Apollo Hospitals’ Response to Covid-19 in India: Behind the Scenes

How the Apollo Hospitals Group handled the intense spike of Covid-19 cases in India, and what they’ve learned from the thousands of families they’ve treated.

Summary

“When it comes to the pandemic, we’re going to have to address the issue of human resource exhaustion,” says the Group Medical Director of Apollo Hospitals Group in India. He describes how Apollo has been mitigating the Covid-19 crisis and handling burnout, the importance of collaboration and the sharing of needed resources such as oxygen, and the treatment of everyone as family.

Namita Seth Mohta, MD, interviews Anupam Sibal, the Group Medical Director for Apollo Hospitals in India.

Namita Seth Mohta: This is Namita Seth Mohta for NEJM Catalyst. I am speaking with Professor Anupam Sibal. Dr. Sibal is the Group Medical Director of the Apollo Hospitals Group. As the Group Medical Director, which is the equivalent of the Chief Medical Officer role here in the U.S., Dr. Sibal has played a key role in the planning, executing, and monitoring of Apollo’s response to Covid-19 in India. Clinically, he sees patients as a pediatric gastroenterologist and holds a variety of academic and research appointments.

The Apollo Hospitals Group was founded in 1983. Since then, it has grown to over 71 hospitals and over 230 primary care clinics with 6,000 physicians, as well as a vast network of diagnostic centers, pharmacies, and teaching facilities.

As we all know, India is in the midst of a difficult situation, with an overwhelming volume of infections and shortages of critical supplies like oxygen, medications, and inpatient beds, as well as an exhausted, although dedicated, cadre of health care workers.

In full transparency, I am an Indian American with lots of family in India, and so this discussion is particularly important to me on many levels.

Our focus today is not going to be on the macro conditions, the policy decisions, the public health infrastructure, or the international response that has led to this current state — though obviously these are critical components. But rather, we will focus on direct care delivery, the opportunities, the lessons learned, and the path ahead to get to the other side of this pandemic. Dr. Sibal, thank you so much for joining us.

Anupam Sibal: Thank you, Namita, for this opportunity. It’s a privilege.

Mohta: We read a lot in the newspapers and the media, but tell us, Anupam, what is the current state of the pandemic from where you are on the front lines?

Sibal: Namita, we feel that things are stabilizing, and who can understand this better than a physician who’s seen it all in the U.S.? You’ve seen 33 million patients, more than 600,000 deaths. We are at 25 million, 289,000 deaths [as of this recording on May 20, 2021]. The pressure it is to be able to handle this kind of volume, and especially when it hits you so suddenly. We had a tough phase of about 4 weeks, but now things are coming down from a high of 414,000 cases a day. We are down to about 290,000, which is a significant drop.

Our protocol now is in its 40th revision.

Mohta: I’m sure that is much due to the hard work of you and your teams at Apollo. Tell me, what has been Apollo’s approach to managing the surge? What tactics are working well? What tactics didn’t work so well, and how did you have to adjust along the way?

Sibal: Let me go back to March of 2020. India went down into a comprehensive lockdown when we just had 564 cases on March 24 last year. Early on in March, we decided that we needed a 360-degree approach. We needed to get multidisciplinary teams across our network to focus on clinical management, on labs, on procurement, on communication, on developing evidence-based clinical protocols.

We dedicated, at that point in time, 2,000 beds. When the second wave came, we needed to rapidly scale, and we went from 2,000 to 4,200. Our testing capability, for RT-PCR — and that was significant at 10 tests per minute — we scaled that up to 15 tests per minute. Our protocol now is in its 40th revision. A Red Book that we follow across the system is in its 16th version. Stay-at-home was something we started last year, and we had 10,000 patients whom we managed at home through technology, through telehealth; we had 10,000 in 9 months, and this time around we’ve had 10,000 in 30 days.

We looked at enhancing our capacity to manage patients in hotels. We had 3,000 hotel rooms across 8 cities, and we’ve seen a considerable utilization of these in the second wave. Our programs of delivering care at the doorstep have scaled up, whether it’s sampling or whether it’s delivering medicines, and we are doing as many as 45,000 home deliveries per day.

All that we did last year is coming in handy, in terms of living up to what the community expects from us in the second phase, but when things in Delhi got out of hand, in a way, we had to add another 40-bed temporary facility. We did that in 72 hours.

