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Judgment
Heard.
Till date we had been monitoring the situation in the context of spread of Covid-19 pandemic in Vidarbha Region and accordingly, we have been
issuing directions from time to time in order to solve the issues which were arising on different occasions in effectively managing the Covid pandemic.
Today, there has been some improvement in the pandemic situation. The total number of active cases in Nagpur district is 9763 and the per day
addition of active cases has been less than 5%. Similar appears to be the position in rest of the districts of Vidarbha Region although we have not been
supplied with any specific information in this regard by the concerned Collectors of the districts. But, going by the newspaper reports there is certainly
overall betterment and improvement in Covid pandemic situation in entire Vidarbha Region. Beds are available and even the drugs mentioned in the
SOP are also available. However, the pandemic has 3 2705smpil4.20.odt its own side effects, this time they are quite severe. As a part of the side
effects, fungal diseases have raised their head in Vidarbha Region in particular the entire State of Maharashtra and, Black Fungus disease has
become a major issue. Now, the administration has to prepare itself and effectively deal with this new disease which is mainly a fall out of the misuse
of steroids and some drugs given to Covid patients and non-maintenance of hygiene.
The Black Fungus, which is called Mucormycosis has been stated to be the result of reduction in immunity levels of the patients who recover from
Covid-19. It is also stated that major reason for affliction of a person by this disease is misuse of steroids or Remdesivir or both given to that person. It
is well known that steroids and Remdesivir both are contributing in increase in levels of sugar and whenever there is increase in sugar level in body of
the person either on account of steroids or Remdesivir it causes concomitant decrease in the immunity of the patients. In medical terms, such patients
are called immuno compromised penitents. The spores of black fungus are said to be present in the air, in the water and also some time in sinus of the
person. But, it is stated that they do not ordinarily cause any harm to a person and they become virulent only when the immunity of a person is
compromised. In other words, Mucormycosis is a disease which is opportunistic and seizes a person as and when opportunity is provided by such
person 4 2705smpil4.20.odt which is in the nature of considerable reduction in level of immunity. So, what is now required to be done is strict
regulation of drugs prescription for managing the treatment of Covid patients, taking precautions for ensuring that sugar level of a patient does not
increase to keep his immunity sufficiently protected, and maintenance of hygiene.
In the last hearing, considering the rise in Mucormycosis cases we had requested the State of Maharashtra to come out with more detailed SOP for
treating the patients with Mucormycosis. We are informed today that on 19th May, 2021 the State of Maharashtra has indeed issued a detailed SOP, a
copy of which has been placed on record. We are satisfied with the same and we are of the opinion that this SOP will go a long way in decreasing the
spread of Mucormycosis in the State of Maharashtra.
We had also directed the local administration to start an awareness campaign in respect of Mucormycosis disease. The Nagpur Municipal
Corporation, as pointed out by Shri Radhakrishnan B., the Commissioner, NMC has started an awareness campaign in right earnest. The NMC has
prepared posters and posters have been distributed and also displayed in Nagpur city. The copy of this poster is placed on record. The poster is
illustrative and in our opinion brings home the point that it seeks to convey. Similar awareness campaign and same posters have also been started and
issued 5 2705smpil4.20.odt by the Collectors of Nagpur and Amravati districts and the Collectors of remaining districts as informed by the learned
Government Pleader.
The matter, however, does not end with issuance of SOP and running an awareness campaign. Something more is required to be done especially in
the area of augmenting the production capacity of the essential drugs required for treatment of Mucormycosis and increasing their supply to each of
the districts in proportion to the active case load of Mucormycosis in those districts. Presently, it is stated that Amphoterecin B Lipid Complex and
Amphoterecin B Liposomal are the only primary drugs which are used for treating the Mucormycosis and each of these primary drugs are essential
during the first 15 days of treatment of Mucormycosis. It is also stated that early detection of disease helps in controlling the disease quite early. But,
whether early or for late detection, what is required is comprehensive treatment with Amphoterecin B Lipid Complex or Amphoterecin B Liposomal.
