Fiat Chrysler looks to resume some Italian production next week: union

MILAN (Reuters) – Fiat Chrysler (FCA) (FCHA.MI) is looking to resume some vehicle production from next week at three plants in Italy if it gets the green light from the government, a union representative said on Monday.

Earlier this month, Italy banned travel within the country and ordered a freeze on all business activities deemed non-essential, including the car industry, until April 3 to curb the spread of coronavirus.

FCA informed unions last week that if the government gave it the go-ahead, the automaker would be ready to resume some of its operations on April 6, Gianluca Ficco, a representative for metal workers union UILM, said.

The sites concerned would be the assembly line for the Jeep Compass in Melfi in southern Italy, Atessa’s plant making light commercial vehicles in central Italy and preparatory operations for the new electric 500 in Turin’s Mirafiori factory, he said.

A spokesman for FCA confirmed that for now, the plan was to resume those three lines next week.

However, Ficco said he did not know whether the government would allow non-essential activities to restart then and thought Rome was more likely to extend the ban.

“In any case, when operations restart, FCA will have to make sure that the highest health and safety conditions are assured in all factories,” he said. “Safety devices will have to be increased for sure”.

Luxury carmaker Ferrari (RACE.MI), which, like FCA, is controlled by Exor (EXOR.MI), the investment firm of Italy’s Agnelli family, said on Friday it would reopen its two Italian plants on April 14, provided it had supplies.

Exor said last week that current plant closures at companies it controls, though temporary, might continue.

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Indian police officers beat up locals defying coronavirus lockdown rules in brutal video

Footage of police officers in India beating residents with sticks and forcing people who fail to comply with the government-imposed coronavirus lockdown to do squats has emerged on social media and media outlets across the world. In videos shown by Channel 4 News on Sunday, residents can be seen doing squats on the street confined in circles drawn on the floor to maintain social distancing within the group of those facing the same punishment.  

Police in western India fired tear gas to disperse a stone-pelting crowd of migrant workers defying a three-week lockdown against the coronavirus that has left hundreds of thousands of poor without jobs and hungry, authorities said on Monday.

Prime Minister Narendra Modi ordered the country’s 1.3 billion people to remain indoors until April 15, declaring such self-isolation was the only hope to stop the viral pandemic.

But the vast shutdown has triggered a humanitarian crisis with hundreds of thousands of poor migrant labourers employed in big cities such as Delhi and Mumbai seeking to head to their homes in the countryside on foot after losing their jobs.

Many have been walking for days, some with families including small children, on deserted highways with little access to food or water.

On Sunday, about 500 workers clashed with police in the western city of Surat demanding they be allowed to go home to other parts of India because they had no jobs left.

“The police tried to convince them that it is not possible since buses or trains are not available…However, the workers refused to budge, and started pelting stones at police,” Surat deputy commissioner of police Vidhi Chaudhari said.

She said the workers, most of them employed in the shuttered textile industry in Surat, were driven indoors by tear gas volleys and on Monday 93 of them were detained for violating lockdown orders.

India has registered 1,071 cases of the coronavirus, of whom 29 have died, the health ministry said on Monday. The number of known cases is small compared with the United States, Italy and China, but health officials say India is weeks away from a huge surge that could overwhelm its weak public health system.

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A health official said the large scale movement of people into the countryside risked spreading the coronavirus widely, compounding the challenge of containing the outbreak in the world’s second-most populous country.

“It’s an evolving situation with daily new challenges coming up, like having migratory populations moving from one place to another.

Like non-affected states adjoining affected states,” said Dr S.K. Singh, director of the National Centre for Disease Control, which investigates and recommends control measures for outbreaks of illness.

In the northern state of Uttar Pradesh, health workers dressed in protection suits sprayed disinfectant on a group of migrant workers who were also trying to make the journey home to their villages, local television showed.

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They were made to sit on a street corner in the Bareilly district and doused with hose pipes, prompting anger on social media.

Nitish Kumar, the top government official in the district, later said health workers had been ordered to disinfect buses being used by the local authorities but in their zeal they had also turned their hoses onto migrant workers.

“I have asked for action to be taken against those responsible for this,” he said in a tweet.

The federal government said on Monday that it had no plans to extend the shutdown beyond the three-week period.

But neighbouring Nepal announced it would prolong its shutdown for another week from Tuesday. The landlocked country has reported only five cases of the virus and no deaths, but it is concerned contagion will spread as more people travel.

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Opinion | Andrew Cuomo, Stop a Coronavirus Disaster: Release People From Prison

This is a public health crisis that threatens to become a humanitarian disaster.

