 hospitals in the region. The administration approved a medical oxygen generator plant at the GMC on 7 September, and a liquid medical oxygen storage tank and vacuum-insulated evaporators to transport liquid oxygen on a rental basis on 26 September. 

There were other bureaucratic hurdles. The GMC invited bids to set up a liquid oxygen plant but received only one bid. “Going by the rulebook, there must be at least three bidders before the contract is handed over to a party,” Dingra said. “We have informed the purchase committee, which is supposed to take the final decision.” An administrator at the hospital, who asked not to be named, told me that the purchase committee awarded a contract for the storage plant on 28 September and the hospital expects to complete construction by the first week of November. 

A shortage of medical staff and sanitation workers has further compounded problems. “Currently, more than hundred members of medical staff at the hospital including medical superintendent of the hospital, doctors, PG students and nursing orderlies are corona positive,” Dingra said, while speaking to me in mid-September. The hospital also has a number of vacancies that have not been filled. Dingra told me that the government has started recruiting doctors on ad-hoc basis to plug these gaps. “At least two hundred nursing orderlies besides some technicians were recruited last week,” Dingra said. “Other required staff will also be recruited shortly to deal with the crisis.” The lack of staff is also symptomatic of a long festering issue in the region. Balvinder Singh, an RTI activist, said, “GMC Jammu is the only level-one hospital”—a hospital that can provide the most comprehensive trauma care for a person with complex injuries or illness—“in the region but its sanctioned staff strength remains the same as it was approved by the government in 1990.” Singh had filed a PIL regarding staff shortages at the GMC at the Jammu and Kashmir High Court in 2018. “Sadly, the population has grown exponentially over the years, but even the sanctioned posts have remained vacant over the decades.” 

Fear of the virus has also played a large part in how some healthcare workers have dealt with patients. On 2 August, a pregnant woman, who had COVID-19, delivered her baby in an ambulance on the Rajouri hospital premises while medical staff refused to assist her for fear of infection. On 6 September, a government district hospital in Samba refused to hospitalise a pregnant woman without a COVID-19 negative report and she reportedly delivered her baby on the roadside. The district administration has ordered inquiries into these cases. 

 At the GMC in Jammu, family members of patients took to posting videos on social media alleging that medical staff had not looked after patients properly. Subsequently, in early September, the hospital administration decided to set up CCTV cameras in all the wards where corona patients are currently undergoing treatment to monitor its staff.  

The cause underlying this unravelling of Jammu’s government hospitals during the coronavirus crisis may be bureaucratic discord. On 12 September, Dingra wrote in a letter to the lieutenant governor that “extra-institutional officials” were interfering in the hospital’s functioning, and offered to quit. His letter specified that there was friction between his office and the COVID-19 control room at the hospital that reports directly to the UT’s department of health and medical education. Dingra, who assumed charge as principal and dean GMC Jammu on 1 May, alleged that he and the authority of his post were demeaned by the administrative department, which rescinded one of his orders. He also said that he was assigned the duties of head of the surgery department even though Medical Council of India rules do not allow the principal of any medical college to act as head of the department. He said that he had been pressured to follow through on pending decisions of his predecessors that may not be in the best interest of the hospital.  He wrote that “one or two heads of the departments and few faculty members who are bypassing the departmental hierarchy and approaching administrative department in technical, professional and administrative matters.” Dingra told me that the issues raised in the letter had not been resolved, but Sinha’s office assured him full cooperation. The UT administration did not accept Dingra’s offer of voluntary retirement. 

Stressing on lack of preparedness in government hospitals across the region even after seven months of the pandemic, Sham Lal Sharma, the former health minister of Jammu and Kashmir, said that there was a leadership crisis at the GMC and at district hospitals. He blamed the mess squarely on the bureaucracy that had taken over after the Jammu and Kashmir state assembly was dissolved in November 2018. “Due to a governance deficit and a lack of accountability, the public distrust towards government hospitals is increasing by the day,” he said. 

Sudhir Kumar, an executive member of the ethics committee of the GMC, said, “Duplication and triplication of authority due to direct intervention of bureaucrats in the routine functioning of the hospital is hampering patient care. Senior bureaucrats are working as per their own whims and fancies without taking the opinions of domain experts into consideration.” He added that the government healthcare system in the region had been facing official neglect for the past several decades and that “the current crisis has only exposed a broken system.”

Meanwhile, Balvinder Singh alleged that hospitals had discriminated against patients without social or political clout. He drew attention to the Narayana Hospital, which is a big and popular private hospital, in particular. “After BJP’s union territory chief Ravinder Raina was admitted in the Narayana Hospital in July, I enquired from the hospital administration over phone, requesting admission of a corona patient,” he said. “The hospital simply refused. Thereafter, several other BJP leaders including Lok Sabha MP Jugal Kishore and his wife, have been admitted in Narayana Hospital.” Jammu’s director of health services Dr Renu Sharma was also treated for COVID-19 at the Narayana Hospital.

I spoke to Ankit Kumar whose brother Ankush, a sanitation worker with the Jammu Municipal Corporation, had been undergoing dialysis treatment at Narayana Hospital in August. Ankit said that Ankush was denied further healthcare on 28 August after he tested positive for the coronavirus. “My brother and mother, who was attending to him in the hospital, were not even provided PPE kits when they left the hospital,” Ankit said.

The northern regional director of the Narayana Health hospital chain, Navneet Bali, said the perception that the hospital was admitting only VIP patients as wrong. He said the hospital’s COVID-19 committee decided which patients to take in depending on their clinical conditions. When asked about Ankit Kumar’s case, he said, “The protocols for admitting and treating corona patients have changed over the months. Now, we don’t refuse treatment to any patient provided there should be bed availability in the hospital. Currently, we have only 60 beds for the corona patients. I will not comment on what happened in the past, from now onwards we will not ask our patients to leave if they test positive.” When reporters confronted Bhatnagar, an advisor to the lieutenant governor, about Narayana hospital prioritising beds for politicians and government officials, he said, “We are trying our best to ensure healthcare (in government hospitals) to everyone. What else do you want to hear from me?”

In light of the September surge, Sudhir, the GMC ethics committee member, proposed steps to increase COVID-19 care capacity. “The administration must immediately convert the Hotel Jammu Ashoka, a government of India subsidiary which recently ceased operations, and the ashram of Asaram Bapu at Bhagwati Nagar into COVID-19 hospitals without wasting any time,” he said. “The union territory administration must also take steps to make sure that non-COVID-19 patients don’t suffer for want of healthcare at the main hospitals of the region.” Several cities in India had begun using hotels for COVID care in April this year itself. 

Meanwhile, the administration does not seem to be taking containment measures seriously. The UT’s administration has decided to partially open schools in the region. Moreover, it launched the third edition of its “Back to the Village” initiative on 2 October, under which government officials are visiting villages to listen to grievances at public gatherings. A block-development officer, speaking on the condition of anonymity, said, “The grievances of the public as far as development related issues are concerned, remain the same. Nothing has changed on the ground since the first phase of the programme was conducted in June 2019.” The government has completed this programme, and has announced a similar programme for urban areas called “My Town My Pride” to begin on 19 October.

Dr Nisar Ul Hassan, an infectious-diseases specialist and the president of the Doctors Association Kashmir, said that there was a strong possibility of a surge in COVID-19 cases in the winter. “If we promote social gatherings then there will be further acceleration in the cases and it will be disastrous,” he said. “We need to keep politics off. Saving lives should be the priority as of now. We can wait for the Back to Village initiative but if a life is lost, we cannot bring it back.”