 Welcome to NewsClick. Today, we are joined by Dr. Sumitre, who works at the Holy Family Hospital in Delhi as head of the critical care medicine and also as a medical superintendent. And of course, at the moment, he has many critical COVID patients under his care. And we want to ask him about his experience as a doctor in this unprecedented crisis and also about these medicines we are seeing which are being prescribed to deal with COVID, to cure COVID, which have not really been proven to be effective. So thank you, Dr. Sumitre, for joining us today in what must be a very distressing and hectic time for you. So to start with, can you tell us about what the situation is like in your hospital right now? What has it been like, you know, handling the ICU? We see that the numbers are maybe slightly coming down in Delhi. So how has this been like, is there a somewhat reduction in the load you are seeing or, you know, is it still a situation where you have to turn patients away? So, what has happened in the last four days, there is a reduction in the number, three, four days is a reduction in the number in the casualty of the emergency room as we call it. But before that, it was beyond absolutely out of control, the number of patients coming in. We have 30 beds in the ER. I'll just take you through this 30 beds in the ER. At any point of time, we had 100 patients almost. There are patients sitting on chairs getting oxygen because there was no space to make them lie down. There was no physical space to put a stretch There are families, sometimes we had to ask the families who were with them, like one attendant was allowed. We had to ask them to step out because there was no space to breathe in the ER. It was that bad. He had no place in the wards or in the ICU for lots of patients. Even if we took people into the ER because we were trying to not refuse anybody at least to give primary care. We could give oxygen, etc. in the first shot of steroids, etc. There were lots of people who could not get a bed in the ICU, could not get a bed in the ward. We did not want to turn them away, but we did turn some of the patients away who came in ambulances, which were good quality ambulances, which could take them to the next hospital. We also received lots of patients who had been all around the city trying to get to a hospital and had died on the way. They had died in the ambulance. So there were lots of patients, people who were like that, unfortunately. There were patients who died in our emergency room because, as I said, we had no space in the hospital wards. We tried to do the best we could in the ER. I mean, no space means no space. We had extended our facilities by 40 percent more beds. We put beds wherever we could and in the ICU, we have trolleys between beds. Even now, there is no physical space in my ICU to walk between beds almost. So the quality of care obviously cannot be the same level as it would be in a normal circumstance in the ICU. So last three days, as I said, the ER has downed down, has become a little more towards normal, I would say. Still much more loaded than it usually is. In the 30 beds, we have 50 to 60 patients, which looks way better than what it was about three to four days back. Having said that, the timeline of COVID is such that patients who get hospitalized or are at home with oxygen or certain percentage will deteriorate. You can do the best amount of treatment, you can do the right thing. People don't realize that even if the doctors are doing the right thing, patients will deteriorate. A certain percentage do deteriorate. That's why even in the best healthcare systems, patients of COVID die because of that. So when they deteriorate, even 10 percent, 8-10 percent of them deteriorate on the wards. There are about 350 patients in the wards in our hospital. Even 8-10 percent deteriorate, you make, you know, calculate the number, about 30 to 45 patients will deteriorate. So they have to be moved to the ICU and the ICU is clogged. Once they come to the ICU, a patient who goes on the ventilator, if they start doing better, it's a three to four week battle on the ventilator. We have increased our bed capacity in the ICU from 48 bed ICU, which was usually had 40 patients at any given time, 38-40 patients. Now almost 66 to 68 patients because of the trolleys that we have put in and we have taken the coronary care unit into also the ICU, COVID ICU. So there is no coronary care unit anymore. It's 100 percent COVID hospital. So 68 patients now and of 50 of them on ventilators and we need even more ventilators. And this is 50 in the last surge, never where we require, did we require more than 30, 32 ventilators? We increased our number of ventilators. We bought ventilators as fast as we could. We rented them. We have reached 50 ventilators, but we will need even more ventilators soon because patients will, as I said, deteriorate in the next few weeks. That's how COVID goes, I mean, a certain percentage. So that's the situation we have. It is difficult, is a very mild word I would say. It is really, beyond difficult. Having said that, I would like to say something else. The poor in this country have to a certain extent faced this even before COVID. It has been triaging for them. I