July to September 2020

 As the COVID scythes its way across the world, our little valley was not spared too. A smattering of positives in the surrounding villages. Most had mild symptoms. The PHC staff, ANMs and ASHA workers took good care, ensuring quarantine of the affected persons. So also the Village Volunteers who contributed their mite to ensuring the safety and welfare of their villages. All have recovered and are back to their normal lives.

Our patient load has been a steady 40 - 50 patients daily. This is a far cry from our normal daily load of 120 - 130. Lack of transport and fear of COVID are the 2 prime factors. Our numbers tell the story. This has affected our finances. Income has dropped quite a bit.

TOTAL PATIENTS: 2960

Under 15s: 45 - 29,  Over 65s: 531: 449, Adults: 936:970

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.

SOME PHOTOGRAPHS

Patient Screening at RHC, the masked staff of the RHC

Getting Ready

Screening

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

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.

OUR RESPONSE 
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.

Teleconsult: 
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.

Sensitisation:
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

PHC: 
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.

PROBLEMS
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:

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.

Unloading

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

PPE: 

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

DISINFECTION
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













Afterword
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

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

Jan to March 2020

The final quarter of the year. The RHC had cut back taking in new patients. primarily due to the inability to handle the large crowds. Lots of fatigue both amongst the doctors as well as the paramedical staff.
Of course March brought with it the ever increasing threat of the Coronavirus sweeping across the globe.
One of the earliest decisions was to close Rishi Valley earlier than usual so that the kids could get back home. The children were sent back home between the 11th and 14th of March. The 10th and 12th standard kids stayed behind and on the 19th came the news that the exams are being indefinitely postponed. So these kids were also sent home.
The Corona virus brought with it many challenges - not the least how to run a busy Outpatient, how to help the villages, hygiene etc. These will be elaborated in a subsequent post.
Suffice to say that the three months have been quite busy

Total Patients 5111
Age, Sex and Income demographics

Female: Less than 15 years: 167, 15 - 65 years: 1905, More than 65 years: 637
Male: Less than 15 years: 174, 15 - 65 years: 1363, More than 65 years: 865

Income: Less than 48000 pa: 4992, Others: 119

Syncretism

Reaching out, helping out has been part of humanity since time immemorial. It is only of late that we have started getting self absorbed in our own selves and become self centred - looking after our own interests at the cost of humanity itself
In such a situation it was hear warming to see an old lady being escorted to the RHC by her neighbour - who is not a relation to ger at all.
The old lady is from Nimanapalle, a small town about 10 km from Madanapalle. Ever since her husband passed away a few years ago, she has been living in Madanapalle with her elder sister. The elder sister herself is paralysed following a stroke. Both these old ladies get a monthly pesnion of INR 2000 from the Government.
Their neighbour, looks after them, cooks for them, helps in household chores etc - and this notwithstanding the fact that the old ladies are Hindus and the one looking after is a Muslim

One can see the staring eyes and expressionless facies of possible Parkinsons

In the times of COVID 19

0730 AM - A couple of three seat Auto Rickshaws draw up disgorging about 08 passengers each. Passengers comprise elderly, the middle aged and a couple of young kids. The older ones make a beeline to the laboratory - these are patients of Diabetes who have started coming in for their blood tests.
0800 AM - By this time a crowd of about 60 patients has collected, about 40 of them milling around the laboratory. The rest wait in front of the registration - jostling, shoving to be first in the queue. Being early means that the wait time to see the doctor is less and they can then get home.
The laboratory assistants arrive and set up equipment for the day.
One of the attendants collects the books/lab slips and lines them up.
An announcement is made
1. All those who have cough, breathing difficulty or fever step aside
2. All those who have returned from Kuwait (used generically for the middle east) in the last 2 weeks please step aside.
There are a fair number of people who work in the Mid East as labour, servants, cooks, drivers, goat herds etc.
The idea is to fast track these patients and get them home quickly.
About 10 patients put up their hands and are taken in first to the lab.
Fasting blood tests done they are asked to wait at a specified place in front of my room.
0830 AM:
The bus from Madanapalle draws up and about 40 patients get down - there is much pushing and shoving to get to the queue either to the lab or to the registration
The registration opens and the patients continue to jostle for that 1/2 inch gain in the line. No amount of entreaties work!!!
I come in along with Dr Anandhi and we take a look at the patients waiting for new registrations. The numbers in the lab are huge and there are large number of patients for review - probably around 120 - 130. Can we see all these patients? This is a call we have to take and one has to be very hard hearted to say NO to a patient who has come from far seeking succour.
Finally we give appointments to a few and the rest - about 20 of them are taken in.
0845 AM: pen down - and the first patient
1. A 60 yr old man, Diabetic, Chronic Obstructive Pulmonary Disease (COPD) - Coughing and wheezing. A quick assessment - no fever, no wet cough - OK Nebulise him, give him inhalers and off you go.
2. 20 year old woman - Cough, fever x 5 days. She works in Hyderabad - ah ha the warning bells go off. She has just come off the night bus and straight to the Health Centre. The poor thing looks so scared - she probably saw my expression change when she said Hyderabad! Anyway I examine her - Just a mild Upper Respiratory - reassurance, medications and send her off with a warning that in case it gets worse go to a Government facility.
The next few are old patients of Asthma or COPD - all a little nervous since the COVID message has been playing non stop on the cell phones - lots of reassurance and cheer do the trick.