Unfortunately, there are more Mucormycosis patients in India particularly in Maharashtra than the production of these aforestated primary drugs.
It has been informed by Shri Bhanudas Kulkarni, learned counsel for IMA, that at least 5 vials per day are required, which requirement is roughly
calculated by adopting the formula of 5 milligrams of this drug per ten kilogram of a patient per day. He 6 2705smpil4.20.odt further informs that said
treatment is required to be given for minimum 10 days which may extend to 14 to 15 days. That would mean, for every patient not less than 50 vials of
said primary drugs per day will be required. Now if we take into account the total number of patients in India, the total production capacity as
mentioned in the pursis of the Central Government appears to be woefully inadequate. It is stated that expected supply of this primary drug in May
2021 is of 163752 for the entire month and this supply is likely to increase to 255114 in the month of June, 2021. In Maharashtra, it is reported that
there are 2275 patients of Mucormycosis as of date and if the number of vials of the primary drugs required for these patients in Maharashtra is taken
into account, the requirement would come to 11375 vials of Amphoterecin B Lipid Complex per day. As against this requirement, the supply and
allocation of this drug to State of Maharashtra is extremely short. The pursis of the Central Government indicates that on 11.05.2021, 16500 vials were
allocated to Maharashtra and thereafter there was a lull in supply till 18th May, 2021. The allocation of this drug started from 19th May, 2021 but on
that day it was only 5700 vials. Thereafter upto 24th May, 2021 vials in less number such as 4360, 5090 and 4060 have been allocated to the State of
Maharashtra. Since the regulation of production of this drug is entirely in the hands of the Central Government, we are of the view that Central
Government needs to jack up its 7 2705smpil4.20.odt efforts in increasing the production of this drug in entire India. Of course, some steps have been
taken by the Central Government and it has been informed that the number of companies which were manufacturing Amphoterecin B Lipid Complex
drug has now risen from 6 to 11, and the newly added companies would be manufacturing this drug shortly. The pursis of the Central Government also
shows that the Ministry of External Affairs has been asked to perform an active role in procuring the raw material from abroad and certain steps have
been taken by the Ministry of External Affairs. But the pursis does not provide us specific information of the steps taken by the Ministry of External
Affairs and by the Department of Pharmaceuticals in this regard. We request the Central Government to apprise us of the steps taken by the Central
Government to increase the production of aforestated primary drugs and increase in their supply to different steps including the State of Maharashtra.
So far as State of Maharashtra is concerned, we find from the pursis that the allocation of the primary drug Amphoterecin B Lipid Complex done
till 24th May, 2021 is not in proportion to the active cases of Mucormycosis. We request the Central Government to make amends in the allocation
made to State of Maharashtra and align the allocation with the active cases of Mucormycosis. It has been informed to us by Shri Bhandarkar, learned
Amicus Curiae that Maharashtra has about 20% of 8 2705smpil4.20.odt total active cases of Mucormycosis in India and if this is true, we would
expect the Central Government to increase the allocation so that it matches with the requirement of State of Maharashtra in terms of its share in total
number of active cases in India.
We have also been informed today by learned Amicus Curiae that pharmaceutical company at Wardha has been granted licence for production of
Amphoterecin B Lipid Complex and it would be producing 4500 vials of this drug everyday from Monday and onwards. So far, it is not known as to
whether the vials so produced by the Wardha company would go to the central pool of the drug or would be exclusively made available for their use in
State of Maharashtra. We would request the State Government and also the Central Government to enlighten us on this aspect.
We have just expressed our concern over the limited production capacity of drug Amphotericin-B in India and the need for the Central
Government to take effective steps for increasing the production capacity including procurement of raw material required for producing this drug. But,
even if the Central Government takes such steps, that will not be enough unless and until there are more manufacturers who are willing to take upon
themselves the task of producing this drug within India. We would, therefore, call upon the Divisional Commissioner, Nagpur and the Divisional 9
2705smpil4.20.odt Commissioner, Amravati to explore the possibility of the Pharmaceutical Companies operating within their respective jurisdictions
regarding their willingness to enter the field of production of drug Amphotericin-B and report to this Court.
