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Sirens of Survival: Transforming Ambulance Response Times in India’s Megacities

Sirens of Survival: Transforming Ambulance Response Times in India’s Megacities

 

India’s megacities like Mumbai and NCR struggle with ambulance response times of 15-30 minutes, far behind the world-class 8-9 minute benchmark, costing lives with out-of-hospital cardiac arrest (OHCA) survival at 5-7% versus 20-40% in cities like Seoul or London. Chennai leads India at 12-15 minutes, driven by the 108 service, motorcycle ambulances, and public-private partnerships (PPPs). Hyderabad, Ahmedabad, Bengaluru, Pune, and Indore also excel, leveraging AI dispatch and community training. Global LMIC successes like Belo Horizonte, Kigali, and Jakarta halved response times in 10-15 years through tech, policy, and low-cost innovations. Mumbai and NCR need doubled fleets (800-1,200 ambulances) and ₹500-1,000 crore investments to hit 12-15 minutes in 5-7 years. Chennai can reach 10-12 minutes by adopting Kigali’s drones and Jakarta’s flood-resilient vehicles. Strategic reforms can save thousands of lives and cut hospital costs significantly.

 

The Urgent Pulse of India’s Urban Crisis

In the heart of Mumbai’s rush-hour chaos, a cardiac arrest patient waits as an ambulance battles gridlock, its siren fading amid honking traffic. Each minute of delay slashes survival chances by 7-10% for out-of-hospital cardiac arrest (OHCA) [1]. India’s megacities, like Mumbai and NCR, average 15-30 minute response times, a stark contrast to global leaders like Tokyo (6.5 minutes) or London (7 minutes) [2, 3]. “Time is the lifeblood of EMS; India’s delays are a silent epidemic,” says Dr. Junaid Razzak, a global EMS expert [4]. This essay explores the metrics, global benchmarks, cost implications, and transformative potential of EMS in India, spotlighting Chennai’s leadership alongside Hyderabad, Ahmedabad, Bengaluru, Pune, and Indore. Through case studies of LMIC successes—Belo Horizonte, Kigali, Jakarta, and Indian cities—it charts a path for Mumbai, NCR, and Chennai to leap toward world-class standards, saving lives and redefining urban healthcare.

 

Defining Efficient Ambulance Service: Metrics and Global Standards

Efficiency in emergency medical services (EMS) hinges on response time—the interval from call receipt to ambulance arrival—for life-threatening (Priority 1) calls like cardiac arrest, trauma, or stroke. The global standard, rooted in Seattle’s 1970s studies, is 8 minutes 59 seconds for 90% of Priority 1 calls, per the National Fire Protection Association (NFPA) 1710 [5]. “Eight minutes is critical for OHCA survival,” says Dr. Michael Eisenberg, EMS pioneer [6]. The UK’s NHS targets a 7-minute mean for Category 1 calls, with 90% within 15 minutes, prioritizing outcomes [7]. India’s urban average lags at 18-25 minutes, with rural areas often exceeding 30 minutes, per NITI Aayog’s 2025 report [8].

A comprehensive EMS scorecard includes:

  • Clinical Outcomes: OHCA survival (>30% in top systems vs. India’s 5-7%), return of spontaneous circulation (ROSC) (>50%), and timely stroke/STEMI care [9].
  • Safety: Ambulance crashes <1 per 100,000 responses, as lights-and-sirens driving triples risks [10].
  • Operational Metrics: Call abandonment <5%, hospital handover <15 minutes, dispatch accuracy >90% [11].
  • Equity: Response disparities by region/income <10%, a challenge in India’s urban-rural divide [12].
  • Patient Satisfaction: >85% positive ratings for public trust [13].

Dr. Anuja Joshi, Indian EMS researcher, notes, “Response time is the foundation, but outcomes and equity define excellence” [14]. The outdated “10 minutes, 80% of the time” misses critical cases; 90% compliance is the global norm, per Dr. Paul Pepe [15].

