Dear Friends,

We appreciate enormously the prayers, goodwill and support of all our friends. So many of you have sent in letters of encouragement, contributed financially, prayed for us continually, connected us with friends and well-wishers and also helped us in other ways. Many of you have made special contributions for the Kannigapuram Campus, for COVID patient care and other causes close to your hearts. Some people have requested for details of specific needs and an update on the COVID situation. This letter is to update everyone and also inform you about the specific needs.

Response to the COVID-19 Pandemic and current status

As soon as news of the novel coronavirus began to circulate in January 2020, CMC began to formulate a response through the institutional Hospital Infection Control Committee (HICC). By the time the global pandemic was declared on 11^th March, CMC already had protocols and plans ready. We were one of the first private institutions in the country to be approved as a COVID-19 testing and treating centre. In March, the State and Local Government authorities approached CMC with the request to provide as many beds as possible for COVID treatment. Dedicated COVID ICUs and isolation wards were prepared and infrastructure changes implemented to enable our hospitals and campuses to cater to suspected COVID patients.

From June 2020, the number of Covid positive patients admitted to the hospital began to increase rapidly and many more beds were created or allocated to COVID needs. The need for a coordinated response at a large scale across the various campuses necessitated the creation of a COVID Command Centre (CCC). Three classrooms in the ASHA building were converted into the CCC. The CCC undertakes multiple roles such as policy making, contact tracing, data management, development of protocols, patient information services, training and deployment of faculty and staff for COVID, financial aspects of insurance, patient subsidy, bed management, staff wellness and encouragement and medical records. A core administrative team meets daily to sort out the various issues.

Testing facilities commenced in April 2020 and services have been ramped up to handle around 400 PCR tests daily. Results are available within 12 hours and the patients are contacted by phone and informed about the results and options of admission and treatment are communicated to them from the CCC. Over 25,000 tests have been performed in CMC so far. To meet the increasing demand for inpatient beds, bed capacity was gradually increased from 150 beds at the start of the pandemic to 910 beds presently, dedicated exclusively for COVID care.

The current breakup of the beds is:

• 830 Level 1 and 2 beds for isolation and care of patients who have tested positive for COVID-19, and have mild to moderate symptoms. The occupancy rate is 85%.
• 80 ICU beds exclusively for critically ill COVID-19 patients (of which 65 have ventilators).

So far, we have admitted more than 8,000 patients with COVID infection and over 85% have recovered and been discharged home. With the pandemic raging on, large numbers of patients come to our Emergency Department every day. Even with 80 ICU beds, we sometimes have had to turn away very sick patients requiring ICU beds. Some have been as young as 21 years of age. It has been very heart-breaking for our team members to refuse patients, especially when we know that many of them have a good chance of survival if only we were able to find resources to admit them.

In Chittoor, to cater to the needs of the district, the outpatient space was increased to enhance social distancing, two full ward cubicles were converted into COVID-19 admission wards, two theatres have been converted into negative pressure theatres and non-invasive ventilation is being regularly provided for patients who require therapy for COVID. So far 250 patients have been admitted for level 2 and 3 care for COVID at Chittoor. A large number, in excess of 600 patients, have been home quarantined or treated for mild illness at home. Regular care has shown a paradoxical increase in patients to all-time-high levels with outpatients sometimes in excess of 800 patients a day and inpatients in excess of 950 patients per month. 

Following the request from the Collector of the newly formed Ranipet District, a section of the inpatient block in Kannigapuram that is under construction was readied quickly to admit COVID-19 patients. After obtaining official permission, 3 wards with a total of 168 beds were commissioned for the care of level 1 patients. So far over 1,200 patients have been admitted in this campus. Work is going on to operationalize ICU beds in this campus so that COVID work can be moved to Kannigapuram temporarily in order to free up capacity in the town campus when transport resumes and our patients return.

Right from the start of the pandemic, CMC was committed to developing educational material on COVID for use within the institution and for dissemination to various partners in the government and in the mission set-up. Training modules were created by the Hospital Infection Control Committee, the Nursing team, the Staff training department and the various academic departments (medicine, infectious disease, critical care, respiratory etc.).