By Mary Bassett, Eric Gonzalez and Darren Walker

Dr. Bassett was the New York City health commissioner. Mr. Gonzalez is the district attorney of Brooklyn. Mr. Walker is the president of the Ford Foundation.

Gov. Andrew Cuomo has been an exemplar of leadership in this time of crisis, someone to whom other state and local officials are looking for guidance. On Friday, the governor took the crucial step of ordering the release of 1,100 people from New York’s jails and prisons. But he must do more. If we don’t act fast, we jeopardize the lives of many. Worse yet, we risk creating a uniquely deadly incubator for the virus.

America incarcerates more people than any other nation on earth — some 2.3 million people, nearly 80,000 of whom are locked up in various New York correctional facilities for young people and adults. No other country in the world faces the kind of threat gathering in our jails and prisons.

Given the conditions in which incarcerated people live — limited access to soap and water; shared bathrooms, mess halls and living quarters — this population is especially vulnerable to the virus, and largely unable to prevent its spread. In New York, we’ve already begun to see the effects. Dozens of residents and correctional staff members have tested positive. More will follow.

The consequences will be devastating, for people both inside and outside prison walls. When officers and staff members who work in prisons get infected, they will bring the virus home to their families. As happened in Italy, mounting tensions inside prisons, where anxious residents no longer have access to family visits or the proper supplies to protect themselves, create security risks that will be compounded by short staffing when correctional officers fall sick.

And because of inadequate medical care in most of these facilities, people in prison who become infected will die unnecessarily, while others will be transferred to local hospitals in rural communities upstate, where most of New York’s prisons are. These hospitals are woefully unprepared for the influx of patients, adding to growing strain on our state’s health care system. Dr. Ross MacDonald, the chief physician for the Rikers Island jail complex, was not being hyperbolic when he wrote on Twitter recently: “A storm is coming.”

We have little time to curb the spread of the virus within our state’s jails and prisons, and, by extension, across our state. This is not only an issue about the health of people in prisons, but also a public health crisis that threatens to become a humanitarian disaster.

For this reason, we and a number of public health experts call on Mr. Cuomo to release as many people as possible from New York’s correctional facilities, and to ensure they have the medical and re-entry help they need when they return home.

Here are several actions Mr. Cuomo must take, in addition to ending money bail for most people charged with crimes:

First, the governor should grant compassionate release to elderly inmates, as well as those with health conditions that put them at higher risk, including people with chronic and co-morbid conditions such as asthma and chronic obstructive pulmonary disease, and those who are pregnant or have with immune deficiencies. We know that older incarcerated people are both more vulnerable to the disease and present the lowest risk of reoffending.

Second, Mr. Cuomo should release the thousands of people currently incarcerated on noncriminal technical violations of their parole, like missing an appointment with a parole officer — except in the very few cases in which a technical violation involves a risk to public safety. There are some 4,000 people incarcerated in New York prisons for such non-crimes. Only the governor has the power to release these people — and 50 current and former parole commissioners around the country already have recommended he do so.

Third, he should grant early parole to people who are up to 180 days away from completing their sentences. After all, they’re coming home in weeks or months.

And, finally, the governor should direct prison and jail administrators to furlough low-risk inmates and use his own emergency powers to extend those furloughs through the end of the crisis.

Mr. Cuomo has often noted that our state does not need public policies that only “sound good,” but rather ones that are “good and sound.”

There is no good reason to keep putting residents, as well as police and correctional officers, at risk — or to turn a parole violation into a death sentence. Why needlessly strain our state’s systems or incubate the virus inside correctional facilities for future spread? There is no sound reason that elderly and vulnerable people, who pose no threat to the public, should be sentenced to die in prison.

We must protect public safety. But, today, there is no greater threat to public safety than the coronavirus. There are hundreds, if not thousands, of incarcerated people in New York who can safely be released to their families and communities.

Mr. Cuomo alone holds the power to save the lives of people trapped in New York’s prisons and jails. We call on him to build on the important step he has already taken and do the good and sound thing for human dignity, public health and a more humane justice system.

Mary Bassett (@DrMaryTBassett) is the director of the François-Xavier Bagnoud Center for Health and Human Rights at Harvard. Eric Gonzalez (@BrooklynDA) is the district attorney of Brooklyn. Darren Walker (@DarrenWalker) is the president of the Ford Foundation.

The Times is committed to publishing a diversity of letters to the editor. We’d like to hear what you think about this or any of our articles. Here are some tips. And here’s our email: [email protected].

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Exclusive: American Airlines in talks to hire Millstein for aid advice

NEW YORK (Reuters) – American Airlines Group Inc (AAL.O) is in advanced talks to hire Guggenheim Securities co-chairman James Millstein for advice on tapping a $50 billion industry relief package available from the U.S. Treasury Department to cope with the coronavirus pandemic, people familiar with the matter said.