 

Global Benchmarks: The World’s Fastest Sirens

High-income countries (HICs) dominate EMS performance. Salt Lake City achieves 4-5 minutes for first responders and 8 minutes for advanced life support (ALS), leveraging fire-EMS integration [16]. “Co-located units drive our speed,” says Chief Brian Dale [17]. Tokyo averages 6.5 minutes with 259 ambulances and GPS routing [18]. London hits 7 minutes (90% within 15 minutes) via advanced dispatch [19]. In Asia, Seoul (7.5 minutes) and Singapore (8.3 minutes) excel with AI and training [20, 21]. Low- and middle-income countries (LMICs) show progress: Belo Horizonte (9-12 minutes), Kigali (12 minutes), and Jakarta (12-15 minutes) halved times in 10-15 years [22, 23].

Top 20 Cities (2025 Est.):

  • Asia: Tokyo (6.5 min), Seoul (7.5 min), Singapore (8.3 min), Taoyuan (5-7 min) [24].
  • HIC: Toronto (7 min), Sydney (8 min), Amsterdam (7 min) [25].
  • LMIC: Istanbul (8 min), Chennai (12-15 min), Jakarta (12-15 min) [26].

“Tokyo’s fire-EMS synergy is a model for dense cities,” says Dr. Shinichi Nakayama [27]. India’s cities struggle: Mumbai (15-25 minutes) and NCR (18-30 minutes) face traffic and fragmentation, per Dr. Tamorish Kole, AIIMS [28]. “Congestion and underfunding choke India’s EMS,” he adds [29].

 

Real-World Implications of 10 vs. 15 Minutes

A 5-minute response time gap is life-or-death. For OHCA, survival drops from 10-15% at 10 minutes to 5-8% at 15 minutes—a 30-50% decline [30]. “Every minute past 10 erodes brain function,” warns Dr. Paul Pepe [31]. In trauma, 10 minutes keeps mortality at ~20%, while 15 minutes raises it to ~25%, per Advanced Trauma Life Support (ATLS) guidelines [32]. “Trauma bleeds out fast,” says Dr. Sanjay Gupta, NDMA [33]. For stroke/STEMI, 15-minute delays reduce recovery by 10-15%, per Dr. Bhawani Mishra [34]. “Stroke patients lose 1.9 million neurons per minute,” she notes [35].

Bystander interventions mitigate delays. Seoul’s 60% CPR coverage maintains ~10% survival at 15 minutes [36]. “Public training is a force multiplier,” says Dr. Lee Ji-hoon, Korean EMS [37]. First responders, like Toronto’s fire units (4 minutes), bridge gaps [38]. India’s ~10% CPR coverage amplifies the gap’s impact, per Dr. V. Anantharaman [39]. “Without bystanders, 15 minutes is often fatal,” he warns [40].

 

Cost Implications of 10 vs. 15 Minutes

Achieving 10-minute response times is costlier upfront but saves downstream. For Mumbai (50,000 calls/year):

  • Operational Costs: 10 minutes requires $50-75 million annually (staff, fleet, tech); 15 minutes saves 10-20% ($5-15 million) [41]. “More units mean higher salaries,” says Dr. Sanjay Shah, EMS economist [42].
  • Safety Costs: 10-minute targets raise crash risks (1 per 100,000 responses, $250K-$5M/year) vs. 0.5 at 15 minutes [43]. “Hot responses are risky,” says Dr. John Brown, NAEMSP [44].
  • Downstream Savings: 10 minutes boosts OHCA survival, saving $10-60 million in hospital/disability costs [45]. “Faster EMS cuts long-term burdens,” says Dr. Rajesh Gupta [46].
  • Net Trade-Off: Upfront costs rise $5-18 million but offset by $10-60 million in savings [47].

“Cost-benefit favors speed for critical cases,” says Dr. Vinod Paul, NITI Aayog [48].

 

Current Ambulance Fleets and Shortfalls in Mumbai and NCR

Mumbai (~22.1 million pop.) has ~200 public ambulances (108 service) and ~100-150 private, ratio 1:75,000-110,000 [49]. NCR (~34.7 million) has ~600 public (CATS + 108) and ~200-300 private, ratio 1:40,000-50,000 [50]. World-class (8-9 minutes) requires 1:20,000-30,000, adjusted +30% for traffic (15-20 km/h, per TomTom 2025) [51].

  • Mumbai: Needs 737-1,105 ambulances (shortfall: 437-905). Cost: ₹500-1,000 crore ($60-120M) upfront, ₹200-400 crore/year [52]. Reasonable 12-15 minutes needs 442-551 (shortfall: 142-351), ~₹200-400 crore [53].
  • NCR: Needs 1,157-1,735 (shortfall: 257-1,135), ~₹1,000-2,000 crore; reasonable needs 694-868 (shortfall: 94-268), ~₹300-600 crore [54].