A majority of the staff have been trained on various dimensions of COVID care including infection prevention measures, triage, treatment, quarantine etc. Apart from these, CMC, through the Distance Education Department, created two online training modules. One is for doctors and nurses, and was supported by a grant from TATA Trust, wherein around 5,000 doctors and nurses from across the country are being trained in COVID. The second program, COVID Surakshya, again developed by the Distance Education Department, has been funded by the Azim Premji Foundation and targets the training of over 10,000 grass root level workers across India.

Preparing for the months ahead

There is no sign yet of reaching a peak in terms of numbers of COVID cases in India. Although Tamil Nadu as a whole has plateaued at less than 6,000 cases per day, we anticipate that the number of cases in Vellore and surrounding districts may rise following the latest lifting of restrictions, and the relatively low proportion of the population who may have been infected.

Placed before you are the needs in the ensuing months. We are thankful to you, our friends and alumni, for having graciously contributed to the needs of the institution and continuing to do so.

1. Oxygen Concentrator Plants: Many COVID-19 patients require supplemental oxygen therapy and the usage of oxygen has increased several fold despite the lower bed occupancy when compared with the pre-pandemic period. The main hospital has a liquid oxygen tank and this is now primarily meeting the needs of the 180 ICU beds, of which around 140 have ventilators. Owing to the lockdown, supplies of liquid oxygen have become limited and at times erratic. A refill of the liquid oxygen tanks lasts about 4 days and the oxygen stored in cylinders is not enough to last a full day, with the current level of demand. The Azim Premji Foundation graciously funded an oxygen concentrator at the Kannigapuram campus at a cost of 1 crore. In the hospital campus, we have decided to go ahead with the installation of two smaller capacity oxygen concentrators to offset the dependence on liquid oxygen. The smaller capacity models were necessitated by the lack of space in the main campus. These provide a reliable steady flow of oxygen concentration at a concentration of 93-95%, which is sufficient for Level 1 and 2 patients. Once set up, the cost per liter will be about half that of bulk oxygen supply. Cost of each Oxygen Concentrator $53,000, total $106,788 including GST.

• Additional ICU beds: At the special request of the Ranipet District Collector, 24 of the 150 ICU beds in Kannigapuram are being readied urgently (by October if possible) for COVID care. We are planning to procure equipment for these beds. We are grateful to our partners, L & T, HDFC Foundation, Eicher Motors, MRF, Titan and others who have supported the cost of procuring some lifesaving equipment already. The cost of equipping the ICU is given below:

Equipment Needed	No. per bed	Unit Cost $	Total $
Ventilator – intermediate to high	1	19,778	19,778
Monitor – low end	1	3,405	3,405
Syringe Infusion Pumps	3	580	1,740
Infusion Pumps	1	580	580
Food Pumps	1	550	550
Subtotal Per Bed		24,893	26,053
Grand total for 24 ICU Beds	$625,205

• Personal Protective Equipment. It is essential that we provide our staff and patients with good protection – especially N95 masks, face shields and full body bio-suits. This is needed not only in the COVID wards, but also in many other areas of the hospital, since we can’t tell who may be infected. The hospital spends approximately $400,000 every month on protective equipment. Rather than pass on the entire cost of this to patients, we are seeking partners who can sponsor part of the monthly cost of PPE, or provide us with gifts in kind of suitable PPE. We are grateful that groups such as Rotary, TATA Trust and other organizations have provided PPEs for the institution.

I am pleased to report that the various efforts that were taken by the institution to provide a safe working environment for our faculty and staff was recognized by the Consortium of Accredited Healthcare Organizations (CAHO) with the award of the 1^st prize in the very large hospitals category (over 600 beds) for “Workplace safety during the Covid-19 pandemic” on 17^th September 2020.

• Patient Support Funds. Many of the patients admitted in our wards cannot afford the full cost of their treatment. The Coronavirus spreads rapidly in congested urban areas, and therefore a disproportionate number of patients are from the economically weak sections of society. We estimate that up to 50% of our patients require subsidy. Our dream is not to have to turn away anyone in need for financial reasons. However, our regular income, from patients, has been greatly reduced during lockdown, while our expenses have been higher than usual in several areas. We therefore need compassionate partners who can help us subsidise economically deserving people undergoing treatment for COVID-19. Bed, nursing and medical charges, together with medications, tests and food cost between $102 to $108 per day in Level 2. On average a moderately sick patient requires hospitalisation for about 10-14 days. Around 5% of Covid-19 patients require intensive care. The average cost of ICU care, that includes bed and nursing, professional fees, investigation costs, ventilation, oxygen therapy, drugs and consumables, is likely to be around $340 per day.

