India's financial capital and one of the most populous cities in the world, Mumbai, continues to witness a sharp rise in coronavirus cases every day - with some calling the situation in the city a "ticking time bomb".
High population density wards in the city account for over 50% of total positive cases.
With strict lockdown norms in place to combat the deadly virus for over a month now, why is COVID-19 transmission not slowing down in the city and what can be the potential exit-plan from here on?
According to the numbers released by the Union Health Ministry, Maharashtra recorded 14,541 total cases as of Tuesday, 5 May - highest than any other state in the country. In the last 24 hours, over 1,500 new cases were tested positive in the state.
The capital of Maharashtra, Mumbai which has one of the highest population density, contributes hugely to the overall positive cases and deaths recorded in the state. As of 5 May, the city alone recorded 9,758 total positive cases and 387 deaths - a mortality rate of 3.96 which is slightly higher than India's overall death mortality as reported by FIT earlier.
Experts believe high population density and over 50% population residing in shanty towns or slums with shared sanitation and water resources have led to a grave situation that Mumbai finds itself in during the pandemic.
A Look at Mumbai's Coronavirus Record
Mumbai recorded its first coronavirus positive case in March. It took over 25 days for the cases to cross the 2000 mark. On 16 April, Mumbai had recorded 2,043 cases. Further, it took only 7 days for this number to almost double up and on 23 April, the city recorded 4,232 cases. In another 9 days, on 2 May, the city recorded 8172 cases.
As of 25 April, according to the data shared by Brihanmumbai Municipal Corporation (BMC), wards namely GS, E, GN, KW and L recorded the highest number of cases and contributed for nearly 50% percent of the total cases. These wards mark areas such as Worli, Prabhadevi, Lower Parel (GS), Byculla (E), Andheri West (KW) and most talked-about Dharavi slum (GN).
Dharavi alone has recorded 632 cases and 20 deaths as of 4 May. With a population of around 1 million, Dharavi, when recorded its first positive case in April-start, had become a reason for fret for Mumbai and for the whole of India. Asia's biggest slum, with a population density of over 200,000 people per square kilometer can't possibly know what social-distancing really is - even if people residing there wanted it with all their might.
Narrow lanes, open sewers, sharing toilets, congested rooms, more than 5 people in one room, common water source among scores of people, etc are just a few reasons why battling coronavirus in this area is no less than a nightmare.
In the past few days, the government of Maharashtra has been contacting tracing and providing door to door surveillance in this area and areas similar to it. The efficiency of the containment-zone strategy can become clear only with time. So far, the numbers are only increasing. On 30 April, the number of positive cases in Dharavi was 369 so it took less than 4 days for the positive cases to almost double up.
According to the latest reports, BMC had declared around 1,459 containment zones in Mumbai but released 331 recently. Of the remaining, around 50% of these zones are in slum areas. These areas are asked to follow strict lockdown measures. At the start of April, there were only 140 such zones. Over the month as cases rose, more such zones were added.
How Does Mumbai Fair in Testing?
According to a video shared by BMC on Twitter on 29 April, Mumbai had tested around 66,000 people. The city observed 5,071 tests per million. Evidently, this is an increase from 884 tests at the start of April. However, experts don't believe this is enough to prepare the city for the post lockdown period.
Speaking to FIT, Professor Ramanan Laxminarayan, Director of Centre for Disease Dynamics, Economics and Policy (DDEP) said, "Growth in daily testing has to keep up with the rate at which the cases are growing if we are to slow down transmission based on a strategy of area-based containment."
He also added, "Today’s cases are a result of transmission from two weeks ago. So we will see a benefit of the lockdown for the next two weeks."
Experts believe that antibody tests could be hugely beneficial for a city like Mumbai in which contact tracing can be difficult.
On the lack of antibody testing, Prof Laxminarayan says, "This has been disappointing since this is the one parameter that could tell us how widely the disease has spread and what proportion are asymptomatic."
Dr Jacob T John, a veteran virologist told FIT, "It's time for more imaginative testing. It's time to shift the testing strategy."
Between 15 April to 29 April, the number of positive cases rose by around 200% and in the same period number of tests increased by only around 100%.
What About Mumbai's Exit Plan?
With the rising number of cases, things look bleak for Mumbai at this point. Experts reiterate testing should be ramped up even further. However, they also believe that lockdown can't continue forever.
In order to remove the lockdown, Mumbai authorities need to prepare a robust exit-plan, say experts.
Many reports suggested that Mumbai still doesn't have enough ICU beds to accommodate all the patients. In the event that the lockdown is lifted, hospitals might not be prepared with all the required healthcare facilities including beds, nurses, ambulance, etc.
The data for how many beds were included during the lockdown period is not available.
A Mumbai Mirror report quoted Dr Sanjay Oak who heads the COVID-19 task force saying, "We definitely need more ICU beds and the aim is to develop 500 ICU beds in the next few days. We need more and more doctors and nurses to treat critical care patients."
Another recent report also shows that Mumbai is preparing for a bigger eventuality by putting isolation beds in places such as Mahalakshmi Race Course, Nehru Science Centre, Nehru Planetarium, MMRDA grounds, etc.
While talking to FIT, Shahid Jameel, CEO of the Wellcome Trust/ India DBT Alliance had suggested that local authorities of a town or city must come up with local models as population density is different in each part of the country.
"Decisions about continuing lockdown, lifting it, etc should depend on the local data and local planning. It can't be guided by Health ministry sitting in Delhi", he added.
Dr John told FIT, "The government should ensure 100% mask availability. This is as good as a lockdown. Further, water is luxury in many parts so alcohol-based hand sanitizer should be made available. These are the basic minimums."
He suggests that each street, each shop and each house must be equipped with these essentials to fight coronavirus post the lockdown.
Dr SP Kalantri, Director Professor of Medicine at MGIMS and Medical Superintendent of Kasturba Hospital told us,
He further warned, "There are some predictions that from mid-May Maharashtra will have more number of cases and areas which are green right now, will observe cases. But since the government is already focused on the areas which are currently red, it will have to partially shift focus. The government will then be trapped and won't be able to allocate resources across the states."
He also emphasises on the standard process: trace, test, isolate and quarantine.
"We need to pick up cases early. The best way to do that is to use Pulse Oximeter to measure oxygen saturation level", Dr Kalantri added.
He further raised some bigger concerns saying monsoon season will invite cases of malaria, leptospirosis, scrub typhus and chikungunya which will fill ICUs and ventilators and pose a challenge to the healthcare system.
Thus far, it is not clear if Mumbai authorities have taken note of these forthcoming challenges.
"The government may want to use large areas, stadiums, etc in the city for COVID-19 patients but there are real problems. Soon monsoon will hit and it will be difficult, so we don't know if we screen everyone in places like Dharavi and find more cases, how will we isolate them? It will be an extremely difficult task", Dr Kalantri said.
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