Millstein is one of Wall Street’s most seasoned debt restructuring bankers and from 2009 to 2011 was the chief architect of the Obama administration’s overhaul of certain financial firms the government had bailed out, including insurance giant American International Group Inc (AIG.N).

While American Airlines has said it has not yet decided whether it will seek U.S. government aid, Millstein’s anticipated appointment indicates the largest U.S. airline is actively preparing for such a move and girding for negotiations with Treasury officials.

Coronavirus relief legislation enacted last week provides up to $25 billion in loans and loan guarantees for U.S. airlines that have suffered from an unprecedented decline in passengers, with an additional $25 billion available in direct cash grants that could result in the U.S. government receiving ownership stakes in the companies.

Were Millstein to be hired, he would be advising American Airlines on the form and terms of aid it should pursue and how to navigate the U.S. Treasury Department’s process for requesting the financial assistance, the sources said. Advice given to the Fort Worth, Texas-based company would be done in his own capacity, independent of Guggenheim, the sources added.

The sources cautioned that no decision on American Airlines accepting U.S. government aid had yet been made and requested anonymity to discuss the confidential preparations.

American Airlines declined to comment, while Millstein did not respond to a request for comment.

American Airlines said last week it would be slashing its capacity 60% in April compared with the same period a year ago and up to 80% in May due to a dramatic reduction in customers and travel restrictions to curb the spread of coronavirus. Its shares have lost roughly half their value in the last five weeks, giving it a market capitalization of about $6 billion.

The company disclosed this month it had access to more than $7.3 billion of liquidity. Its long-term debt as of the end of December totaled about $23.9 billion.

American Airlines Chief Executive Doug Parker said last week that the company would be eligible for up to $12 billion in total U.S. aid. He added that combining government relief with a “relatively high available cash position” would “allow us to ride through even the worst of potential future scenarios.”

Some terms of the cash grants “aren’t currently well defined,” Parker said, adding that the company was not yet certain it would meet the conditions necessary to receive those funds. He said he expected the aid terms “will not be onerous.”

Millstein, a former Lazard Ltd (LAZ.N) banker, has worked on bankruptcies and other challenges facing many U.S. conglomerates over the last two decades, including representing unionized workers in labor negotiations with General Motors Co (GM.N) and other automakers.

Millstein sold his restructuring advisory firm to Guggengeim in 2018. He most recently advised Puerto Rico on its debt woes, as well as California on how to best grapple with catastrophic wildfires and the bankruptcy of power utility PG&E Corp (PCG.N).

Millstein worked with Parker when he advised US Airways on its merger with American as part of the latter’s bankruptcy reorganization in 2013. Parker was CEO of US Airways before assuming the same role in the combined company.

POTENTIAL STRINGS ATTACHED

Should American Airlines seek government aid, it may be forced to accept conditions. Requirements for airlines receiving cash grants include continuing to fly in and out of all U.S. airports that currently have commercial air service, and agreeing to avoid involuntary furloughs of employees, both through the end of September.

The aid would also include restrictions on executive compensation and stock buybacks, as well as suspension of dividend payments. Similar strings are attached to government loans.

United Airlines Holdings Inc (UAL.O) and Delta Air Lines (DAL.N), the other two largest U.S. carriers, have expressed cautious optimism about the government assistance, while warning further measures would be required to stabilize their businesses.

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Coronavirus: Spain surpasses China COVID-19 cases as deaths rise to 7,340

Spain has become the third country to confirm more cases of coronavirus than China – as its number of deaths rose by 812 in a day to reach a total of 7,340.

Confirmed COVID-19 cases have increased by 6,398 since Sunday to reach 85,195 in total, Spain‘s health ministry said.

The country has now joined the United States and Italy in having more coronavirus cases than China, which had confirmed 82,156 cases as of Monday.

At midday on Monday, a minute’s silence was held in Madrid, Spain’s hardest hit city, for those who have died as an adagio was heard in one of the capital’s best known squares, Puerta del Sol.

Monday’s figures for those who have died in Spain were slightly less than Sunday, when 838 people died – the highest number yet for the country.

Authorities stepped up the country’s 15 day lockdown on Monday, with a new two week period of “hibernation” to alleviate pressure on the healthcare system, a Spanish Cabinet member said.

Only workers in hospitals, pharmacies, the food supply chain and other essential industries are allowed to work until the end of Easter, in mid-April, while everyone else has been asked to stay at home and scale back their work.

Spain’s government has ordered that flags be flown at half-mast and a minute’s silence be observed every day to pay respects to those who have died.