	No. days	Unit Cost $	Total $
Care for a moderately sick patient	10	102	1,020
ICU care with ventilation	10	340	3,400

In August alone we wrote off bills for around 900 patients, to the tune of nearly $280,000. We are truly grateful to several partners like Fairbridge Capital Ltd. and the Azim Premji Foundation who have made contributions to patient subsidy.

Impact on CMC

The first lockdown in India was announced on 24^th March 2020. This had immediate effect, and was one of the severest lockdowns in the world. It was initially for 21 days, but has been progressively extended with some relaxations in regulations each month or so.

The immediate effect on CMC was an 80% reduction in our outpatient numbers, and consequent fall in inpatients. Initially we were only permitted to treat emergency cases and COVID-19 patients. We witnessed a surge in patients seeking antenatal care and delivery at the main and peripheral hospitals which has persisted due to closure of most private clinics. Cancer care services and emergency work in medical and surgical departments has also remained high, with the biggest fall in specialty elective work. The lockdown was relaxed after a few weeks, but outpatient numbers have remained very low for two reasons. 1) Travel became difficult – even within the district – with no trains, buses or flights. Where travel was possible, the need to obtain e-passes and the need to undergo quarantine after entering the state continued to deter most people. 2) People understandably preferred to avoid coming to a hospital known to be treating COVID-19 patients.

Meanwhile expenditure (apart from a few variable items like Pharmacy purchases) continued at more or less pre-COVID levels. We have continued to pay salaries every month, on time, and tried to meet all our other contractual obligations. In addition, we:

• Carried out extensive infrastructure modifications to reduce the risk of spread of COVID and to keep non-COVID patients safe. We have converted several wards and other spaces into COVID ICUs.
• Opened 168 beds for Covid care in the Kannigapuram Campus, with another 168 general beds and 24 ICU beds on the way. We fast-tracked the purchase and installation of an Oxygen Concentrator Plant at Kannigapuram and ordered for an oxygen concentrator in the main campus.
• Invested in ventilators and other costly ICU equipment.
• Ensured that our staff are adequately protected with PPE.
• Pressed ahead with the conversion of the old Student Nurses Hostel into an inpatient facility. This will provide another 105 low dependency and 12 ICU beds.

With reduced income and higher than normal cash outflows, we are stretched financially, and it is difficult to tell when things would revert to normal. We have been helped through:

• Donations and CSR grants in India of $1.5 million.
• Senatus members and other staff who have committed to contributing to COVID work by donation through salary deductions amounting to over $600,000.
• Staff being willing to defer portions of their salaries until the circumstances are more favourable.
• Grants and donations from the international Friends of Vellore and Vellore CMC Foundation amounting to nearly $500,000, on top of their existing commitments and donations towards the Kannigapuram Campus.
• Gifts in kind, especially of PPE, from various organisations. So far we have received gifts valued at nearly $70,000.

Impact on those around us

Staff rallied round to help people badly affected by the lockdown. During the early weeks, special efforts were made to help

• Those living on the margins. LCECU organised a huge daily food distribution programme with many volunteers and donors lending a hand. The Chatram residents were provided breakfast and meal vouchers. Along with a local NGO rations were delivered to the disabled, isolated and vulnerable in the Jawadhi Hills. RUHSA looked after their local communities and also stranded migrant workers.
• Community patients with chronic diseases. CHAD, LCECU, RUHSA and CONCH all organised schemes to ensure that those with hypertension, diabetes and other conditions could receive their medications even though they couldn’t travel to a clinic or hospital.
• CMC patients from other states and countries, stranded in Vellore. Wherever there was a need we ensured they could get food through the Manna Midday Meals Scheme. Over 18000 food coupons have been distributed during the pandemic. Some were threatened with eviction from their lodges. We advocated for them, and where necessary tried to help them find alternative accommodation.