have trained in a public hospital in a public medical college in the 80s and 90s. And even later we have seen the poor lie in the emergency two to three to a bed in government hospitals because they have no access to private hospitals. They are triaged to which patient you can accommodate in the ICU because there is always more patients than beds than ventilators. So this time, yes, the scale is even more. The poor are also dying, but it's also people like us. It has affected people like us. And that's why even more, you know, we get to see this more across the world and in the media. And I think if this is not a wake up call to improve our healthcare infrastructure, then I don't know what will be. Right. And oxygen seems to be amongst the most critical of this, of what we need right now, which is, you know, the most crucial treatment, which I think COVID patients need at the moment. So what we see is that the Delhi government is saying it needs 700 metric tons of oxygen daily. But it's just been reported that at least last week it was only an average of around 530 metric tons, which was supplied. So can you tell us about this? What is the need and how have you been managing in this in the shortage? To tell you honestly, last week, last four or five days onwards, the oxygen supply has improved to all the larger hospitals. We haven't been in trouble. The reserves that we now consider safe is about six, eight hours of reserve. We consider safe now. It's a new normal. You know, earlier we would feel safe if there was a reserve of at least two days in our options. And now we feel safe if there is six to eight hours reserve because it was being cut so fine that we were sometimes down to half an hour reserves, two hours. I mean, so from there, it has improved. Actually, the worst days were when in Delhi was supplied only a liquid medical oxygen of about 300 metric tons or three to 350. Those were terrible days. Everybody was running helter-skeletal every hospital. Right now, the bigger hospitals are much better off. The problem is with the smaller hospitals and basically those hospitals which depend on cylinders, oxygen cylinders, which have a lag time to fill them up and get them back into the system. So those are the hospitals which are facing a problem even now, but much less than before because I can see it in the, there are WhatsApp groups for oxygen management started by the government. I can see that there is almost no panic anymore. I mean, there was few days back, so that has surely improved even with more than 500 metric tons coming in. I think the situation is much more stable. Probably, we will need some more. 700 probably is a number which they want so that they can escalate, I mean, build surge capacity and increase the number of beds in Delhi. So oxygen, but what has happened in the whole oxygen conversation or narrative is that people seem to have forgotten that oxygen is only one element of the therapy. We need ventilators, we need ICU beds, we need more beds, we need more staff. Staffing, everybody is stretched beyond their capacity there. The people, I mean, the doctors, the nurses, the cleaning staff, the maintenance people, the people maintaining the oxygen plant, etc. They are working way beyond the biomedical, the cleaning staff, the people moving oxygen cylinders from one place to another. They are working beyond almost physical capacity and endurance almost without complaining. There will always be some people who will complain, but mostly people are volunteering, volunteering for more. That is the incredible part that I've seen. Right. And before we move on to the part of discussing the medicines and how effective they are and all of that, I want to ask you about another aspect which I feel has not really been looked at enough. You of course just talked about the people running around to get us our oxygen and how they have been enduring all of this great amount of stress, working countless hours to do this for us. At the same time, of course, we want to ask you about the situation in hospitals in terms of doctors, nurses, attendants and workers, you know, we have cleaners and sappai karam chai in all of them. So how has this been affecting them in terms of their health, mental health and also are they vaccinated? So a fair number of people are vaccinated. How it is affecting their mental, it depends on what kind of work they're doing. So many of the residents and nurses are very, I mean, they almost are being affected to the point that they feel that we could have done better if we had the resources, if we didn't have such patient flow. They have seen young people die because of lack of resources dying in the ER. There have been resident doctors and nurses who have called me up just to say we have no complaints. We just want to cry because they have seen us do a very good job in the previous surge and they know that we could save a lot of people even in the ICU, even on the ventilators. Our outcomes were as good as the Western world as good. I'm not trying to brag, but it was as good as the Western world. We keep working on the evidence, looking at the evidence, looking at our clinical outcomes et cetera. It was as good as anywhere else. And this time, obviously