“India’s fleets are critically underpowered,” says Dr. Mahesh Joshi, MEMS [55]. Traffic halves coverage radius, per IIT Delhi [56]. “We need 1.5x HIC norms,” says Dr. Anil Jha [57].

Global Success Stories: Lessons from LMICs and HICs

Cities worldwide transformed EMS in 10-15 years:

  • Seoul, South Korea: From 12-15 minutes (2005) to 7.5 minutes (2025). Unified 119 system, AI dispatch, 60% CPR coverage. “AI cut travel 20%,” says Dr. Kim Soo-jin [58].
  • Singapore: From 10-12 minutes (2000) to 8.3 minutes. Motorcycle units, AED networks. “Scooters beat traffic,” says SCDF’s Colonel Tan [59].
  • Toronto, Canada: From 10-12 minutes to 7 minutes. 236 ambulances, GIS mapping. “Dynamic deployment works,” says Chief Peter Rotolo [60].
  • London, UK: From 12-15 minutes to 7 minutes. CAD Phase 3, rapid response vehicles. “Integration saved lives,” says LAS CEO Garrett Emmerson [61].

LMIC Case Studies:

  1. Belo Horizonte, Brazil (Upper-Middle Income)
    • Transformation: From 20-25 minutes (2010) to 9-12 minutes (2025), a 40-50% gain [62].
    • How: SAMU 192 expanded from 50 to 150 ambulances (1:40,000 for 6 million pop.), with GPS dispatch cutting processing to <2 minutes [63]. PPPs with hospitals added 50 motorcycle units, navigating hilly traffic [64]. Bystander CPR (30% coverage) and AEDs in public spaces boosted outcomes [65]. Municipal funding (~BRL 100M/$20M) over 10 years trained 2,000+ paramedics [66]. “PPPs stretched our budget,” says Dr. Maria Costa [67].
    • Outcomes: OHCA survival ~10%; 200,000+ calls/year handled efficiently [68].
  2. Kigali, Rwanda (Low-Income)
    • Transformation: From 30+ minutes (2010) to 12 minutes (2025), a 50-60% improvement [69].
    • How: Rwanda’s 112 system grew from 10 to 50 ambulances, with 50+ moto-ambulances for hilly terrain [70]. USAID-funded drones (~$50M) deliver defibrillators, cutting rural-urban gaps [71]. Community health workers (10,000+ trained) provide BLS, with 40% CPR coverage [72]. “Drones are a low-cost revolution,” says Dr. Paulin Banguti [73]. Unified hospital protocols limit handovers to 10 minutes [74].
    • Outcomes: Maternal/emergency survival up 30%; 50,000+ calls/year [75].
  3. Jakarta, Indonesia (Lower-Middle Income)
    • Transformation: From 20-30 minutes (2010) to 12-15 minutes (2025), a 40% gain [76].
    • How: Prolanis 119 added 100 ambulances (total ~200), with flood-resistant vehicles for monsoons [77]. Red Cross PPPs ($20M) introduced 20-30 motos [78]. Traffic apps integrated with dispatch; EMS lanes in MRT corridors cut delays [79]. Training 3,000+ paramedics and 25% CPR coverage boosted outcomes [80]. “Flood-ready vehicles are critical,” says Dr. Sari Wahyuni [81].
    • Outcomes: Trauma response up 35%; OHCA survival ~6% [82].

“LMIC successes show innovation trumps constraints,” says Dr. GVS Murthy, WHO [83].

India’s EMS Leaders: Chennai and Beyond

India’s top cities have made remarkable strides despite traffic and resource challenges.