Impact on Students

Starting with the cancellation of the students’ inter-batch music competition, the evening before it was due to be held, life has been extremely different for the undergraduates. Face to face teaching had to stop, and the students were confined to the Campuses and hostels from 24^th March. Since then there has been no clinical experience possible, although online classes have been going on. Most of the students were eventually allowed to return home towards the end of April or in May, though some are still living in the hostels for various reasons.

Impact on Staff

Travel restrictions, fears for ourselves and our families, closure of shops, eating places and amenities have all made this a difficult and stressful time for everyone. With schools and colleges closed, staff have had to organise child care, and find ways to occupy their children. CMC organised buses to transport staff living in different parts of the town. Canteens inside the hospital distribute limited packed food items, which have to be eaten elsewhere. Counselling services and stress management services have been made available.

With fewer patients in some of the departments, many staff have had a less pressured working environment, and early on we gave generous additional leave provisions to enable people to organise things at home and have a break. Other faculty and staff in very busy areas unfortunately could not utilize all these leave provisions. They went an extra mile to ensure that the services to patients were not disrupted and provided optimally. Once the number of COVID-19 patients began to increase, clinical staff from all departments had to be drafted in to man the isolation wards and ICUs, and also to help with the CCC. 

A number of our staff have come down with COVID-19, and a few have experienced very severe symptoms, needing ICU care. However, we are very grateful to God that, through his grace so far, all have recovered from the illness. A lot of community support has emerged for the families of those affected.

Major Development Projects

The COVID-19 pandemic has struck CMC at a time of unprecedented capital investment. Alongside regular maintenance and refurbishment activities we have three major projects underway:

• Conversion of the old Student Nurses Hostel into an inpatient Orthopaedic facility. This in turn was intended to allow us to completely renew the existing operation theatre complex in the main hospital. This project has proved to be significantly more complicated that envisaged, and has taken longer than we ever expected. It is now almost completed.
• Development of the Chittoor Campus. The patient flow has increased rapidly over the past few years. Additional outpatient, inpatient, and diagnostic space is needed, along with staff accommodation. The Radiology suite with the CT scan machine has started functioning. We have started the College of Nursing there, currently based in rented premises – we will need to construct our own college buildings in the next few years and expand further on the clinical facilities which have reached the point of saturation. 
• Kannigapuram Campus. We have completed the staff accommodation area, and people will be moving in there shortly. The main hospital (1,500 beds) is almost complete, but since March progress has been very slow because of various restrictions and a shortage of labour. Most of the skilled labourers were from out of state and returned home when they could. Apart from the Covid Wards that we have completed and inaugurated, finishing work is still needed. Much of the equipment required is yet to be installed.

Around two thirds of the funding for the Kannigapuram project is from a bank loan. The rest has to come from our internal reserves and from grants and donations. Drawdowns of the bank loan have to be made in proportion to the “equity” invested from our own resources. Even before the pandemic struck, it was a challenge to ensure we could provide the equity required to maximise the bank loan available. The reduced rate of progress has given us some respite, as has the reduction in interest rates and a payment moratorium. The more we can raise through donations and grants, the less dependent on the bank loan we will be.

Conclusion

This is a broad overview, with some of the details intentionally sparse. However, I hope that it has given you a flavour of life under lockdown at CMC, and in particular an awareness of the issues faced – in terms of care of Covid patients, and the financial challenges that we must weather in the coming months and years. What will happen next is uncertain, however what is certain is that without partnership and a shared vision, we face an uphill task. It has been said that partnership and co-operation is the deep conviction that nobody gets there unless everybody gets there. CMC’s distinctive over the last century has been its unique ability to offer health and hope and healing for all, especially for those who suffer as a result of social and economic inequalities. Our mission cannot and should not change, and so we invite you to partner with us once again to help us meet the needs of those who knock on our doors at this difficult time.

We are truly grateful for the friends and alumni who have been with us through this very difficult period and we look forward to continuing to partner with you to fulfil the motto of CMC, “Not to be ministered unto but to minister”.

Yours sincerely,

Dr. J.V. Peter

On behalf of the CMC Community