NEW DELHI (NYTIMES) - The shifts are long, the wards full, the demand so urgent that medical students and interns have been coaxed into filling in. Hundreds of workers have died. Family members at home have fallen ill.
India's doctors and other medical responders find themselves short-handed and underfunded as they battle the world's worst coronavirus outbreak.
Beyond the physical danger they also face, they have been forced by the devastating size of the outbreak and the government's mismanagement of the crisis into cruel routines of helplessness, making decisions day after day that could determine whether a patient lives or dies.
As beds fill up, they have to choose who among the throngs outside the hospital gates to allow inside for treatment. As the oxygen runs out, they have to choose who gets precious supplies. The emotional toll is mounting.
"All your life you prepare yourself to exhaust every option to save a patient, but imagine when you have to prioritise?" said Dr Mradul Kumar Daga, a professor of medicine at the largest Covid-19-designated hospital in New Delhi.
"Those are the most heartbreaking decisions as a doctor you have to make. And that is what has happened in the last three weeks of my life."
India's second coronavirus wave is killing thousands of people a day, and the country's front-line medical workers have shared in the cost.
The Indian Medical Association said more than 1,000 doctors have died from Covid-19 since the pandemic hit last year, with a quarter of those dying since the beginning of last month alone, said Dr J. A. Jayalal, the organisation's president. He estimated at least 40 per cent of doctors have been infected. Recent data on other medical personnel was not available.
The country's health care providers work amid an inadequate and deeply unequal medical system. According to the World Bank, India's healthcare spending, public and out of pocket, totals about 3.5 per cent of its gross domestic product, less than half of the global average.
They also face intimidation and violence, with videos circulating of angry family members thrashing medical staff in hospital halls covered in blood, or local strongmen bullying and scolding them.
"Everybody who comes is tense, and even a small issue sparks a big fight and the people are not understanding of the situation," Dr Jayalal said. "Unfortunately, health care professionals have been asked to manage all this." Nothing has underscored their helplessness more than the sometimes avoidable death of their own colleagues in front of their eyes.
Dr R.K. Himthani, the head of the gastroenterology department at the Batra hospital in New Delhi, became one of 12 victims when the hospital ran out of oxygen for 80 minutes early this month. Dr Himthani had treated Covid-19 patients for 14 months before he and his wife were infected.
As the oxygen ran out, Dr Shiv Charan Lal Gupta, the director of the hospital and a friend of Dr Himthani for three decades, ran up and down the hallways sending messages to government officials, media outlets and anybody who might help.
In their masks and gowns, the hospital staff gathered with teary eyes and folded arms at the main gate to pay their final respects as Dr Himthani's body was wheeled out. Then they went back to work.
"The oxygen did arrive, but we couldn't save those 12 lives, including my friend," Dr Gupta said. "We are feeling so empty and helpless from the inside these days." He added: "I have not slept for a long time."
India was already short-staffed in health care. India had about 17 active health workers - doctors, nurses and midwives - per 10,000 people, according to the Indian Institute of Public Health-Delhi and the World Health Organisation (WHO). That is far below the WHO's threshold of 44.5 trained health workers per 10,000.
The distribution is unequally concentrated in urban centres. About 40 per cent of health care providers work in rural areas, where more than 70 per cent of India's population lives. Bihar, one of India's poorest states, has only 0.24 beds per 1,000 people, less than one-tenth of the world average.
"When I close my eyes, I feel someone needs my help," said Ms Lachhami Kumari, a nurse at a government hospital in the Rohtas district of Bihar, one of India's poorest states. Her 80-bed facility has been overwhelmed by critical Covid-19 patients.
"When I manage to fall asleep, I see people all around, begging for help. That has kept me going." At another government hospital in Patna, Bihar's capital city, Dr Lokesh Tiwari said almost half of the doctors and paramedic staff have lost family members.
He said the 400 beds in the general ward, and the 80 intensive care beds, remain full around the clock. Doctors and nurses have broken down so often that the hospital has started providing counselling services to its staff and their families.
"When you see people walking fine and suddenly collapsing and dying in one hour, it has an impact on your mental health," Dr Tiwari said.
In a sign of the second wave's toll on medical staff, Prime Minister Narendra Modi recently announced extraordinary measures to address the worker shortage. He called on officials to reach into the pool of tens of thousands of final year medical students and medical interns for Covid-19 duty, offering monetary packages and priority treatment in future government recruitment.
"We are sent right into the high of the tornado," said Dr Alisha Akhani, a 22-year-old medical intern who has been doing Covid-19 shifts in Anand district, in the state of Gujarat.
"The times are difficult, the times are uncertain. But we will come out as better doctors."
Dr Akhani has worked mostly night shifts in the intensive care unit, which has 40 beds. When the shift ends at 8am, she drives to her hostel, eats a quick breakfast and showers before trying to get a few hours of sleep. Between shifts, she listens to music and exercises - a badminton game or a quick run - to clear her head.
She also needs to find time to study for her placement exam after her year-long internship is over.
Some nights, as many as five patients die, she said. The deaths that are most difficult for the staff, when they are the most emotionally drained, happen around dawn.
Sometimes, the loss hits close to home. Dr Akhani said one patient, a 50-year-old woman, was a relative. As she weakened, Dr Akhani had to call the woman's husband.
"We were not sure if she was going to make it through the night," Dr Akhani said. "I had to call her husband to say she might not make it, that it would better if you call your kids and be with your family during this time."
Sometimes families ask the doctors for help to say goodbye.
At a hospital in the eastern city of Kolkata, one man, Mr Soham Chatterjee, asked the doctors if they could arrange a final video call with his dying mother, Sanghamitra Chatterjee, a 48-year-old psychologist and music teacher.
As the doctor held the phone and nurses gathered around, Mr Soham Chatterjee sang his mother a Bollywood song from the 1970s, choking on the verses. It is a song she sang to him when he was upset, he told The New York Times. Mother and son would also duet at dinners and family gatherings.
It's like we knew each other before, a heart isn't won just like that. Both of us will continue meeting, that is the promise I make this evening.
"I just stood there holding the phone, looking at him looking at his mother and singing," the doctor, Dipshikha Ghosh, said on Twitter. "He asked her vitals, thanked me and hung up."