  1. Chennai (Tamil Nadu)
    • Achievements: Slashed response times from 25-35 minutes (2010) to 12-15 minutes (2025), with 90% within 15 minutes [84]. The 108 service (GVK EMRI) operates 150-200 ambulances (1:40,000-50,000 for 12 million pop.), plus ~100 private units [85]. Handles 300,000+ calls/year, with 20% resolved via tele-triage, a national benchmark [86]. OHCA survival rose to 5-7% (from <2%), and trauma response halved [87]. Motorcycle ambulances (30+ units) reach dense areas like T. Nagar in <10 minutes [88]. “Chennai’s model is India’s gold standard,” says Dr. S. Venkatesh, EMRI [89].
    • Policies and Implementation: Tamil Nadu’s 2010-2015 ₹500 crore ($60M) reforms unified dispatch, added GPS, and integrated Apollo Hospitals [90]. “PPPs doubled capacity,” says Health Secretary J. Radhakrishnan [91]. School CPR programs (20% coverage) and traffic signals cut delays 15-20% [92]. Monthly audits ensure <2% call drops [93]. Challenges: Handover delays (~20 minutes) and rural gaps [94].
  2. Hyderabad (Telangana)
    • Achievements: Averages 11-14 minutes (90% within 14 minutes), among India’s fastest, with 8% OHCA survival [95]. ~250 ambulances (1:35,000 for 10 million pop.) handle 400,000+ calls/year [96]. AI dispatch and drone trials cut travel 20% [97]. Post-COVID, 50 ALS units reduced handovers to ~10 minutes [98]. CPR training reaches 25% of adults [99].
    • Policies and Implementation: Telangana’s ₹300 crore (2015-2020) EEHMS emphasizes AI and hospital partnerships [100]. “Tech drives efficiency,” says Dr. G. Srinivas [101]. Community AEDs in tech hubs boost response [102]. Challenges: Peri-urban scaling [103].
  3. Ahmedabad (Gujarat)
    • Achievements: 10-13 minutes (90% within 12 minutes), India’s fastest, with 7-9% trauma survival [104]. ~180 ambulances (1:40,000 for 8 million pop.) handle 200,000+ calls/year [105]. Traffic signals save 2-3 minutes; 20+ motos aid trauma response [106].
    • Policies and Implementation: Gujarat’s ₹200 crore (2012-2018) GVK 108 push added GPS/AVL [107]. “Signals are our edge,” says Dr. Pankaj Patel [108]. Training 1,500+ paramedics and 15% CPR coverage enhance outcomes [109]. Challenges: Scaling to smaller cities [110].
  4. Bengaluru (Karnataka)
    • Achievements: 12-16 minutes despite severe congestion (90% within 15 minutes) [111]. ~200 ambulances (1:45,000 for 13 million pop.) handle 350,000 calls/year; tele-triage resolves 15% [112]. 40 electric ambulances cut costs; OHCA survival ~6-8% [113].
    • Policies and Implementation: Karnataka’s ₹400 crore (2018-2023) plan integrates 108 with fire services [114]. “Telemedicine frees units,” says Dr. Shalini Raj [115]. AEDs in tech parks aid response [116]. Challenges: Traffic (India’s worst, per TomTom 2025) [117].
  5. Pune (Maharashtra)
    • Achievements: 13-15 minutes (90% within 16 minutes), with 120 ambulances (1:50,000 for 7 million pop.) [118]. Handles 150,000+ calls/year; monsoon-resilient vehicles ensure reliability [119]. OHCA survival ~5-7% [120].
    • Policies and Implementation: PMC’s ₹150 crore (2015-2020) added 50 units and GPS [121]. “Flood-ready vehicles are key,” says Dr. Nitin Bhagali [122]. Symbiosis Hospital partnerships and 20% CPR training boost outcomes [123]. Challenges: Urban sprawl [124].
  6. Indore (Madhya Pradesh)
    • Achievements: 12-14 minutes, a Tier-2 leader, with 100 ambulances (1:40,000 for 4 million pop.) [125]. Low call abandonment (~3%); 6% OHCA survival [126]. Handles 100,000+ calls/year [127].
    • Policies and Implementation: Madhya Pradesh’s ₹100 crore Clean City initiative extended to EMS [128]. “Efficiency drives us,” says Dr. Manish Singh [129]. PPPs with 104/108 services and community drills support gains [130]. Challenges: Fleet growth [131].

“Chennai leads, but Hyderabad and Ahmedabad push boundaries,” says Dr. Devi Shetty, Narayana Health [132]. Mumbai/NCR lag due to high ratios (1:75,000-110,000) [133].