the outcomes are bad because as not as good because we could not provide ventilators to those who needed them. We could not provide isopads to those who needed them. Obviously the outcome is going not going to be good. And that's what they lament that we know that we could have done better, sir, if there were these. And that is going to affect them for a long, long time. And they are younger. They're starting off their careers in many ways. And for them, it's a difficult thing. For people like me who are much older and have gone, you know, experienced a little more in many ways. Yes, it's an absolutely new situation in scale. It does affect us because we also feel that we could do better. But as I said, we have seen this to a lesser extent probably in the public health systems when we were young and when we were training. So maybe we are a little better prepared, but you can never be well prepared for this. It is, it is having said all this, I think it is. It is very painful. It is very in sometimes the battle to keep all our hopes up. Losing hope is something we can't do. And battling that is important. And that's what we are fighting. But at least now in Delhi, different parts will get affected differently. Now we see some light at the end of the tunnel in terms of the numbers. We know that the numbers will come down. If the numbers outside come down, a few days down the line, a few weeks down the line, the numbers in the ice use will also come down. And until then, I mean, at least there is some hope that if you work hard now, you can pull through this crisis and reach a point where you can do even better. So you're talking about, you know, hopefully we'll be doing better. But again, looking at the situation right now, coming back to the point of medicines, you know, we have, we see patients, families running around, you know, desperately trying to find medicines like rendersware, then there's Ivermectin, Pabitu, I think these are some of the common ones. How effective are these medicines? So I'll go about the evidence. Okay. So what is the evidence for remdesivir? Remdesivir is not a life saving problem. It's a drug which has been, the studies have shown that it is a small subset of patients who are on low requirements of oxygen. If a patient does not require oxygen or requires very high oxygen or isn't the ventilator, it is does not save lives or reduce length of stay. But those on low amounts of oxygen, if started early, you know, if started within the first seven to 10 days, it reduces the length of stay in the hospital. That is all it has been proven to do. Well, is that beneficial? Yes, it's beneficial to the system, because if you get a bed three days earlier than you would get, that puts that we can place another patient there, right? So that's the role. And I've said it in the news channels, etc. that do not, if you are not getting it, don't run around, particularly patients in the ICU. It is not going to be a life saving drug. If your loved one is in the ICU requires and the doctor has prescribed remdesivir. If you find it, okay, if you don't find it, it is not going to probably change the course of illness. In terms of medications like Fabiplu, zero evidence, zero evidence to support it, it's useless, it causes gastritis, you know, and it makes life miserable for the persons taking it, most of them in terms of, you know, nausea, etc. And without any benefit. Ivermectin, again, the evidence is weak. There have been some studies, there is a group in the US, which of doctors who promote inexpensive therapies, they have been pushing for it. The evidence is not very strong, some from Bangladesh and some from Romania and some other papers have come in to reduce the, they suggest that it would reduce the need for hospitalization if started early. To tell you honestly, you know, it's equivocal. Have I used it in this surge? I have used it for patients not in the hospital, those pre-hospital because we are desperately trying to reduce the number of patients coming into the hospital because there was no space. And I had no mind space to tell you honestly, to argue with anybody, because when I, when I don't prescribe, I wasn't prescribing it, there were people saying, okay, that doctor prescribed it. So I said, look here, the evidence is weak. If you want to take it, you go ahead. I did not have the mind space to argue that you take or not take. Fabiplu, I flatly said there was no benefit. There's no evidence to suggest these are benefits. So that's the steroids. I would like to talk about steroids now. Steroids are very useful, but timing is most important. It is being overused. Some people are overusing it in the outpatient department practice, they are starting it too early. Too early when the phase of viremia is there, when the virus is still in the bloodstream, still in the body, if you start using steroids, it can be counterproductive because your immune system is necessary to throw out the virus of the body. It's a necessary evil. What the steroid does is tone down your immune system so that your immune response, which causes the harm. So, so it's complicated that your, the viral infection triggers an immune response for most people, which is balanced, but for some people, it