Distancing? What is that in the context of such a large number of patients landing up in overcrowded Auto rickshaws and buses?
What about doctors? The length of a stethoscope is 45 cm - much less than the mandates 1 metre
Can these rules be followed in a country like ours, with such a large population and so many needing health care under even normal circumstances?
I don't have the answers but am wondering about the practicality of the repeated reminders on Social Distancing.

Hygiene? Its a daily battle to prevent patients from hawking, spitting bringing out phlegm and just letting loose - Cough and sneeze hygiene - forget it! Carrying a handkerchief - you must be joking!
In all the crowd there will be a couple of youngsters who wear a handkerchief around their nose and mouth.
Water is at a premium - particularly when one has to fetch it from a communal tap. Why waste water on washing? Use hot sand or better still don't wash!! That's an option many of us, who read this will not even understand. We are so used to our 24 hr water supply.

Job Losses: Towards the end of the day a smartly dressed young man accompanies his father to my room. The father is a Diabetic and has been so for many years. He has come to the RHC for treatment. After I finish my examination and spiel on diet etc, I spend time with the young man.
He had till about a week ago a flourishing single man hair cutting shop in Electronic city, Bengaluru. Ever since COVID hit, work from home has started. He has steadily lost clientele and income. He has now come back to his village to ride out the storm. His family is dependent on his income. What's going to happen?
What will happen to the parking attendants, sweepers, baggage cart handlers at Bengaluru Airport? many of them are migrant workers from near our area. They will be all out of jobs and their families will suffer.

School Closures: Yes great idea to mitigate crowding. But what will happen to the kids whose only source of nutritious food is the MID DAY MEAL. They will now be forced to stay at home and help out in the fields or household chores. Typically in rural communities both parents work - and they work long hours. How do these parents make time for their kids? So not only do these kids miss out on meals they also miss out on education.

Hospitalisation?: If someone from the village gets a Pneumonia and progresses to Respiratory Distress (ARDS in medical terms) - they have to travel 120 - 150 km to a tertiary care centre at Tirupati or Bengaluru. Many a time - even under normal circumstances, there are no ventilators available. Whatever can be done is done.
The call on how much to do is routinely taken by doctors. Many a time I have spent time with  a seriously ill patient's relatives laying out the pros and cons of taking such patients to a higher centre. Some of them choose to stay at home and we provide palliative medications to the extent possible and also teach them the basics of home care.
Others choose to go - some pull through and the others pass on.

Afterword: Yes COVID is a frightening reality. It is sweeping through the world. I shudder to think what will happen if it takes root in a community. The already stretched medical system will possibly break under the burden of disease. I read that hospitals are closing down since doctors got infected. Yes we doctors need to protect ourselves but then what about the people who depend upon us. Its like saying that the Armed Forces will cease to fight because a few soldiers got killed!!!
The GOI has done a tremendous job of keeping tabs on the epidemic. Village level volunteers have gone house to house checking on foreign returnees. These get a call from the Primary Health Centre checking on their status. More labs are being roped in to do tests. Here's hoping that the COVID involutes upon itself. Till then we continue to do what we are trained to do - PROVIDE HEALTH CARE TO THE SICK & NEEDY
Jai Hind
Kartik

October to December 2019

As the rains abate and winter sets in, there is a gentleness to the land - the groundnut harvest come in, the fields are fallow, giving a chance to the soil to regenerate.
The rains have been decent for the crops - however there has not been that intense rain to fill up the tanks with water. The ground water has not recharged enough. We are OK for now lets see what the summer brings.

The patient load is as it is
Patient Data
Total: 5360
Children: Males: 182; Females 176
Elderly: Males 768; Females 605
Adults: Males: 1466; Females 2163

The RHC had closed for 2 weeks during Deepavalli. A well deserved/needed break.

In November, Rishi Valley Education Centre hosted the Krishnamurti Gathering   - well attended with over 300 participants.

Some photos and stories of the 3 months gone by

REPOSE - The Verandah of the Health Centre provides a resting place for a baby and an old man

When one is tired any place providing a place for rest becomes a haven

An old couple awaiting their turn at the RHC
The tree providing them a space to sit and eat

For those more romantic one could call it a picnic!

 Bundled against the cold and rain, this lil boy has a plastic packet on his head - a makeshift cap and rain protector

     A patello tibial brace for an old woman with a severe diabetic foot
The ulcer has healed beautifully with the brace