With a population of 47 million compared to China’s 1.14bn, Spain’s healthcare system is struggling to cope with the number of seriously ill patients at once, with hotels converted into makeshift hospitals and a Madrid ice rink turned into a temporary morgue.

At least six of Spain’s 17 regions have reached their limit of ICU beds, with three more close as Madrid started using a convention centre as a hospital and field hospitals continue to be frantically built.

Also on Monday, a health official said Spain’s health emergency chief, Fernando Simon, had tested positive for COVID-19. He is leading the country’s coronavirus response and is in regular contact with Prime Minister Pedro Sanchez.

Health official Maria Jose Sierra, who replaced Mr Simon at a daily news conference, said Spain’s trend in daily infections had changed since a lockdown was imposed on 14 March, with new infections now rising at about 12% a day over the past five days instead of the previous 20%.

She also announced 12,298 health workers in Spain have tested positive for coronavirus – about 14% of the country’s cases, roughly the same proportion as last week.

Spain and nearby Italy account for more than half the world’s 34,000 coronavirus deaths, with Italian officials cheering when they reported only 756 deaths in one day on Sunday.

Italy has reported 97,689 infections and 10,779 deaths so far, but on Sunday said the number of confirmed cases had increased by only 5.4% in the past 24 hours and deaths had decreased by about 10% a day since Friday.

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EU double recession warning: Bloc poised for second crash AFTER coronavirus crisis

As Europe is the epicentre of the coronavirus outbreak, countries across the EU have gone into lockdown – including some of the bloc’s biggest economies. This has brought economic activity to a halt and provoked drastic measures from the European Central Bank as it bids to save the euro. President of the ECB – Christine Lagarde – launched a huge bond-buying programme earlier this month worth £680billion as she looked to stimulate the European economy.

But Professor Iain Begg tells Express.co.uk that the move, if done without necessary caution, could lead to a second economic crisis.

He said: “It is a return to a practice the Fed, the Bank of England and later the European Central Bank used to deal with the financial crisis.

“It is simply a monetary instrument being used to stimulate the economy. With interest rates so low, the ECB has no other option but to pump money into the economy.

“The danger is if you pump too much money in, two thousand years of history tells us that leads to inflation.

“But inflation in the short term is not the problem, we may not even need to worry about it for quite some time.

“There is some view is that if you have a monetary stimulus on this scale, it diminishes the profitability of banks because they can’t charge as much interest and that in turn undermines their safety.

“Therefore there is risk of a financial crisis as a response to the previous financial crisis – in this case the coronavirus pandemic.

“But that’s speculation rather than certainty.”

The UK has dealt a similar response to the coronavirus crisis, pumping upwards of £600billion into the economy while also dropping interest rates to just 0.1percent.

The Bank of England warned: “The spread of COVID-19 and the measures being taken to contain the virus will result in an economic shock that could be sharp and large, but should be temporary.”

However, Professor Begg also highlights how the EU has become divided as a result of the ECB’s measures, as German banks feel they may be forced to share damage with Southern Europe as happened in 2008.

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The economist added: “In political terms there has been a strong resistance, especially from Germany and some of the other creditor countries inside the eurozone to this action by the European Central Bank.

“It was very much seen in the days of Mario Draghi (former President of the ECB) as something he was doing as it suited Italy, and was against the German ethos of having monetary stability.

“So you might see that kind of objection resurfacing not immediately, but a few months down the line you could see opposition to what Christine Lagarde did from German sources.”

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RPT-GRAPHIC-Three months that shook global markets

(Repeats story from Sunday)

By Marc Jones

LONDON, March 29 (Reuters) – How much damage has the coronavirus and the oil price collapse inflicted on global financial markets this year? Put simply, it has probably been the most destructive sell-off since the Great Depression.

The numbers have been staggering. $15 trillion has been wiped of world stock markets, oil has slumped 60% as Saudi Arabia and Russia have started a price war and emerging markets like Brazil, Mexico and South Africa have seen their currencies plummet more than 20%.

Volatility and corporate borrowing market stress has spiked on worries that whole sectors could go bust, airlines have had half their value vaporised, while cratering economies risk a new wave of government debt crises.

“It has been like a train wreck,” Chris Dyer, Director of Global Equity at Eaton Vance, said. “You could see it coming and coming and coming, but you just couldn’t stop it happening.”

That carnage has seen 22% and 24% slumps for Wall Street’s Dow Jones and S&P 500, almost 25% for MSCI 49-country world index and 27% for London’s internationally exposed FTSE.

For reference, the record quarterly drop for Wall Street was 40% in 1932 in the midst of the Great Depression. The fact that the S&P and Dow were at record highs back in mid February has made the crash this time seem more brutal.

