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Friday, July 03, 2020

Through the lockdown - April to June 2020

The experiences and learnings of the last three months need to be documented for successive generations of health care professionals.
COVID 19 has made us look anew at  disease epidemiology, progression, pathogenesis and management protocols. All of us, HCPs, have been involved in trying to understand, contain and control this pandemic. To a large extent we have been groping in the dark trying to understand this virus. Theories propounded only to be debunked in a few short weeks. 
To me it is reminiscent of the way humanity grappled with Cholera, Typhoid, Small Pox and Plague in the late 19th and early 20th century. It is only from the mid 1950s were we able to get a handle on infectious diseases. When I read accounts of past epidemics, I sometimes wonder how people could have been so stupid and not followed what we, today consider as basic tenets of hygiene, wound care etc!
I am sure that 30/40/50 years down the line, Health Care Professionals will laugh at the way we handled the COVID pandemic and feel the same way.
What has definitely improved is possibly personal hygiene - washing hands, feet before entering home, not shaking hands, maintaining a distance etc. 
However as time goes on, there has been an acceptance that this disease is not going away in a hurry. We have to learn to live with this and protect ourselves to the extent possible.

Patients have been trickling in through the lockdown, finding someway of accessing the RHC. There is a sense of trust and faith in the RHC. Many youngsters just come to collect medications for their grandparents or elders in their village. A coming together of the community, helping each other; something which has not been prevalent last many years.

Total Patients: 1383 (Our normal monthly attendance is about 1500 patients)
The majority of them (1355 patients) earned less than 48000 pa.
Children accounted for 26 and elders 385.


Patient Screening at RHC, the masked staff of the RHC

Getting Ready

Staff waiting for the patients

PATIENTS - Patience is the name of the Game


Orderly queues outside the RHC. Distancing maintained


Waiting for her turn

An elderly couple with their daughter in law

Relaxing on his tricycle!

A shoulder to lean on - much needed

Medicine distribution


Waiting for Medicines

Food for the Soul

The open air eatery run by this couple

A tree falls

An old Peepul tree more than 70 years old, died. Successive droughts had battered it and then possibly a fungal attack on its roots, withered the tree from inside. The tree had to be brought down before strong winds uprooted it.

Thats for Now Folks

Wednesday, April 29, 2020

A Rural Health Centre in the times of Covid - during lockdown

The Corona virus pandemic sweeping across the world had its fallout on the health centre also.
None of us were prepared or knew what to do, how to deal with patients, what was the infectivity, transmission etc.
There was also a lot of fear and false information generated amongst the public, largely due to a lot of misinformation and myths being propagated on social media.
On the 22nd of March a 01 day Janata curfew was imposed, to which people responded positively.
The Government then decided to impose a 21 day lockdown from the 24th of March till the 15th of April.
This threw us into a quandary. How to run the health centre in these times?
Some of the problems are given below
1. Staff could not come from Madanapalle, since there were no buses or public transport plying.
2. Patients could not access the health centre from their remote villages.
3. More than 90% of our patients are from Below Poverty Line Rural families, and are dependent on the RHC for their tests and medicines.
4. Should the RHC be kept open and in the process, expose ourselves and staff to possible danger?
5. There were some confusing messages from the IMA, AP Govt and Centre, initially, which then were clarified.

The lockdown was further extended to 03 May with  some restrictions being lifted from 20th April.

1. Keeping RHC open
This was essential, in the spirit of humanism, compassion, caring etc etc, the RHC had to be kept open.
We worked with skeleton staff, multi tasking, reducing the tests, turn around time.
All the staff were given masks as well as gloves and continuously educated on personal hygiene.

2.  Patients attending the RHC
1. We set up a hand washing area with soap  and water. One of our staff ensured that the patients washed their hands before coming to the reception
2. Segregation of all those patients who had fever, cough or breathlessness.
These were examined by a specified doctor and nurse, with masks and gloves. Fortunately none of them had history of contact, travel etc. None of them also had symptoms of Severe Acute Respiratory Illness (SARI) or Influenza Like Illness (ILI)
3. Fast tracking of asymptomatic patients who reported either
a. A member of their household with respiratory illness.
b. Respiratory illness in the street/village.
4. Social Distancing was put in place at the outset itself
5. Since most of our patients have Non Communicable Diseases (Hypertension, Diabetes, Heart Disease) it was easier to sort out and quickly do their tests and send them back home.
6. For those patients whose phone numbers were available, we called them and asked them to continue medications from local medical stores or from Government hospital.

We set up a 24 hour mobile number, answered by one of our staff to answer all queries.
Those needing consult with doctor were given a landline number to call between 0830 -1030 to speak with a Doctor (Dr Kartik).
A number of patients were treated this way. Some of them, however chose to come all the way to the RHC to see the doctor and collect medications. Faith I presume and also a morale booster in seeing a familiar presence in these uncertain times

Patient Attendance
Daily we are seeing about 30 - 40 patients, which is 1/3 of our normal load.
Patients are being constantly educated on safe practices during the ongoing lockdown. We are also reiterating the need to continue with these practices once the lockdown is lifted and "normalcy" is restored.

