Coronavirus: Why Gujarat has India's highest mortality rate

The Ahmedabad Civil Hospital has recorded more than 60% of Gujarat's deaths in Covid-19
On May 20, Parveen Bano felt slightly breathless. When she told her son Amir Pathan, he took her to the nearest hospital.
He said he was concerned because his 54-year-old mother had diabetes and a history of heart disease. Even worse, their neighborhood - Gomtipur in Ahmedabad, India - had recently registered a number of Covid-19 infections.
The next 30 hours were shattering for the family. Mr. Pathan says they went to three hospitals - two private and one governmental - but none of them had a bed available.
So Mr. Pathan decided to take his mother home. But he says that her "discomfort" worsened during the day and night, so the family took her to the Ahmedabad Civil Hospital, one of India's largest state institutions, the next morning.
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She was wiped and oxygenated for a Covid 19 test because the doctors found her blood oxygen level was low. Mr. Pathan says the levels were irregular throughout the day, so doctors connected them to a ventilator that night.
Hours later - on May 22nd at 1:29 am - she died. Her corona virus test result came the next morning - it was positive.
The hospital did not respond to the BBC's requests, but Mr. Pathan believes that his mother might have lived if she had been hospitalized the day before.
The Ahmedabad Civil Hospital has made headlines time and again when struggling to cope with it. The Supreme Court called it the "dungeon" and stated the number of Covid 19 deaths - 490 - recorded so far. And the court also reprimanded the state government for dealing with the pandemic.
But the government has denied any negligence on its part.
What drives Gujarat's high mortality rate?
Ahmedabad, home to more than seven million, is the largest city in the western state of Gujarat.
It is also the worst affected by the pandemic, accounting for more than 75% of the state's casualty numbers and almost all deaths.
With more than 21,500 confirmed cases, Gujarat has India's fourth highest number of cases. The state's mortality rate - the proportion of deceased Covid 19 patients - is highest at 6.2%. This is more than double the national average of 2.8%.
Gujarat diagram
When the Gujarat Supreme Court expressed "concern about the alarming number of deaths in Ahmedabad hospitals," the state government said that over 80% of those who died had comorbidities or other illnesses that made them more susceptible.
However, public health experts say that it is difficult to determine a single reason for the mortality rate.
While some point to the state's high disease burden, others say it doesn't only occur in Gujarat - in fact, Tamil Nadu has more diabetics than any other state, but his mortality rate is far lower.
Questions have been raised about whether India counts Covid 19 deaths, but if it did, there is no evidence that Gujarat is an exception.
Vijay Rupani, the state's prime minister, has repeatedly accused international travelers and those who visited a Delhi religious community that later developed into one of India's largest clusters.
But none of these factors is unique to Gujarat - Kerala saw a larger influx of foreign returnees, and Tamil Nadu brought far more people back to the community. And while this can explain the increase in cases, it doesn't explain the disproportionate number of deaths.
Low tests, lack of trust and stigma
"People who report to hospitals late can be one of the main reasons," said Bharat Gadhvi, director of the Ahmedabad Hospitals and Nursing Homes Association.
Because private hospitals either refused to accept Covid 19 patients or were unable to accept them, many were reluctant to seek treatment in state hospitals, doctors say. The reasons for this are poor facilities and a lack of trust in the quality of care.
Doctors have said stigma could also be a reason. Dr. Randeep Guleria, director of India's largest public hospital, referred to this after seeing doctors from Ahmedabad Civil Hospital in May.
"An important issue that has been discussed is the stigma associated with Covid-19. People are still afraid to come to hospitals to get tested."
Hospital admissions increased in May, possibly due to increased examinations and tests that prompted doctors and officials to identify potential "super spreaders" - such as fruit and vegetable suppliers and shopkeepers.
Public health experts say, however, that tests were still poor in parts of the city, particularly in the so-called "old city" that has parts of it walled.
"The government has shown a lack of focus in dealing with the situation, particularly in security zones," said Kartikeya Bhatt, an economics professor.
Gujarat was reopened by Covid-19 despite a high number of infections and deaths
He says 10 out of 11 zones in Ahmedabad's old town were security zones and all were densely populated.
He adds that while these areas were isolated from other parts of the city, officials did not do enough to check the spread within the zones themselves.
"Physical or social distancing is almost impossible because people even wash clothes and utensils outside their homes," says sociologist Gaurang Jani.
Experts suspect that the infection spreads quickly in these parts, and due to stigma or lack of awareness, according to an analysis by the Observer Research Foundation, many people may not have applied for hospitalization early enough.
An overwhelmed city
But even those who survived the virus say that the city's hospitals are not equipped to deal with the crisis.
"It was only after waiting for hours that I was able to get a hospital bed," said Laxmi Parmar, 67, who was treated at the Covid-19 ward of Ahmedabad Civil Hospital for 10 days.
"In the beginning there was no breakfast and I had to complain to a local politician to intervene. We had two toilets that we could share between 40 and 50 patients on the ward."
Experts say the pandemic has exposed the state's poor health infrastructure.
Ahmedabad hospitals lack staff due to protests against cut wages
"Otherwise nobody would have bothered to know the state of the hospitals in Gujarat. Now that the shortage of doctors and paramedics is open, we have seen quick hires even during the closure," says Professor Bhatt.
According to a recent Brookings study, Gujarat has only 0.3 beds per 1,000 people, which is below the national average of 0.55.
And the surge in cases has led to a lack of hospital beds, PSA kits, and quarantine facilities. In recent weeks, Tamil Nadu has overtaken Gujarat in terms of total infections, but given the high mortality rate, the situation still seems to be bad.
"I do not believe we have failed to do our duty," said State Health Minister Nitinbhai Patel to the BBC.
"We currently have 23,000 hospital beds in the state and our medical staff work 24 hours a day in every hospital. We also provide them with the best medical equipment to deal with the situation that is slowly coming under control."
But his government has been criticized for what many see as a missed opportunity because Gujarat didn't record his first case until March 19, just a few days before the country was closed.
"Government policy could have been much better. The test and isolation facilities initially seemed robust, but have weakened over time as the administration appears tired," said Gadvi.

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