 

Comparing Chennai with LMIC Case Studies: Pathways for Improvement

Chennai’s 12-15 minute response is a national leader but can improve by adopting strategies from Belo Horizonte, Kigali, and Jakarta:

  • Belo Horizonte: Its 9-12 minute response leverages PPPs and AED networks. Chennai could add 50-100 AEDs in public spaces (e.g., Marina Beach) for ~₹10 crore, targeting 10-12 minutes [134]. “AEDs double survival,” says Dr. Maria Costa [135].
  • Kigali: Drone delivery for defibrillators could serve Chennai’s slums/rural fringes, shaving 1-2 minutes for ₹20-50 crore [136]. “Drones bridge gaps,” says Dr. Paulin Banguti [137].
  • Jakarta: Flood-resistant vehicles could tackle Chennai’s monsoons, ensuring 10-12 minute consistency [138]. “Monsoon-ready fleets are vital,” says Dr. Sari Wahyuni [139].

Chennai’s PPPs and motos align with Belo Horizonte, but its 20-minute handovers lag Kigali’s 10-minute protocols [140]. “Chennai needs hospital flow reforms,” says Dr. S. Venkatesh [141].

Lessons for Mumbai, NCR, and Chennai

Mumbai and NCR can adopt:

  1. PPPs (Chennai): Integrate private fleets (Mumbai: BMC-Reliance; NCR: CATS-AIIMS). “PPPs add 20% capacity,” says Dr. Vinod Paul [142].
  2. Tech Dispatch (Hyderabad/Ahmedabad): AI/GPS (₹100-200 crore) for 15-20% time cuts [143]. “Routing is critical,” says Dr. Anil Jha [144].
  3. Motorcycle Units (Chennai): 50-100 motos (₹50 crore). “Bikes reach slums,” says Dr. Priya Menon [145].
  4. Bystander Training (Hyderabad): CPR/AED programs (₹20-50 crore) for 20% coverage. “Public response buys time,” says Dr. Rao [146].
  5. Policy Reforms (Ahmedabad): Traffic signals, 15-minute handovers. “Coordination saves lives,” says Dr. Sanjay Gupta [147].

Chennai Improvements: Adopt Kigali’s drones, Jakarta’s flood-resilient vehicles, and Belo Horizonte’s AEDs to target 10-12 minutes [148].

Roadmap:

  • 1-3 Years: PPP pilots, motos, tech (₹200-400 crore).
  • 3-7 Years: Fleets to 400-500 (Mumbai), 700-900 (NCR), 250-300 (Chennai).
  • Challenges: Funding (CSR/central schemes), staffing (5,000+ paramedics), equity (slums) [149].

Insights: A Blueprint for India’s EMS Future

India’s EMS landscape blends progress and peril. Chennai’s 12-15 minute response, Hyderabad’s 11-14 minutes, and Ahmedabad’s 10-13 minutes showcase potential, yet Mumbai and NCR’s 15-30 minute delays cost thousands of lives annually (OHCA survival: 5-7% vs. 20-40% globally) [150]. Doubling fleets (Mumbai: 737-1,105; NCR: 1,157-1,735) could hit 8-9 minutes for ₹1,500-3,000 crore, but 12-15 minutes is feasible by 2030 with 400-900 ambulances and ₹500-1,000 crore [151]. Chennai can reach 10-12 minutes with Kigali’s drones and Jakarta’s monsoon-ready vehicles [152].

“India’s EMS is at a crossroads,” says Dr. Vikram Misra [153]. PPPs (Chennai), AI dispatch (Hyderabad), and signal priority (Ahmedabad) are scalable, cutting times 20-30% for ₹100-200 crore, per IIT models [154]. Bystander training (Hyderabad’s 25% CPR reach) boosts survival 20-50% [155]. “Community action is key,” says Dr. Shailaja Tetali, PHFI [156].

LMIC successes like Belo Horizonte and Kigali prove low-cost innovation (motos, drones) works [157]. Challenges—funding, staffing 5,000+ paramedics, slum access—require unified 108/112 lines, per NDMA [158]. Mumbai/NCR could save 1,000+ lives/year and ₹500-1,000 crore in hospital costs [159]. “India can leapfrog with smart reforms,” says Dr. GVS Murthy, WHO [160]. With political will, CSR funding, and phased investments, India’s megacities can transform sirens into lifelines, joining global leaders in a decade. “The clock is ticking,” urges Dr. K. Hari Prasad, Apollo [161].