We’ve been looking at strengthening the supply chain, which is robust anyway, to meet increased demand of medication and consumables. I should add here that health is a state subject, it’s not a federal subject. State governments have full autonomy in how they want to administer health care delivery.

Overall, we were looking at how many lives we might have touched through different programs, and it’s pretty high at 79 million.

In terms of procurement of medication, we’ve been working with state governments and manufacturers to make sure that we have enough supplies. When it came to oxygen, the requirement went up more than fivefold in the second phase in Delhi. Delhi consumed a lot and does not produce any oxygen, so the oxygen had to come from the south and the west, and tankers can take as many as 3 days to get to Delhi. So, oxygen was a challenge, and we worked with manufacturers and a host of agencies to make sure that our patients got the oxygen that they needed.

In terms of being able to use technology, we had developed last year a risk scan because people are worried and they want authentic information, and that has continued to benefit our citizens. We’ve had 20 million downloads.

Overall, we were looking at how many lives we might have touched through different programs, and it’s pretty high at 79 million.

Mohta: That amount of scale and scope, particularly over such a short time period, is truly remarkable. What were some challenges that you all faced in implementing some of these strategies, and how did you overcome them?

Sibal: I’d start with the positives first in what worked well for us.

We were able to use technology well and connect with our teams across the length and breadth of the country, and the team approach we strengthened with 24-by-7 connectivity simple, rapid decision-making — a huge amount of empowerment to local teams. The spirit that we built of working together helped us a lot.

The fact that we could reach out to the community at their doorstep helped the people who were afraid of availing health care, and they needed that help right at home. Technology has been a huge boom. Our clinicians, nurses have really come together, and while we’ve been working very hard clinically, there’s been a fair amount of research that’s come out. If you go on PubMed Central and type in “Covid-19 and Apollo Hospitals,” there are as many as 221 papers.

Time has been used quite productively, and we’ve learned so much from the 150,000 patients we’ve treated, from the families who’ve trusted us. When we look back, the pandemic has taught us so much and made us a much stronger organization.

We’ve learned so much from the 150,000 patients we’ve treated, from the families who’ve trusted us.

What was hard was, we were taken aback by the numbers. If you look at all the predictive models, they had suggested that India would get into a peak somewhere in May and June [2020], and that didn’t happen. The peak actually happened on September 16 when we hit 97,000 cases, and then things started to get better, and in February [2021], the entire country saw less than 10,000 cases.

For a country with a population of 1.35 billion, less than 10,000 cases is remarkable. But then, come March, we saw cases go up in Maharashtra. In April, the numbers started to rise rapidly, and then on May 6, when we had the peak at 414,000 patients, the system really got stretched. While there was physical fatigue, there was also this emotional trauma on just having to care for so many patients. The pressure on the staff has been immense.

We needed to deploy more staff, so we had to think of how we’d be able to get more clinicians. We got our specialists, our cardiologists, our gastroenterologists, neurologists to buddy with internists and pulmonologists and critical care doctors. We got the National Board, which oversees postgraduate education, and we had more than 900 fellows and trainees, and their training was extended by 3 months so that they could support us.

One of the challenges we found was that with so much information available to the public at-large — and as we all know, some of that information is incorrect, and sometimes it’s partly incorrect — vaccination started off well, and then people started having doubts about vaccination. That was in many ways disappointing. We decided we needed to impart education. Our teams went out on television and did a lot of effort on social media to promote vaccination. We recently came out with a study that looked at health care professionals in our Delhi facility, where 3,235 health care workers were vaccinated. We looked at infection rates in them. Just 2.6% became positive after vaccination, only two of them needed hospitalization, and no one went to the ICU and we had no mortality.1

That was the kind of positive messaging that we wanted to disseminate, and we are doing more of that now. Soon we will have data for about 33,000 health care workers who were vaccinated and tracked for infection.

Mohta: Let me rewind to your comment about the emotional trauma and exhaustion of the health care staff. Burnout was, last summer — and, quite frankly, continues to be — a big issue at our institutions here in Boston. Tell me a little bit about how you all are addressing clinician burnout.

While there was physical fatigue, there was also this emotional trauma on just having to care for so many patients. The pressure on the staff has been immense.

