(Names have been changed to maintain privacy, images are representational only)
Dr Kumar is a government doctor in rural Uttar Pradesh, a good distance away from the state’s metropolitan centres. He works at the block level, where a network of Community Health Centres (CHCs) and Primary Health Centres (PHCs) cater to more than 2.5 lakh people living in 100-odd villages.
So far, the lockdown has gone well in Dr Kumar’s block. Everyone is scared of getting the disease and there is no way of fighting it except by maintaining distance. So that is what people are doing.
There is a steady stream of people coming back to their villages from different states across the country. By Dr Kumar’s estimate, about 1000 people must have returned to his block in the last 3-4 weeks. In the first fortnight of the lockdown he received a list of more than 250 names, these were people returning from outside UP. Dr Kumar and his team thermal scanned more than 200 from the list. No one showed any significant symptoms of the infection.
Nonetheless, Dr Kumar and his team are asking those returning to their villages to self-quarantine or complete two weeks quarantine in government facilities. Thermal scanning is not a diagnostic test. It is only a way to identify people, that they have come from outside and have fever, then we take their travel history and symptoms and assess whether they need further treatment. Beyond this, iska koi significance humari samajh se nahi hai. Every village has a primary school, and these have now been designated as quarantine facilities managed by the Block Development Officer (BDO) and other local authorities. But it isn’t as if every person who returned has been quarantined. Dekhiye, ho nahi paata hai local sthar par, hai na. What happens is, when they come from far away alone it is possible to catch and isolate them. If they come in a group and manage to reach their village, wahan jaake unki bhasha boli sab kuchh badal jaata hai, hai na. Kehte hein, hum kyun jaayen jaanch karaane, kuchh nahi hua hai, hum nahi jaayenge, gali galoch, mar peet. If such situations arise, we take the help of the police and administration in sending these people to testing and quarantine facilities. But it is not easy. We have had to send the police to several places. Because woh saaf saaf mana kar dete hein ki humko kuchh nahi hua hai. Sometimes they fight with the police and also get into physical altercations. That is not all. Kayi baar aisa hota hai that after someone has been taken for screening and isolation, uske baad woh lad jhagad ke kisi tarah se wahaan se bhag jaate hein. Ki hum nahi rahenge, humara toh jaanch ho gaya hai. Then we take the help of senior authorities and police to track them down again and bring them back. But it is also true that sometimes people are coming voluntarily to get checked and, in some places, villagers are themselves letting us know if someone has returned from outside.
It is absolutely true that if even one asymptomatic person comes to the village and spreads the virus, it can create a very very difficult situation at the rural level. Abhi itne jaada log aaye hein jab se lockdown hua hai. If they pass the thermal scanning but after that cases start to emerge, the chances of the virus spreading are high. But so far, in the last one week, 10 days, no such issue has come to the fore. There is also no mauhal of mistrust against health workers and no indications that such an environment might develop in the coming days. Where there are a few people who are expressing such misgivings, it is being dealt with at the local level.
In Dr Kumar’s block there are no ICUs and ventilators. It is not possible to set up such facilities there at the moment. The only testing facility within the zilla is in the city. At the moment the only thing Dr Kumar and his team can tell people is to save themselves from the virus and explain how. If a case is found and treatment is necessary, zilla mukhyalay is the only place where it can be done.
About 100 health workers work under Dr Kumar. He is not happy about the multiple weeks it took authorities to make PPEs available to health workers at the local level. After Dr Kumar put in a formal request, it took more than 10 days to secure PPE for himself and his team. Do tareh ki baatein hoti hein. As a doctor hum kisi cheez ko mana bhi nahi kar sakte hein, kaam bhi karna hai, aur jis sthithi mein kaam kar rahe hein who suvidha humein nahi di jaa rahi hai, toh woh humein thoda achha nahi hai.
At the zilla HQ, wahaan par jaise ki baton ko ghuma phira karke kaha jaata hai. Ki theek hai mil jaayega, ya, bhej dijiyega kisi ko. Aur koi gaya bhi, toh itni maamuli si chizein milti hein ki who sufficient nahi hoti hein. The first time Dr Kumar sent someone to the HQ as a reminder for PPE, they returned with just a few masks, gloves, and sanitizers. He then used block level funds to buy sufficient quantities of each. Meetings reiterating that we have to keep ourselves safe, tab hi dusre ki seva aur treatment kar paayenge, were able to assuage the concerns of his subordinates. They continued working with the trust that higher authorities will send more and proper gear soon. The gear did finally come, and now Dr Kumar and his team are feeling safe, kam se kam itni sureity toh ho gayi hai ki hum surakshit hein.