Stocks in China, where the virus hit first, have faired relatively well in comparison with only an 11% drop in dollar terms, but the impact on other major emerging markets has been devastating as their main commodity markets, and currencies, have also collapsed.

Russian stocks, which topped the tables last year, have been routed 40% in dollar terms. South Africa, which was stripped of its last investment grade credit rating on Friday, has fallen by the same percentage, though Brazil has been the worst, plunging 50%.

A large part of that is down to some wild FX market moves. All three of those countries have seen their currencies lose over 20% this year, which also ties in to the commodity market carnage.

Brent crude oil has fallen by 62% in the quarter to just $25 a barrel. This was not only because of the coronavirus crisis, but also the price war between Saudi Arabia and Russia, which is putting their public finances at risk.

Industrial metals like copper, aluminium and steel have all dropped 15-22% and some agricultural staples like coffee and sugar are down 17% and 10%.

“These are truly historical moments in the history of financial markets. 2020 will go alongside 1929, 1987 and 2008 in the text books of financial market panics,” Deutsche Bank Strategist, Jim Reid, said.

GIVE ME SHELTER

So are there any places to shelter? Yes, but not many.

Sit-on-your-sofa-suited stocks like Netflix and Amazon have risen 10% and 2.5% respectively and some specialist medical equipment companies have surged.

Ultra-safe U.S. government bonds have returned 13% as the Federal Reserve cut U.S. interest rates to effectively zero, leading a charge of around 62 interest rate cuts globally.

The dollar has rocketed against emerging market currencies. It had also shot up against the majors too, but has eased back over the last two weeks and will end the quarter only 2% up against those bigger currencies.

This has left the Japanese yen, the other traditional FX safe-haven, with only a 0.4% gain. The Swiss franc is down against the dollar, although it has climbed steeply against the euro and many other currencies.

Will April bring much relief? JPMorgan reckons the coronavirus will have pushed the world economy into a 12% contraction in Q1 and with pandemic still spreading rapidly and keeping large parts of the global economy shuttered it is unlikely to get much easier in Q2.

The cavalry has arrived though. G20 governments have promised a $5 trillion revival effort, major central banks have cut rates and restarted asset purchases. Markets bounced big last week until Friday came and may still end Q1 on a relative high.

Stephane Monier, Chief Investment Officer of Lombard Odier, is looking to see whether infection rates in Europe and elsewhere peak as they did in Asia. If they do, markets could see a V-shaped 30% recovery, although if they do not and cases jump in Asia again as lockdowns are lifted, it could be akin to a “war” situation which would impact the economy for 1-1/2 years.

“Our expectation is for a very volatile second quarter,” Monier said. “It is important to keep in liquid, high-quality assets.”

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India's COVID-19 lockdown hits HIV+ and chronic patients hard

HIV+ and other patients with critical conditions face problems in accessing health services amid strict lockdown.

On the morning of March 26, the third day of lockdown in India’s capital over coronavirus fears, 15-year-old Himanshu’s mother tried to board a state-run bus to collect her son’s medicines for HIV from a government-run hospital.

It was her scheduled day to pick up the monthly anti-retroviral therapy (ART) drugs, the HIV-suppressing drug that has to be taken lifelong, provided free of charge to patients registered with government hospitals.

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But with strict travel restrictions in place, the conductor did not allow her on the government-run bus, despite her furnishing the “green book” provided by the Kalawati Saran Children’s hospital located in central New Delhi’s Gole Market area.

Himanshu’s father volunteered to go by bicycle to pick up the drugs instead, but a policeman stopped him and turned him back, as well.

“Sometimes, the Delhi police see your hospital book and let you go. But sometimes, they will see the word HIV and chase you,” says Loon Gangte, co-ordinator of the Delhi Network of Positive People – a collective that works for people living with HIV.

“It is the term HIV. They think we are all sex workers and drug addicts. Yesterday [March 25], police beat up one of our outreach workers who was trying to organise. There is still prejudice even though it is now against the law to discriminate against persons with HIV.”

HIV-positive people

India is believed to be home to the third-largest population of HIV-positive people in the world. There are 21.4 million Indians living with HIV, according to the National Aids Control Organisation data in 2017.

The Indian government provides ART to all HIV+ people registered in government hospitals, most of whom are overwhelmingly the poor and rely on public transport.

But public transport across the country, including metro rails, taxis as well as buses, have been banned as Indian Prime Minister Narendra Modi imposed a lockdown on Wednesday and urged people to maintain social distancing to prevent the spread of coronavirus that has killed more than 30,000 people worldwide.

The move seems to be taking a toll on the HIV-positive people along with other patients with chronic conditions.

The government clarified that people would be allowed to go out for essential supplies, including groceries and medicines, without being asked for documentation to prove the nature of their trip. 

