Un­spo­ken truths of its COVID-19 model

Down to Earth - - Front Page - RE­PORT: BAN­JOT KAUR PHOTOGRAPH­S: ADITHYAN P C

Dhar­avi has proven the dooms­day pre­dic­tions wrong and is now be­ing hailed as a global model to com­bat COVID-19. How did one of the world’s big­gest slums cur­tail the spread of the pan­demic, when at least 10 peo­ple live in a cramped 1-2-me­tre shack? How did it man­age to keep the num­ber of cases and deaths low de­spite pa­thetic hy­giene con­di­tions and with­out proper med­i­cal fa­cil­i­ties?

ISO­LA­TION. IT’S an un­fa­mil­iar word for those liv­ing in Dhar­avi, one of the dens­est and poor­est habi­ta­tions on the planet. More than 0.86 mil­lion peo­ple live here—every sq km houses 0.2 mil­lion peo­ple, mak­ing it 600 times more densely pop­u­lous than the coun­try av­er­age. Spread over 2.2 sq km in the heart of Mum­bai, the com­mer­cial cap­i­tal of In­dia, this set­tle­ment is dot­ted with 300 cm x 300 cm shacks, dubbed kho­lis, each shared by five to seven peo­ple. At places, the con­ti­gu­ity of their blue tarp roofs gets bro­ken with dou­ble storey tin-roofed houses and some 450 com­mu­nity toi­lets which cater to the needs of 80 per cent of the pop­u­la­tion.

So, on April 1 when Dhar­avi re­ported its first case of COVID-19, it sent jit­ters among the au­thor­i­ties, al­ready strug­gling to con­tain the spread of COVID-19 in Mum­bai. With hos­pi­tals run­ning out of beds, and death toll touch­ing new highs, the city had be­come one of the hot­beds of in­fec­tion in the coun­try.

It was feared that Dhar­avi’s cramped set-up would soon lead to com­mu­nity trans­mis­sion, mak­ing mat­ters worse and throw­ing a med­i­cal chal­lenge seen never be­fore. Af­ter all, main­tain­ing the phys­i­cal dis­tance of at least 6 ft (2 me­tres), which is the first line of de­fence to pre­vent the spread of COVID-19, is nearly ab­sent in Dhar­avi even if one gets con­fined in a shack. Wear­ing masks in suf­fo­cat­ing set­tings and reg­u­lar wash­ing of hands and main­tain­ing hy­giene are the other im­ped­i­ments. But Dhar­avi has sur­vived the brush with the pan­demic.

Af­ter 105 days since the first case was re­ported, we were in Dhar­avi to trace the pan­demic’s trail in mid-July. By this time, Ma­ha­rash­tra was still in the ex­po­nen­tial phase of COVID-19 in­fec­tion, and was re­port­ing 7,000-8,000 cases every day (see “The learn­ing curve” on But Dhar­avi bucked all dooms­day pre­dic­tions and emerged as a global role model of COVID-19 man­age­ment; cases there had dropped from a high 140 a day in May to just nine in the third week of July. We reached here as­sum­ing a habi­ta­tion un­der

com­plete lock­down, en­forced with mil­i­tary pre­ci­sion. What we found in­stead was a strange sense of vic­tory as well as re­jec­tion among peo­ple.

THE DHAR­AVI MODEL

The con­gested and dimly-lit by­lanes of Dhar­avi were, as usual, hum­ming with life in mid-July. The mar­ket at one of the busy roads, named 90 Feet, was over­crowded and filled with noise. Reg­u­lar traf­fic jams near the Ka­ma­raj Memo­rial English High School, a fa­mous land­mark in Dhar­avi, gave an im­pres­sion that COVID-19 had be­come his­tory for the place.

In one of the by­lanes of Kam­lana­gar lo­cal­ity, Saraswati Kunchikor was pre­par­ing food in her kholi. Two months ago, one of her neigh­bours, liv­ing in a house barely at an arm’s dis­tance, had con­tracted

COVID-19 and suc­cumbed to it. “That in­ci­dent in­stilled so much fear in us that we all re­mained cooped up in our one-room house for a month. But no one has fallen ill in our chawl since then,” she added.