Ms Mitisha Kotecha, learned Counsel for Intervenors assisting Mr.S.P.Bhandarkar, learned Amicus Curiae has filed a pursis on record which
reveals that the website ""Covid Nagpur.in"" which has been created in compliance with the directions issued by this Court by the Collector, Nagpur is
not updated on daily basis. The pursis gives a chart showing the information updated on the web portal. On perusal of the chart, we find that most of
the hospitals in the City of Nagpur are lagging behind in updating the information on its web portal. We direct all these hospitals to update the entire
information by removing the backlog and start updating the information on this web portal w.e.f. 1 st June, 2021 on daily basis. The update must be
done within 24 hours of the day which has gone by. If there is any failure on the part of any of these hospitals in complying with this direction, the
failure shall be taken by this Court seriously.
There is an issue raised by the Nagpur Municipal Corporation about some of the private hospitals not complying with the norms set out in the
notification dated 31.8.2020 issued by the State of 10 2705smpil4.20.odt Maharashtra. According to this notification, 80 % of the total patients
admitted to Covid hospitals are required to be charged at the rate given in the notification dated 31. 8.2021 and only 20 % of such patients are
permitted to be charged by the hospitals as per its own rates. However, it has been further pointed out that these rates despite the notification dated
8.2021 are not being followed and in some cases, over-charging has taken place. It has also been informed that several complaints of over-
charging and excess billing have been received by the Nagpur Municipal Corporation and in order to scrutinize those complaints and find the truth of
the matter, certain information is requisitioned from the hospitals against whom complaints are received, But, unfortunately, in some comes, it is further
informed, the information has not been provided, rather it has been refused to be provided.
Mr.B.G.Kulkarni, learned Counsel for Indian Medical Association states that there may not be any hospital which has expressly refused to provide
the information and all that the hospital may have demanded from Nagpur Municipal Corporation would be of some more time for providing the
information. According to him, only five days' time is stipulated in the notice received by hospital which is not enough. He submits that atleast three
weeks time is required by the hospitals for supply of the information. He also submits that in any case billing 11 2705smpil4.20.odt done by the private
hospitals is subjected to audit through its own Auditors of Nagpur Municipal Corporation and therefore, in the opinion of I.M.A., no further information
is required to be provided to the Nagpur Municipal Corporation, except in cases where specific complaints of over charging have been received.
Dr.Pradeep Arora who says that he has been authorised by the Vidarbha Hospitals Association through a resolution to represent it in the Court of law
in these cases, appears online. He submits that fundamental right including privacy right of private hospitals is violated when the information regarding
80 % rate capped beds and charging of bills to these patients by hospitals is requisitioned by the Commissioner of N.M.C. He submits that the
notification dated 31.8.2021 does not authorise the nodal Authority under the Epidemic Disease Act to call for such information. He further submits
that there is no law presently available which compels the hospitals to provide such information to the N.M.C. He also submits that it is none of the
business of the N.M.C. to scrutinize the complaints of over-charging by the hospitals and if there are any grievances, those grievances must be raised
by filing appropriate proceedings in a Court of law where hospitals would be getting sufficient opportunity to defend themselves.
Since these contentions would require consideration, we direct the I.M.A. and V.H.A. to place 12 2705smpil4.20.odt in writing their stands on this
issue and we would also direct the Nagpur Municipal Corporation to submit its response on these stands so placed on record in writing by these
Associations.
Today, V.I.A. has filed an affidavit giving list of Industrial houses situated in the districts of Nagpur, Bhandara and Wardha which are willing to
make their contributions for helping Covid cause and improving health care in Vidarbha region. We request the learned Counsel for the V.I.A. to
supply the list to the Divisional Commissioner, Nagpur forthwith and thereupon, we would request the Divisional Commissioner, Nagpur to get in touch
with these willing Industrial houses for mobilising the resources from them.
The Divisional Commissioner, Nagpur and the Divisional Commissioner, Amravati have placed on record information regarding CSR funds
available with different Companies operating within their respective jurisdictions. Copies of these documents be supplied to the learned Amicus Curiae
who shall then compile the same and place it on record.