Many patients, who live in smaller towns or rural areas but are registered with the government hospitals in cities are finding it difficult to travel amid the ban on public transport. Many were forced to use private transport, such as cycles or motorbikes to travel.

Himanshu’s parents, who live in a working-class neighbourhood of Jahangirpuri in New Delhi, eventually walked to the hospital and walked back home, 19km (11.8 miles) on foot each way. 

“I have applied to the police for a traffic permit. I want to be able to reach them on my bike when the police stops anyone,” Gangte said.

“But the lines at the police station are so long, the first day it was almost two kilometres (1.25 miles) long. I came away because I am already immune-compromised; HIV itself means immunity deficiency. But when my outreach worker was beaten, I decided to brave the crowds to apply for the permit.”

Lack of planning

Critics have accused the government of imposing the lockdown for 1.3 billion people without proper planning.

Over the past week, social media has been full of imagery and stories of policemen beating up vendors, smashing shops, deflating the tyres of vendor carts. In one striking photograph, a policeman is beating a person with a lathi while speaking on the phone.

Tens of thousands of migrant workers have been stranded in cities following the shutdown of businesses and factories, with many walking hundreds of kilometres to reach their homes amid lack of transport.

Modi addressed the nation twice in the past 10 days but failed to spell out specifics of how people are to manage their essential needs during the 21-day lockdown period, in particular, people with special needs and chronic conditions, who need regular access to medicines, diagnostic tests and other healthcare.

A government circular listing released after PM’s speech last Tuesday failed to mention support services for chronic patients. There were no directives on the vast numbers of health personnel who work in small concerns or provide home services and lack company ID cards.

What has followed is confusion, delays and anxiety.

Naresh Lama, husband of a cancer patient

Mary Lama* (name changed), an HIV-positive patient diagnosed with cancer of the tongue, has been advised a number of tests before her surgery initially scheduled for early April.

This week, she received an SMS informing her that her MRI appointment was delayed minutes before she was about to leave home for it. Her calls to the laboratory received a standardised response that all tests were delayed by the lockdown.

“I am unable to contact her doctors at the hospital to tell them about the tests, and the treatment is also delayed,” said Naresh Lama, Mary’s husband.

“Will the cancer not spread without treatment?” There are 1.6 million living with cancer as of 2018, according to Indian government data.

Auto-immune and rare conditions

Karishma Khemlani, who describes herself on her Twitter as a person with 17 incurable conditions, is used to planning ahead because she cannot afford to take chances.

It is a preparedness for crises developed over 17 years of living with auto-immune and rare conditions. A week before the Janta Curfew (public curfew last Sunday), she placed an order for her immunosuppressant drug CellCept at her local pharmacy. These drugs are specialised, lifesaving and rarely available without order. But as March 22 drew near, her pharmacy and all the pharmacies in her locality in Andheri, Mumbai, was unable to deliver the drug.

Khemlani is an enterprising social media activist and a tweet about running out of medicines was retweeted several times. Eventually, a journalist with a press pass scoured the city, and secured supplies for her. 

There is little data available on patients with rare, chronic conditions like Khemlani’s. The government estimate relies on a global statistic – 6 to 8 percent of the population has rare diseases – the population of 1.3 billion A sudden lockdown like this may have left many without stocks of their hard-to-source medication.

In other places, drugs are available, but transport is not. An official of the pharmaceutical giant Novartis, who did not want to be identified, said immunosuppressants are available at their centre in the eastern city of Kolkata, but patients have to travel to collect medicine that their agents and courier companies would normally have delivered.

Immunosuppressants are a lifeline for organ transplant patients. India maintains no national organ transplant registry, and data is, therefore, based on projections.

The government’s own undated estimate is that 6,000 kidney, 1,500 liver and 25,000 corneal transplants are performed annually, in addition to much smaller numbers of heart and lung transplants. All transplant patients require immunosuppressants to ensure their bodies do not reject the transplanted organs. 

“We could quickly be facing a non-COVID humanitarian crisis if the government fails to act to restore health services, particularly for those with critical conditions that require sustained medication/treatment,” said Malini Aisola, public health activist and co-convenor of the All India Drug Action Network.

“Measures can be put in place, such as stringent infection control protocols and triaging systems, to make the necessary care available. As sound public health policy, the government should be concerned with meeting needs of special groups because they are in fact more vulnerable and risk worse outcomes in the event of COVID-19 infection due to lower immunity and preexisting conditions. Unfortunately, from the stories emerging, the government seems to be lurching from crisis to unfolding disaster.”