Sibal: This is at multiple levels. First of all, we asked ourselves, is there anything we can do to decrease the workload for clinicians? We started looking at nonessential administrative work, some documentation that someone else could do. We started deploying the standardized protocol quite effectively in getting junior doctors to follow the protocols under supervision, but taking some of the pressure off the senior doctors.

In India, family is central to our existence, so when family members started to fall ill and they needed support, we made sure that we reached out, because we at Apollo believe that we are one large family. We started emotional support groups. We received support from the Global Indian Physician Covid-19 Collaborative. There are 1.4 million doctors of Indian origin across the globe, and we have a substantial population in the U.S., UK, the Caribbean, South Africa, and in many parts of the world. GAPIO, which is the Global Association of Physicians of Indian Origin, has members in 53 countries. GAPIO, along with AAPIO, which is the American organization, BAPIO which is the British association, the Australians, and the Canadians came together and founded this collaborative.

The idea was to exchange knowledge, because we knew that what was happening in the U.S. and UK would happen in India a few weeks later, but we also felt the need for emotional support. Because of the important role spirituality plays in India, we had several spiritual talks. We had Sister Shivani, we had Sadhguru, we had Sri Sri Ravi Shankar, and then we had His Holiness the Dalai Lama address us. I think that also helped.

For nurses, we launched a program called Angel, for thanking a nurse, a program with a lot of partners outside of Apollo, outside of health care, about scholarships, recognition, and respect. We’ve been trying to do a lot of these initiatives to make sure that we take away some of this emotional strain and pressure that everyone’s facing.

Mohta: We have all been reading about extensive reports around problems with the supply chain of necessary resources, medications, oxygen. What are some examples of how your teams are coordinating with government agencies, other hospitals in the area, and community organizations to secure supplies, as well as to provide support to other organizations who might need it?

In India, family is central to our existence, so when family members started to fall ill and they needed support, we made sure that we reached out, because we at Apollo believe that we are one large family.

Sibal: As India’s largest health care provider in the private sector, we do have a lot of links that have been built over 3.5 decades with the companies, and that includes equipment manufacturers, pharmaceuticals, and vaccine manufacturers. We decided early on that we would place bulk orders, whether it was for vaccines or medication, when Remdesivir became licensed, or when other medications became licensed. So we did not have a supply problem. What we saw was that smaller institutions did not have the ability to procure supplies and were struggling. We reached out and supported them. We had our own needs that were huge, but we did reach out and say, “We can help you with this. We can make the connection so that you are able to get supplies.”

Oxygen is something, as I mentioned, a little complicated, because it has to come to Delhi from other locations. We didn’t have these problems in other states where oxygen is produced, but Delhi was a challenge; we had to look at procuring oxygen from multiple sources. Different governmental agencies worked closely with the public sector, the private sector. I distinctly remember an SOS from a large hospital about 7 or 8 kilometers away from us, and they said, “We are going to run out of oxygen in 60 minutes. Do you have a tanker?” I said, “Yes, we have a tanker, but we haven’t started unloading it. Why don’t you take the tanker?” We dispatched the tanker to them, and I said, “When you get your tanker, you send it to us.”

We saw the spirit of everyone coming together. Also, the crisis gave us opportunities to look at systems. For example, for oxygen, we realized we could save oxygen, and I don’t think clinicians think of oxygen as something that they need to worry about. When you’re having tea or you’re eating a meal, the oxygen continues to flow. We figured out that we could save about 10%. Going forward, we’ve learned how to conserve oxygen.

We have a large network, which is spread [out]. [When] we needed ECMO [extracorporeal membrane oxygenation] in one hospital, we would transport ECMO from one city to another. Sometimes we needed to move ventilators if there was a sudden spike in cases in a particular location.

All that was possible because of the ability to support each other through a large network. We reached out to smaller hospitals through our eICU [electronic intensive care unit] platform, and we were supporting nine centers. Telemedicine has become very, very important now, and we are seeing on any given day 4,000 tele-consults. We’ve done 120,000 free tele-consults supporting colleagues in other parts of the country. The Government of India supported telemedicine early on, and at the start of the pandemic guidelines were published to encourage telemedicine. This gave a lot of clarity and has been helpful.

Mohta: Let’s talk for a minute about vaccines. You mentioned vaccine hesitancy earlier on, and some tactics around social media and the clinicians sharing the positive aspects of it. What do you see happening in the weeks and months ahead around vaccinations in India?