We talked to the workers, staff and workers of the Rural Education centre and other staff of Rishi Valley. We also addressed some village volunteers/ elders educating them on

The Corona virus: What is the it, why it is spreading, the disease it causes and that prevention is the key to keeping safe through the following:
a. Personal Hygiene
b. Social distancing
c. Use of masks

We also worked with the ANMs, ASHA workers and the PHC Kurbalakota doctor in charge. Doctor Sreenivas has done a real great job of monitoring and ensuring preventive measures.

1. Accessibility: Our patients mostly come from a radius of  30 km. They were not able to access the RHC since there was no public transport. However, in due course of time, some of them hitched rides on motorcycles or sent their hospital books to the RHC for refill of medication.
2. Medicine availability: By the 07th of April we had started running out of common user medicines like anti hypertensives, oral anti diabetics and Insulin.
Our response was to lower the dose, accepting higher sugars and blood pressure levels, fully knowing the risk such an approach posed. The rationale was that something is better than nothing and also ensuring that whatever is remaining is able to serve a larger population - the principle of Distributive justice.
3. Lack of PPE: We made do with using a combination of surgical mask and a cloth mask. Double layering. Getting an N95 mask was next to impossible. We were also reusing surgical masks after drying in shade.

Some Pictures from the RHC

Social Distancing in the Patient waiting area

Seat Markings
Place Markings

Enjoying a meal after their sugar tests.
These 2 from the same village traveled 60 km one way to collect medicines

Bikes parked outside the RHC

Blood tests in the verandah of the RHC

19th April: Resuming supplies

Medicines reaching the RHC
A special goods train carrying medicines was scheduled from Vadodra to Bengaluru and Coimbatore. In that train 23 boxes for the RHC were loaded from LOCOST Vadodra. These boxes were unloaded at Dharmavaram junction, about 150 km to the north of us.
Am inter district permission to transport medicines was obtained by our pharmacist.
An intrepid luggage auto driver, drove to Dharmavaram  and brought back the medicines for us.
Indian ingenuity and determination always works.
Boss Maal aa gaya


Medicines being dispensed - Kept in a stool and explained to patient

Patient Comfort - Tea made in a nearby village to be served to the patients coming to RHC

The truck with PPE
PPEs made by KPR mills were dispatched from Coimbatore in a truck carrying a massive consignment to Hyderabad.
The mill owners are parents of Rishi Valley School and made these PPEs available to us.
The truck was diverted through Madanapalle and at about 1200 on Sunday, the truck driver contacted me saying he was approaching the Rishi Valley Cross. Thanks to GPS,  precise coordinates were given and I drove to the main road (3 km) to pick up the full PPEs. Will start using them as and when needed.
Transferred to my car
Unloading at RHC

Teaching on how to use the sprayer
Spraying in progress
Using a hand operated knapsack sprayer with a solution of Bleaching powder all the common user surfaces are sprayed 3 times a day. A video and photo are given below

The virus continues to sweep across the country. The lockdown has definitely helped in dramatically slow the progression of this virus. People have also slowly adjusted to a new normal.
However, economic activities have taken a hit all over.
In our area with the harvesting of Tomato almost over, there was not much activity. Milk production has continued in the villages with supplies to the dairies as well as the nearby town of Madanapalle continuing
Floriculture and vegetable selling took a big hit as there was no market to go and sell the produce to.
So also daily wage workers and itinerant salesmen (bangle sellers, pani puri sales, loaders in the mandi's, street vendors of vegetables/fruits, roadside dhabas, tyre repair shops etc) all took a big hit.
However, the spirit of the people remains high and there are hopes of containment and acceptance of a new normal.
Jai Hind

Tuesday, April 21, 2020

Rural Life in COVID

Rural life somehow carries in. Agricultural activities somehow have to be kept going, albeit in a small scale. This anyway is true of our region with small holdings, largely farmed without much labour. Farmers tend to help each other out in times of planting, harvest etc.

A family set up shop on the road side with tomatoes, greens, gourds and ladies finger, all grown locally. Farm fresh. It also gave the kids, who had no school something to do.

This old lady set up shop selling musk melons straight from the field. I have not had such sweet melons.
One can see the fields in the background

A truck brought in 28 tonnes of bananas from Pulivendla, about 130 km from us. However the market yard took only 15 tonnes. The rest was literally left in the truck. Villagers got together to buy the produce at literally throw away prices of Rs 100 for a bunch of bananas. This translates to about Rs 3/kg.
A lot of the bananas were squashed and fit only as animal fodder

A family collecting the bananas to take home

Kids at play on the road - no school so happy times