Kidney transplant patients

The stories of kidney transplant candidates dealing with exhausting trips to hospital for their weekly dialysis appointments have been reported from Mumbai and the southern city of Chennai.

Sejal Jobanputra, a chronic kidney disease patient who lives in Kandivali in Mumbai city, said her Whatsapp group of kidney patients all spoke of long strenuous, and sometimes harassed, trips to hospital as some policemen did not understand why they were travelling, even after they showed their hospital records. Other policemen, however, were helpful.

“I realised I am lucky among them because my hospital is also in Kandivali,” said Jobanputra, over a chat on Whatsapp. A phone conversation was not possible because she suffers from hearing impairment.

Malini Aisola, public health activist and co-convenor of the All India Drug Action Network

“But it is exhausting for me to stand for even 10 minutes. Policemen kept directing me to the bus-stand, but it is physically impossible. I went back home, and rescheduled my appointment. My family will drop me to hospital.”

India has 34 million patients in need of dialysis as of 2018, according to the national dialysis registry, with 220,000 patients added every year.

Although age is not a chronic disease, the elderly are also left vulnerable in the lockdown. There is no government data available, but an estimate by the home healthcare service venture Medwell suggested that India has the second-largest geriatric population in the world, numbering 104 million.

Medwell defined geriatric as those over the age of 60, and estimated home healthcare services to be $1.5bn market in India, mainly providing care for chronic conditions at home.

Home healthcare workers have been severely affected by the closure of transport services, especially as they often do not possess company identification cards stating they are health workers. 

This leaves many of the elderly, who live alone and are sick, without essential support.

Even those who live with family face the real possibility of dying without medical help. 

On Thursday, journalist Joanna Lobo tweeted to the chief minister of Goa state about her grandmother, Lourdes Lobo, in the village of Camurlim, who is 111 years old.

She had taken a turn for the worse during the previous weekend as the state went into lockdown. 

No doorstep medical assistance was available, no grocery stores were open, and her parents who live nearby were unable to step out of their homes. The family increasingly prepared for the traumatic possibility that the old lady might pass away at home without any assistance.

“At least my aunts are with gran,” said Lobo. “There are octogenarians who live alone in our village. I wonder how it is for them.”

The special secretary in the Delhi government’s health and family welfare department, the principal secretary of the country’s health and family welfare department and the National Aids Control Organisation did not respond to emails before the time of the publication of this article.


101 East

India: The Child Sex Highway

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Trump Said He Was the President of Manufacturing. Then Disaster Struck.

For a leader who has embraced the language of a wartime president, it is as if the Pentagon asked for missiles and bombers but wouldn’t say how many or where they should be delivered.



By David E. Sanger and Maggie Haberman

When President Trump came to office, he promised a new day with America’s manufacturers, casting himself as the first president who understood their needs. He toured factory floors, often handing out his signature “Make America Great Again” hats.

Yet in the first national crisis that required harnessing American manufacturing ingenuity and ramping up production of ventilators, perhaps the most crucial piece of equipment for patients in crisis, the White House’s ability to gather the power of American industry crumpled.

It was unable to communicate how many ventilators it would need or how quickly it would need them. Mr. Trump set states off on a mad scramble to find their own, leading to bidding wars against one another. Even today it is unclear who is deciding where the new American production will be directed — to the highest bidders or to the cities that need them most.

A week after praising General Motors and a small ventilator manufacturer, Ventec Life Systems, for their voluntary efforts to combine cutting-edge technology with G.M.’s expertise at supply chains and mass production, the president blew up at the world’s largest carmaker, accusing its chief executive, Mary T. Barra, of moving too slowly and trying to “rip off” the federal government. In fact, G.M. and Ventec had already signed a partnership — without government help — to ramp up production.

Interviews with White House officials, industry executives and outsiders who tried to intervene make two problems clear. Mr. Trump’s first mistake was recognizing the problem far too late, even though his own medical experts had identified a probable shortage of ventilators as a critical problem in late January, as panic set in that the virus was headed to the United States. Had the president acted sooner, thousands of new ventilators would probably be coming off production lines next month, when they are likely to be desperately needed.

And even after the problem was recognized, and the president’s son-in-law and senior adviser, Jared Kushner, took over the process, both the White House and the Federal Emergency Management Agency struggled to define what was needed, who would pay for it and how to solve the problem of supply chains that stretched across more than a dozen countries.

“We’re going to have plenty,” Mr. Trump said Friday afternoon, declaring that he was invoking the Defense Production Act, a Korean War-era law, to force the companies to make more. But he gave no numbers — and glided past the complexities of getting between 700 and 1,500 components from more than a dozen nations.

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Opinion | The Psychological Trauma That Awaits Our Doctors and Nurses

Don’t underestimate the moral anguish of deciding who gets a ventilator.