What was the target? 300 million. Now, 300 million is just 30 million short of the entire population of the United States, and 30 million more than the fourth most-populated country in the world, Indonesia. That was just phase one.

Anupam Sibal: Let me give you a sense of what vaccination entails in India. The vaccination campaign was launched on January 16. We started off with health care workers, and then moved on to the front line, and then older than 60 and older than 45 with comorbidities. What was the target? 300 million. Now, 300 million is just 30 million short of the entire population of the United States, and 30 million more than the fourth most-populated country in the world, Indonesia. That was just phase one.

Where are we today? The United States has administered 276 million vaccines, and India has administered 185 million [as of May 20, 2021]. The highest number of vaccines administered in a single day: United States, 4.6 million; India, 4.3 million.

We need to scale up, and that is going to happen. The government has mentioned that we will have as many as about 130 million doses available per month from July, and by the end of the year, we will have 2 billion doses.

What we’re going to see in the coming months is scaling up like the world has never seen. We, at Apollo, have 6,000 touch points when we look at our diagnostic centers, clinics, hospitals, pharmacies. We have set ourselves a target with the supply — which is going to get enhanced in the coming weeks — of vaccinating, as an organization, 20 million Indians by October. We are going to see some dramatic moves in vaccination, and I think that is really going to turn the tide for us.

Mohta: Are there any challenges that you’re anticipating in order to get to that 20 million by October?

Sibal: We’ve now planned this well, so we don’t visualize any difficulty if the vaccines come. And we firmly believe they will, with more and more vaccines getting licensed, and the production for the three that we already have in use increasing considerably.

[As for t]he challenges, when it comes to the pandemic, we’re going to have to address the issue of human resource exhaustion. A break is essential, so that is something that we are hoping for when the numbers come down. We hope and pray that there isn’t a third wave, but if there is, at least it would have been after a bit of rest for our human resources.

The lessons from the second wave will help us plan better for the third wave, that is, if you see a spike in a particular part of the country, it doesn’t take long, if there are no restrictions, for the numbers to spread across the country. With the kind of restrictions we’ve had in most states, the numbers have come down. Should there be a rise anywhere in the country, I think the different state governments will act rather quickly and institute restrictions the next time around.

The public-private partnership that we’ve seen this time around has been strong, and we’ve worked closely breaking silos. For those outside India, I might want to add that about 65% of health care in India is through the private sector. It’s extremely important for the private sector to play an important role in managing this pandemic. When we start getting to a figure hopefully of vaccinating 5 million Indians a day consistently in July and then 10 million a day, I think we will see a quite a shift in how we’ve been looking at the pandemic.

When it comes to the pandemic, we’re going to have to address the issue of human resource exhaustion.

Mohta: Let’s end on a positive note, from more of a frontline perspective. Can you share one success story from the last few weeks?

Sibal: Let me share a few quickly. A lot of people with noncommunicable diseases, in the first few months of the pandemic, were afraid of coming to the hospital. We perform more than 1,400 solid organ transplants a year, every year, and last year from April 1, 2020, to March 31, 2021, we did 866 solid organ transplants. This year, if you look at March, April, and May — and March is when the numbers started to increase, April was a huge surge, and May was the peak — we have performed 237 solid organ transplants, including 42 liver transplants. These are complex procedures, which means the team has committed to managing Covid-19 on one side and non–Covid-19 work on the other side.

We’ve done air rescues for patients, Indians outside India who’ve needed to come in. We’ve airlifted, we’ve gone into another city in an air ambulance, started a patient on ECMO and transported that patient. We have many examples of patients having done well and gone home. We all derived a great big deal of joy from the fact that a 100-year-old doctor in Hyderabad and a 107-year-old lady in Bengaluru went home.

Mohta: On that note, Anupam, thank you to you and all of your teams for all that you are doing, and thank you for speaking with NEJM Catalyst today.

Sibal: Thank you so much, Namita. I’d like to thank the medical community across the world, who’ve been so generous in their support, sharing their knowledge, what their key learnings have been, and how governments across the world have reached out and said, “We’ll support you with whatever you need.”

In India, we believe Vasudhaiva Kutumbakam, which means “the world is one family.” What we’ve gone through with the second phase has reaffirmed the faith that we all are indeed one large family. Thank you.