En­sur­ing all this was like solv­ing a rid­dle, ex­plained Kiran Dighavkar, as­sis­tant com­mis­sioner of Bri­han­mum­bai Mu­nic­i­pal Cor­po­ra­tion (BMC), un­der whose ju­ris­dic­tion Dhar­avi falls. BMC of­fi­cials planned a change in strat­egy. In­stead of adopt­ing the “re­ac­tive” ap­proach of iden­ti­fy­ing virus-in­fected peo­ple, they de­signed a “proac­tive” one. And this meant go­ing af­ter the virus be­fore it in­fected peo­ple.

This strat­egy re­quired con­duct­ing test­ing on a Hi­malayan scale. But since this was not pos­si­ble, they mounted mas­sive med­i­cal screen­ing drives. Be­tween April and mid-July, BMC of­fi­cials screened 0.4 mil­lion peo­ple or 40 per cent of Dhar­avi’s pop­u­la­tion on two symp­toms of COVID-19: tem­per­a­ture checks through in­frared ther­mome­ters and blood oxy­gen lev­els through pulse oxime­tres. Nearly 15,000 peo­ple, who had symp­toms, were tested for

COVID-19. While those who tested pos­i­tive were sent to iso­la­tion wards in hos­pi­tals, those who tested neg­a­tive were also mon­i­tored for 14 days at quar­an­tine cen­tres.

This not only helped them pull the virus out of the sys­tem, but also re­duced the bur­den of con­duct­ing large-scale test­ing (see “The model...” on

But the ma­jor achieve­ment lies in im­ple­ment­ing this ap­proach in a set­tle­ment with 860,000 pop­u­la­tion. For in­stance, said Dighavkar, how does one de­cide who to screen? So, his team fo­cused on 13 ar­eas with high case load for door-to-door vis­its or fever camps. “Doc­tors prac­tis­ing in Dhar­avi also in­formed BMC about peo­ple who came to them with COVID-19-like symp­toms. They were soon seg­re­gated and then ex­pan­sive screen­ing was con­ducted in their by­lanes,” ex­plained Pradeep Awate, chief epi­demi­ol­o­gist of Ma­ha­rash­tra.

Ini­tially, there was hes­i­ta­tion among health­care work­ers. Then some lo­cal pri­vate doc­tors who prac­tise in Dhar­avi came for­ward and 10 teams, com­pris­ing 24 health­care work­ers, were formed in the first phase for screen­ing. Grad­u­ally, the size and scale of screen­ing went up. Si­mul­ta­ne­ously, quar­an­tine cen­tres were built up in schools, col­leges, parks, hos­tels and halls, with 3,840 beds. The state gov­ern­ment also ac­quired three pri­vate hos­pi­tals and the gov­ern­ment’s own Sion hos­pi­tal in Dhar­avi was des­ig­nated for COVID-19 treat­ment. Through this screen­ing and test­ing strat­egy, as BMC deputy health of­fi­cer Dak­sha Shah claimed, 50-60 per cent pos­i­tive cases were iden­ti­fied. “For every pos­i­tive case, we con­tact-traced 15 peo­ple at least.”

Many in­formed us that vis­its of doc­tors in­stilled con­fi­dence among them to vol­un­teer for test­ing. “So in the sec­ond week of April, when doc­tors opened clin­ics, peo­ple started com­ing for self-iden­ti­fi­ca­tion of symp­toms. This eased our bur­den of iden­ti­fi­ca­tion. We worked in tan­dem with the gov­ern­ment and would re­port all sus­pected cases for tests. This co­or­di­na­tion paid off,” said Anil Paschnekar, who has been prac­tic­ing in Dhar­avi for 25 years and is also the na­tional vice-pres­i­dent of the In­dian Med­i­cal As­so­ci­a­tion.

There was another group of med­i­cal

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April 2020

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