is dysregulated. Those who have a dysregulated immune response, that dysregulated immune response causes the more damage to the lungs, etc. It's not just the direct effect of the virus. So in those who have a dysregulated immune response, starting steroids may be necessary, but that should be after the phase of viremia or towards the end of the phase of viremia, usually after seven days. And not for everyone. In only those who have a hyper inflammatory response, who's, who require oxygen or are having persistent fever, their inflammatory markers, the CRP, etc., not for everyone, getting steroids is dangerous. It actually can cause more harm. And that has to be emphasized. Do not start steroids early. People we know have started steroids on the second, third day of fever. They actually have a fever may come down for a few days. And then when it comes back, it is a worse, it's a more dangerous fever. And we also have hydroxychloroquine again, which is has not been proven to be effective, but we see that even the ICMR is recommending it. So why is that? Yeah. So the AIMS ICMR recommendation, the new one suggests that you could use Fabiflu and ivermectin. As I said, the evidence for that is not much there. And that also makes, if somebody prescribes it, it's difficult to stop people from prescribing it. HCQ also, the evidence is almost not there. I mean, most of the studies have not real good studies. Randomized control trials have not shown benefit. So I don't see any reason to prescribe it at all. And how about plasma therapy? Does it work? Plasma therapy is another one, which actually there is again no evidence for its use in even the ICMR's own study with AIMS showed no benefit of the called the Placid trial. The trials from outside abroad also haven't shown randomized control trial, which are the real, you know, which are the kind of what we can call as the gold standards of research haven't shown any benefit. There is some indication in a trial, an observational trial that if it's the elderly, a small subset of elderly with low antibody levels, they are the ones who may benefit. But actually the problem with convalescent plasma, people don't realize it can be harmful for two reasons in COVID. It's not without side effects. The two reasons is one, COVID predominantly is also a pro-thrombotic state. That means there is increased clotting and plasma is used for promoting clotting. Second, if most of the patients who are worsening are worsening because of a hyperimmune response, a more aggressive immune response, and you are giving antibodies of the plasma to increase that response. So it doesn't make sense. It doesn't make logical sense. It is only in the subset who have low antibody levels for persistent viremia, particularly in the small subset of the elderly, it may benefit. For sure, in the others, it does not benefit. And it is a very interesting way of keeping the family occupied, making them run around, helter, skelter. And it's also part of our, I think, socio-cultural being, the Indian socio-cultural being that So that works very well. And it is pretty useless, I think. And it has been promoted by a couple of centers, repeatedly come on television because promoted by a couple of centers. But there is no evidence to suggest. And I don't use it. I'll be, I do not use it at all. But there have been some of our doctors who have prescribed it also because of the fact that the families insist on it. So sometimes it becomes difficult in spite of yourself to convince them that this is going maybe harmful. So they say, my patient is not doing well, what is your problem? So in spite, so in the last search, I don't know the data for this search because we haven't had time to collect the data. 3000 patients we had in the hospital, 6 more than 600 in the ICU. And we use plasma in five patients. And this was under family pressure, not because we wanted. So that's the number we have. So, you know, why do you think families are pressuring doctors this way despite the advice doctors are giving, why is there such a lack of trust? There has always been a lack of trust with the healthcare system and understandably and justifiably so. Our healthcare system and our has not represented itself, you know, very well in the past. So there is a lack of trust, but this is more than lack of trust. This is not, it's actually reason is different. This time the reason to do it is probably information and infodemic on COVID and people do not understand the contextualization of medical knowledge, right? You have to contextualize. I keep this giving this example when we were in third year MBBS and we joined third year MBBS and we started going to the clinics and looking at clinical subjects. We used to when we read something we thought that we had that disease. Every disease we read about we had that we used to call it the third year syndrome. Okay, so for people who cannot contextualize so just reading numbers or reading data, you cannot contextualize to the disease process. It is very complex. The human body is very complex. It takes years of knowledge and understanding to get to it. Even then we understand only some part of it. So no disrespect to people's intelligence. It is that it's a width and depth