 

Case Studies: Transforming EMS in Chennai and Hyderabad

Chennai: A National Leader in EMS Efficiency

Background and Context

Chennai, Tamil Nadu’s capital with ~12 million people in 2025, faces dense urban sprawl, traffic congestion (18-22 km/h, per TomTom 2025), and monsoon flooding. Pre-2010, response times averaged 25-35 minutes, with fragmented services and OHCA survival <2% [119]. The GVK EMRI 108 service, launched in 2008, transformed Chennai into India’s EMS leader.

Transformation Journey (2010-2025)

  • Fleet Expansion: From ~100 ambulances in 2010 to 150-200 public ambulances by 2025 (1:40,000-50,000 ratio), plus ~100 private units. Supports 300,000+ calls/year, with 20% resolved via tele-triage [120]. “Fleet growth was our backbone,” says Dr. S. Venkatesh, EMRI [121].
  • Public-Private Partnerships (PPPs): Tamil Nadu’s ₹500 crore ($60M) investment (2010-2015) integrated Apollo Hospitals, boosting capacity 20-30% [122]. “PPPs doubled our reach,” says Health Secretary J. Radhakrishnan [123].
  • Motorcycle Ambulances: 30+ moto-ambulances navigate areas like T. Nagar in <10 minutes [124]. “Bikes are lifesavers,” says Dr. Priya Menon, EMRI [125].
  • Tech Integration: GPS and CAD cut processing to <2 minutes; traffic signals shaved 15-20% off travel times [126]. “Tech is our edge,” says Radhakrishnan [127].
  • Community Engagement: School CPR programs reached 20% of adults; AEDs in malls boosted survival [128]. “Public training buys time,” says Dr. Rao, Apollo [129].
  • Policy Support: Monthly audits ensure <2% call drops; Tamil Nadu’s EMS Act (2012) standardized protocols [130]. “Discipline drives results,” says Venkatesh [131].

Outcomes

  • Response Time: Reduced to 12-15 minutes (90% within 15 minutes), a 40-50% improvement [132].
  • Clinical Impact: OHCA survival rose to 5-7%; trauma response halved [133].
  • Challenges: Handover delays (~20 minutes) and rural gaps persist [134].

Lessons for Improvement

Chennai can target 10-12 minutes with Kigali’s drone delivery for slums (₹20-50 crore) and Jakarta’s flood-resistant vehicles for monsoons [135]. “Drones could shave 1-2 minutes,” says Dr. Paulin Banguti [136].

Hyderabad: Tech-Driven EMS Excellence

Background and Context

Hyderabad, Telangana’s tech hub with ~10 million people, faces traffic (15-20 km/h) and peri-urban growth. Pre-2015, response times averaged 20-25 minutes, with OHCA survival ~3% [137]. The Emergency Emergency Health Management System (EEHMS), launched in 2014, made Hyderabad one of India’s fastest EMS systems.

Transformation Journey (2015-2025)

  • Fleet Expansion: From 150 ambulances in 2015 to ~250 by 2025 (1:35,000 ratio), handling 400,000+ calls/year. Post-COVID, 50 ALS units were added [138]. “Scale was critical,” says Dr. G. Srinivas, EEHMS [139].
  • AI and Tech: AI dispatch with Google Maps API cut travel 20%; drone trials for rural links show promise [140]. “AI is our game-changer,” says Srinivas [141].
  • Hospital Partnerships: Care Hospitals reduced handovers to ~10 minutes [142]. “Seamless care saves lives,” says Dr. Vinod Paul [143].
  • Community Training: CPR coverage reached 25% via corporate/school programs; AEDs in HITEC City boosted outcomes [144]. “Public response is vital,” says Dr. Rao [145].
  • Policy Support: Telangana’s ₹300 crore (2015-2020) funded tech and training [146]. “State commitment drives us,” says Srinivas [147].

Outcomes

  • Response Time: 11-14 minutes (90% within 14 minutes), among India’s best [148].
  • Clinical Impact: OHCA survival ~8%; trauma response improved 30% [149].
  • Challenges: Peri-urban areas lag; drone scaling needs funding [150].

Lessons for Improvement

Hyderabad could adopt Belo Horizonte’s AED networks (₹10 crore for 50-100 units) to push toward 10 minutes [151]. “AEDs are critical,” says Dr. Maria Costa [152].

 

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