The Rural Front Line

This is the first piece in a series titled “The Rural Front Line,” by Yogesh Jain and Naman Shah, about the COVID-19 pandemic. Jain and Shah are both doctors working with Jan Swasthya Sahyog, a public-health initiative based in rural Chhattisgarh. Over the course of the series, they will address the issues they witness on the ground while dealing with the virus, and discuss how policy decisions affect the lives of India’s rural residents.

On the first day of a three-week nationwide lockdown, Jan Swasthya Sahyog’s hospital, in Ganiyari village of Chhattisgarh’s Bilaspur district, remained largely empty. In a place like Ganiyari, an empty hospital does not mean that less people are ill; it means the ill are simply not getting medical care. At 8 pm on 24 March, Prime Minister Narendra Modi had announced a 21-day nationwide lockdown to curb the spread of the COVID-19 pandemic, effective from midnight. With just four hours’ notice, the lockdown left both the JSS and its patients unprepared to face the many problems it created.  

JSS is a community-based health programme in rural Chhattisgarh that was founded in 1996 by a group of postgraduate students at the All India Institute of Medical Sciences in Delhi. Over the twenty years since the hospital at Ganiyari was set up, JSS became an integral component of public health for patients from across rural Chhattisgarh and Madhya Pradesh, providing care for over fifty thousand patients per year. Working in a region marked by deprivation, JSS provides preventive, primary and complex healthcare where little else exists. The 100 beds at the hospital are permanently oversubscribed, and families lie sleeping throughout the corridors as the healthcare demand tragically requires several days of waiting just to be seen. The consequences of the national lockdown in such an institution are grave and may be irreversible.

On the morning of 25 March, the usual bustle at the registration counter was missing. A typical Wednesday is crowded because it is a clinic day. New patients are investigated at length and old ones return for check-ups and to collect medicines, among other reasons. At the JSS hospital, many conditions cannot wait to receive medical attention because diseases present themselves in advanced stages, in worn bodies with little reserve left. These delays occur not because people are irresponsible, but because obtaining food and caring for others takes precedence over securing their health, until the latter comes in the way of the former. As a result, the routine becomes urgent, and the urgent becomes emergent.

A regular clinic day would normally bring between three hundred and four hundred patients to the hospital, and at least ten new admissions. On 25 March, the numbers came down by around ninety percent across clinics, emergencies, deliveries and surgeries. The hospital saw between thirty to forty patients at the clinic, and just two new patients admitted to the hospital. The operating theatre schedule had only one entry when it was usual for the list to stretch beyond the board. The cases of patients with recalcitrant infections such as tuberculosis and leprosy are particularly concerning, because the interruption in these treatments, forced by the lockdown, will be disastrous, including the possibility of developing drug resistance.

But even for other patients, the prospect of being unable to go to the hospital can be severe, and even fatal. At least two hundred people who were regularly taking drugs for chronic illnesses such as psychosis, chronic joint-deformities, asthma and diabetes could not come to collect their refills. Individuals undergoing cancer treatment, including those who had already started chemotherapy, will lapse with the unexpected break. Young rheumatic heart-disease patients, whose valves were replaced with great difficulty in specialised centres in Ranchi, Bhopal or Delhi, will become disabled or die from blood clots without their medicine or dose adjustments. Mothers with complicated pregnancies will roll the dice and birth their infants at home or in smaller facilities ill-equipped for their care.

The hospital normally treats patients from over ten districts across Chhattisgarh and Madhya Pradesh, many of whom travel hundreds of kilometres to receive the medical care. But none of these patients own a car, and without trains, buses, and auto rickshaws running, only nearby patients can come. Hiring a car would cost many an entire month’s earnings.

Not only can people not get in, they cannot get out. Kalivati is a tall 28-year-old woman who weighs a pithy 32 kilograms after both her lungs were consumed by tuberculosis. After a long stay of 19 days, she finally turned her fever on 18 March. Kalivati had finally regained the energy to move, even though she would have to take five pills a day for the next eight months, and may never fully recover her strength. By 24 March, she was safe and anxious to return to her children and the small field on which she must continue to work. But she can no longer go home. Kalivati is from a village in Madhya Pradesh’s Mandla district, around 220 kilometres away from Ganiyari.

Twenty-eight other patients, like Kalivati, are ready to be discharged but stuck because of the lockdown. At the hospital, we are trying to arrange transport for them, and writing to individual district collectors, seeking permission to allow them to travel. We worry about the suffering of such patients across the country. The efforts of the patients and their families, as well as that by nurses, pharmacists, doctors, lab technicians and cleaners, have been set back. Will they return when it is over? Will their illness still be treatable? Thinking about our missing patients, the current lull at the hospital hurts.

Yet, with the looming storm, the lockdown has also provided everyone at the hospital some room to breathe. Our over-extended staff is using the new-found time to write protocols, stock key supplies and reorganise spaces for treating suspected COVID-19 patients. The emergency room will soon become a special ward for the sickest, claiming four of our five precious ventilators. The hospital typically uses breathing machines for, among other illnesses, snakebites, when a cobra or krait’s toxin would paralyse a victim’s lungs. All snakebite patients who reached us have survived, for which the ventilators were essential. We hope some space remains for these patients too.

The lockdown opens many questions, but most prominently, why was it so poorly planned? In an uncertain, evolving crisis, knowing what comes next is anyone’s guess. But even in emergencies, forethought and guidance are achievable. Conspicuous for its absence in the government’s actions so far has been any clear, coherent plan. The consequences have been dire. While we are struggling to continue safe healthcare, many others have stopped. Outpatient departments of public hospitals have been instructed to close across the country. Even the AIIMS network is turning sick patients away. In villages, diligent Accredited Social Health Activists checking newborns and distributing medicines have been scolded by panchayats.

Working in rural central India brings clarity to the need to address all preventable deaths, COVID-19 or otherwise. We cannot abandon patients. Saving someone from a pandemic but at the cost of allowing them or others to succumb to hunger or malaria is cruel. The need of the hour is to continue essential clinical services while minimising the real risk of further spreading the novel coronavirus. Ultimately, our planning should not be judged by whether the lockdown worked or not, but by what we did with the opportunity, at what cost and for whom.