As the air quality fell, first to severe, then to emergency levels this week, doctors at Sir Ganga Ram hospital knew they needed to start fast-tracking patients.
“They come in, they get a nebuliser, and they go,” says Arvind Kumar, a lung surgeon at the medical facility in north Delhi.
Doctors have declared a public health crisis in the city. Dust, industrial emissions and vehical fumes have been sealed in by cool temperature and still winds.
At the same time, mass burning of crop waste across the north Indian hinterland has sent dense smoke billowing across one of the world’s most populated regions.
The air has heavy metals and other carcinogens at levels more than 30 times World Health Organization limits, conditions likened by medics to smoking at least 50 cigarettes in a day.
More than 6,000 schools have been shut and the local government has ordered traffic to be rationed next week to alleviate the crisis.
At Sir Ganga Ram hospital, beds must be freed up fast. On one morning this week, 12 patients had already arrived complaining they could not breathe.
One of them, Neela Arora, said she felt her chest begin to strain on Tuesday, just as live pollution meters posted on billboards across Delhi were reaching the limits of what they could measure.
In these conditions, even healthy people feel their throats tighten. It is involuntary: the windpipe contracts to keep toxins out. “God has given us this natural reflex,” Kumar says.
A nebuliser is relaxing the muscles in Arora’s throat and chest; steroids will reduce the inflammation. Soon she will be able to take full breaths of the same air that is making her sick. “We’re trying to blunt the natural response of the body,” Kumar says.
The veteran doctor looks exhausted. His eyes will not stop burning, he says. Even the halls of his chest surgery department are hazy with toxic air.
For children and the elderly people especially, exposure over many hours can cause the muscles in the throat and chest to spasm, what doctors describe as “asthma-like symptoms”.
Neha Bhasin’s two-year-old daughter, Landini, has developed severe bronchitis and pneumonia. “My daughter was hospitalised two weeks back,” Bhasin says. “She hasn’t stepped out of the house since.”
The child takes several steroids and uses a nebuliser each day to ward off severe coughing fits. Seven air purifiers run full-blast in the family home.
“The paediatrician is asking us to leave the city,” Bhasin says. “I’m angry, I’m helpless. We are paying taxes and doing everything the government is asking – and getting nothing in return.”
This may be the last Delhi winter they endure, she says. “We’ve been discussing moving out of the city within six months. It’s getting too much to handle.”
In the longer term, consistently poor quality air is altering the demographics of cancer in the city, Kumar says. Earlier in his career, he says about 90% of the lung cancer patients he saw were smokers. Most were men in their 50s or 60s.
“In the last two years, half my lung cancer patients have been non-smokers,” the surgeon says. “I am seeing a peak in people aged in their 40s, even people in their 30s. Our cancers are occurring earlier, more in non-smokers, and more in females.”
Indian state and central governments are impotent in the face of the crisis, says Aishwarya Sudhir, an environmental researcher. “There is a sense of hopelessness combined with helplessness.”
An action plan to curb the problem has been unevenly implemented. Diesel generators have been banned, a nearby coal-fired power station shut and fireworks have been temporarily outlawed by the Indian supreme court.
But the problem is not entirely of the city’s making. “The Nasa satellite imagery makes it clear the entire Indo-Gangetic belt is being affected,” Sudhir, the researcher, says.
Thirteen coal-fired power plants lie within a 185-mile (300km) radius of Delhi. The governments of Punjab and Haryana have failed to persuade their farmers to comply with a ban on burning crop waste.
“Depending on the direction of the wind, Uttar Pradesh, Haryana or Punjab are all contributing to the crisis in Delhi,” Sudhir says.
“Unless and until these places also have some way to curtail the local pollution being generated, there’s no way you can address Delhi’s air quality.”
The Punjab chief minister has so far declined to meet with his Delhi counterpart, asking instead for the central government to coordinate a response.
But the prime minister, Narendra Modi, seemingly unwilling to claim ownership of such a challenging issue, is yet to comment.
His environment minister, Harsh Vardhan, said on Thursday there was “no reason to panic”, adding: “Take precautions, try to stay indoors and don’t expose children to polluted air.”
With no prospect that air quality will improve next year, Kumar, the surgeon, fears Delhi residents will simply adjust. His wealthier patients are already investing in nebulisers for the home.
“People are getting used to it,” he says. “They’ll adjust, but at a high cost. Every year, weeks of exposure to these conditions will shorten their lives by several weeks.”