By Jennifer Senior

Opinion columnist

This is the moment to pray for the psychological welfare of our health care professionals. In the months ahead, many will witness unimaginable scenes of suffering and death, modern Pietàs without Marys, in which victims are escorted into hospitals by their loved ones and left to die alone.

I fear these doctors and nurses and other first responders will burn out. I fear they will suffer from post-traumatic stress. And with the prospect of triage on the horizon, I fear they will soon be handed a devil’s kit of choices no healer should ever have to make. It’s a recipe for moral injury.

Succinctly put, moral injury is the trauma of violating your own conscience. It is an experience known to many combat veterans — the term was in fact popularized by Jonathan Shay, a longtime psychiatrist at a Department of Veterans Affairs outpatient clinic in Boston, in his book “Achilles in Vietnam.”

That this violation may be in the service of a larger, more defensible objective doesn’t matter — or rather, it does little to mitigate the guilt, self-reproach or spiritual crisis activated by making choices that feel so very wrong.

Moral injury is now a looming reality for our front-line medical professionals, should they be forced to ration ventilators or other lifesaving resources. This is not why most of them went to medical and nursing school. “It’s something none of us have been trained for, except perhaps military physicians,” Dr. R. Sean Morrison, chair of geriatrics and palliative medicine at the Icahn School of Medicine at Mount Sinai in New York, told me. “There’s a tremendous amount of worry about what it’ll feel like in the moment.”

An article published on March 23 in The New England Journal of Medicine estimates that the number of American patients who will require ventilation for the coronavirus could be as high as 31 per machine. A New York hospital, according to The Washington Post, is already putting two patients at a time on ventilators designed for one.

Triage, in other words, is probably inevitable.

Twenty-first century doctors in wealthy countries have no scripts for this. But there are resources emerging. Morrison pointed me to an astonishing website run by VitalTalk, an organization that under ordinary circumstances specializes in helping doctors communicate clearly and compassionately about serious illness.

It has a brand-new set of talking points for the coronavirus, including rationing. Morrison said it’s what the health care professionals at Mount Sinai will be referring to, should things get dire. And they’re utterly surreal.

Patient family: You’re playing God. You can’t do that.

Clinician response: I am sorry. I did not mean to give you that feeling. Across the city, every hospital is working together to try to use resources in a way that is fair for everyone. I realize that we don’t have enough. I wish we had more. Please understand that we are all working as hard as possible.

Patient family: Can’t you get 15 more ventilators from somewhere else?

Clinician response: Right now the hospital is operating over capacity. It is not possible for us to increase our capacity like that overnight. And I realize that must be disappointing to hear.

Patient family: How can you just take them off a ventilator when their life depends on it?

Clinician response: I’m so sorry that her condition has gotten worse, even though we are doing everything. Because we are in an extraordinary time, we are following special guidelines that apply to everyone here. We cannot continue to provide critical care to patients who are not getting better. This means that we need to accept that she will die, and that we need to take her off the ventilator. I wish things were different.

New York State does, in fact, have guidelines for ventilator allocation, written in 2015. They recommend that hospitals appoint triage officers or committees — made up of experts who do not have clinical responsibilities for the patients at issue — to make the difficult calls, thus easing the moral burden on the men and women on the ground. Who does and doesn’t get a ventilator, and for how long, will depend on a range of criteria, from the overall health of the patient to how well the patient is doing at that particular moment.

I’ve spoken to a number of doctors who said they’re comforted by these guidelines. There are clear rules to follow.

But Stephen Xenakis, a psychiatrist and retired brigadier general who has spent decades treating veterans, says that rules aren’t sufficient to inoculate first responders from psychological suffering.

“We have rules too, in the military,” he told me. “Rules of engagement. And you may follow the rules of engagement, and everyone around you may say that you followed the rules of engagement. But after the incident occurs, you ask yourself, ‘Did I make the right decision?’ Because the outcome was not acceptable, was not digestible.”

Or it’ll be something even more nuanced than that. The outcome may be acceptable — that is, reconcilable — in the moment. But not later on.

Xenakis gave an example of a doctor who removes a 70-year-old patient from a ventilator. The man’s children are pleading. But the if-then of the algorithm requires it. A decade later, that doctor’s own father is 70. And it hits her, hard: Did she really make that decision?

“The angst that clinicians may experience when asked to withdraw ventilators for reasons not related to the welfare of their patients should not be underestimated,” warns the authors of the article in The New England Journal of Medicine. “It may lead to debilitating and disabling distress.”

We look at veterans and thank them for their service, never being able to fully comprehend what they’ve been through. The same may soon be true of some of our health care professionals. We may think we know. But we don’t.

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