of information and knowledge which has its context. And if you do not understand to contextualize it, you will start trying to do therapies just because somebody has build it or somebody has your some friends, brother, sister has used it and they got better. They may have got better in spite of it actually. Right. And I also wanted to ask you about vaccinations. So of course, on the one hand, we don't have enough doses and so people are facing shortages and they are not able to get vaccinated. On the other hand, there are people who don't want to get vaccinated because of all the misinformation that there is. Why do you think that is and what needs to be done about this? So I wouldn't say misinformation. There is vaccine hesitancy to a certain extent because there was a lack of data transparency about both the vaccines. If you see the adverse events post immunization for AstraZeneca vaccine, there is data from across the world that there is certain problems. One has to be aware of it. One has to not hide it. The tendency in India was to hide that data. The 1600 patients who were vaccinated in the study in India, the phase three clinical trial that data hasn't come out yet. So these are the reasons that and if you see the other vaccine, the co-vaccine, the safety data is there, but the efficacy data is still not out. I mean the real public is not been published. So there is a lack of transparency in the process of giving approval to these vaccines. The other example has been just look at the FDA giving approval to Pfizer and Moderna. It was an absolutely public process. Anybody could go in and watch it, the process of giving approval to these vaccines. The evidence was very strong, the evidence was out there. So all this helped vaccination much more. There will always be vaccine skeptics, but most people would take the vaccine if they are fairly sure that the data that they get is transparent. Right. And finally, Dr. Sumit to conclude, I just want to ask you about looking at the situation right now, situation of the health care system, which is still under immense pressure cases, which are even a Kundalini maybe will seem some reduction, but in other states they are rising, situation of oxygen, all of these crises which are still there. Right. What do you think about future ways because we're seeing that experts are saying even a third wave is inevitable. Will we be prepared then? Yes and no. We'll be better prepared than this one probably, but if our basic health infrastructural facilities do not improve, do not strengthen, do not widen, do not numbers increase in terms of beds, ice use, primary care, secondary care, staffing, nursing, doctors, technicians, etc., it is going to be again very, very difficult. We have to invest in health. I mean, everybody says that. I mean, everybody was there in the medical profession knows that 1% or 1.2% of the GDP for public health is totally inadequate. There are so many expert groups which had said that 2.5 to 3% of the GDP into public health by 2025. We've seen no sign of sound of that being invested in any way. So one is investment in infrastructure and in people, but also the other thing which we need to know and that should come from us from the medical profession is accountability. A combination of investment and accountability, good public health systems run on the basis of these two. Investment, accountability and the third is equity and all these three things are probably missing in this country. All these three things in terms of investment, our accountability to people as healthcare workers and third is equity of distribution of health. Even in the vaccination, you see, why would we be separate vaccination for, you know, you have an advantage in a private hospital, you go and pay money and get it earlier and better. This is not public health. That is inequitable public health. Vaccination is a small example. I mean, in every way it is inequitable. So we have to improve upon all these things. So there has to be short-term targets, mid-term targets and long-term targets, absolutely. And the third wave also is going to hit us hard, but probably we will be better prepared than this one because in terms of oxygen, et cetera, I think we produce enough. It's the logistics of distribution that I think will be taken care of soon. That is probably, I think the least difficult of, I'm not saying it's not difficult, but the least difficult of the problems. But the other problems are going to be actually people, even if you have oxygen, if you don't have ventilators and ICU beds, et cetera, people will die. Finally, people die in the ICU or they survive in the ICU, right? Because if you get really sick, you can either make it because you go to the ICU and survive out of the ICU and you get a ventilator or other life support systems or you do not make it in the ICU. And if you need an ICU and you do not get an ICU bed, you are going to not make it. So all these things have to be built up. Thank you, Dr. Sumit, for joining us today. I wish you all the best for the work that you do and thank you for the work that you do. And that's all the time we have. Keep watching. It's a job I have to do. There's no need to thank. It absolutely don't need to thank.