Mr.D.M.Kale, learned Counsel for respondent no.35 submits that the MSETCL is willing to make its contribution under CSR and details of the
same would be placed by him as soon as the information regarding that is received by him and it would be on or before the next date. He further 13
2705smpil4.20.odt submits on instructions that the MSEDCL has already made its contribution to the extent of Rs.1,10,00,000/-, from which twenty
ventilators have been purchased by the Government Medical College, Nagpur.
Mrs.Ketki Joshi, learned Government Pleader, on instructions, submits that NTPC, Mouda has also swung into action and it has shown its
inclination to spend some money from out of its CSR funds, provided certain information is given to it. This information is about the specific
requirement of a hospital, if possible, to enable its Management to take appropriate decision in the matter.
We are of the view that every hospital treating Covid patients and also patients of Mucormycosis is having some or the other requirement and
therefore, it may not be possible for the Collector, Nagpur to provide such information as required by the NTPC, Mouda. It may be pointed out here
that we have already made ourselves clear in our earlier order that the funds which are required to be spent under the CSR heads are for the purpose
of improvement in health care and there is also a notification issued by the Central Government on 23/03/2021, which shows that these funds can be
spent for management of Covid pandemic. So, in our view, the NTPC, Mouda, if it follows the said notification, would not be in need of any specific
14 2705smpil4.20.odt requirement of a particular hospital to enable it to take its decision in the matter. We would, therefore, suggest that NTPC,
Mouda may take a decision in this regard, without waiting for any further information, which we hope will boost our collective fight against the
dreaded Covid-19 and Mucormycosis. After all, speed in response in a fight like this is what matters, just as in a war.
We have already referred to the new SOP issued by the State of Maharashtra in treating black fungus or Mucormycosis. There are also reports
that post Covid patients are also getting afflicted with such diseases as white fungus or yellow fungus. So far there is no information placed on record
about the incidence of white fungus and yellow fungus diseases in the State of Maharashtra. Admittedly, there is also no SOP prescribed for treating
these diseases, and it would be very much needed if at all these infections afflict patients in the State of Maharashtra. We are of the view that the
State of Maharashtra would have to start preparing itself also for tackling these two new diseases. We, therefore, request the State of Maharashtra to
place on record the latest information of these diseases and also consider issuance of SOP for treating these diseases.
In our earlier order, we had directed the State to apprise us of the steps taken by it for dealing with the third wave, which if it comes, is anticipated
to be affecting more the younger generation and even 15 2705smpil4.20.odt children and so the State has to prepare itself to deal with it. As a step
towards such preparedness, more neonatal and pediatric wards would have to be created. Vaccination programme of the State would also have to be
extended to the younger generation including children. We would, therefore, like to know from the State, the steps taken by it in this regard.
Information about it may be placed on record on or before the next date of hearing. We would also request the ASGI to take instructions from the
Central Government regarding extension of vaccination programme to the younger generation including children.
Mr. S.P. Bhandarkar, learned Amicus Curiae points out that the black fungus, white fungus or yellow fungus diseases are not only the side effects
of post Covid and that there are more diseases which may develop in such patients after they recover from Covid. He submits that one of these
diseases is serious and it needs preparedness of the State. He submits that it is called Multi System Inflammatory Syndrome in children, also called
MIS-N"" in Neonatals. He submits that this disease causes impairing of heart, lungs and kidneys and therefore in anticipation of these diseases the
State Government would also have to make appropriate preparations for dealing with them. He submits that one of the steps in this direction would be
inclusion of the diseases in Jyotiba Phule Jan Arogya Scheme. 16 2705smpil4.20.odt We request the State Government to consider the anticipated
onset of MIS-C and MIS-N and their inclusion in Jyotiba Phule Jan Arogya Scheme, apart from the other steps that would have to be taken in the
matter.
At the request of learned ASGI, we extend earlier provisional Occupancy Certificate, granted to AIIMS, Nagpur for further period of fifteen days
w.e.f 01/06/2021.
Stand over to 02/06/2021 at 11:00 a.m