At the moment only people who need urgent care are being taken to health facilities in the block, others are being asked to avoid hospitals and health centres. These precautions are necessary considering it’s a rural area. Even so, some people do not understand. For instance, if people have come to the OPD, they stand together, or if they are going to a particular doctor, there they form a crowd. Through our hospital we are teaching them the necessary best practices.
Spreading awareness about Covid-19, a poster by the Uttar Pradesh government
A few cases of Covid-19 have been found in blocks close by, but so far, no positive cases have been detected in Dr Kumar’s block. There was one young man who showed some symptoms and was sent to the city to be tested. It turned out he had TB. Dr Kumar is not worried about a TB outbreak in his block. T.B. ka toh bahut achha programme chal raha hai, hai na. One person from the block had gone to the Tablighi Jamaat meeting in Nizammudin in mid-March, but he did not return to his village. When he was contacted it was found that he has been tested and is quarantined in Delhi itself.
About his block Dr Kumar can say that based on observations for the last 3-4 weeks, things are in control. Healthcare teams conducted a field survey from village to village, checking everyone with symptoms such as fever, cough, and cold. This was a one-week exercise. The teams did not find anyone displaying serious symptoms and the overall situation of the block can be described as good. By and large, the return of migrant labourers from across the country too has not caused a spike in cases. If it were to happen, by now some indications would have started arising. Kuchh parinaam aane shuru ho jaate. Because people have been coming back for 10-15 days now. We can say that if things remain this way, cheezein bigdengi nahi. Community transmission has not taken place, so we can expect things to improve in the future.
There was news that if cases do not increase, the lockdown will be relaxed to some extent. But in the city a handful of new cases were recently found, most linked to the Jamaat, and it has been decided that a strict lockdown will continue in the district. But it is also true that the recovery rate in the district (with most cases concentrated in the city) is also quite alright. As long as the city has cases, the chances of the district opening are low.
There isn’t so much trouble in the villages because of the extended lockdown. The problem is in the cities. Houses in the city comprise of just a few rooms, and people must stay confined within. Gaon waale toh fir bhi thoda tehel lete hein, hai na. So far there hasn’t been a scarcity of food in the villages. The labour class in cities is facing difficulties and the government has taken steps to help them, in the villages no news has come yet that people are facing serious hardships. On the block level arrangements have been made that where required food will be made available. Lekin bahut aisa sankat nahi hai abhi.
The police and local level authorities are all cooperative and everyone is working together. Dr Kumar and his team follow instructions from the CMO and zilla Adhikari and so far, Dr Kumar is satisfied with the orders coming from higher up. As of now his work has not become too hectic. He has not had to work 12-hour shifts. The doctors on emergency duty do have 12-hour shifts in this situation. At his level and with his CHC being at a good position within the district, there are several doctors and people are able to manage well. He is of course concerned about his family and takes precautions to keep them safe.
Dr Kumar can only say that humko jo bhi suvidha mil rahi hai sarkar ki taraf se, usmein improvement ho, and people follow the guidelines of the lockdown. The biggest cure of the virus is keeping safe from it.
Update 02/06/2020
Over the last month atleast 2,500-3,000 people have returned to our block. Earlier a large number of people were returning, now the numbers have reduced.
When people started returning 15-20 days ago, primary schools were demarcated as quarantine facilities in each village. But in each village the situation is different. In some villages the Pradhanji log were cooperating, in others they weren’t paying any attention. In some places it has also happened that those quarantined would be in the quarantine center during the day, but at night they’d go back home. About 2 weeks ago instructions were given for everyone to be home quarantined.
People returning from outside are thermal scanned at the block level. Those suspected of having COVID are sent to the district headquarters. The rest are sent home. Earlier, those who were coming by train were being scanned at the railway station itself. But there were also people jo apne saadhan se aa rahe the, kuchh log busson se aa rahe the, kuch paidal aa rahe the. These people would go to their villages directly, but villagers in many places sent them to us, saying that they will not be allowed into the village if they don’t get checked first. Some people who had returned from outside came directly to us and went home only after getting themselves scanned. About a week ago, upto 800 people were coming each day to our hospital for thermal scanning. Now the numbers have reduced to 150-200.
Afra-tafri ka mauhal tha beech mein. Some people were not obeying the directives about getting scanned and quarantining at home. The police had to be called in at some places. But now things have stabalised. Earlier khauf toh bahut zaada tha, jaankaari ho jaane ke baad khauf mein kami aayi hai. And in the last 2 weeks the situation has normalised. Most people are following home quarantine and are also isolating themselves from their family members at home.
Like earlier, testing still happens only at the district headquarters, but sampling facilities have now been made available at the block level. Nine cases were found in our block over the last month. Four or five of them have recovered. The good thing is that none of their contacts tested positive. Even in the city only a handful of new cases are emerging daily, so the rate of increase in cases has fallen. Mostly it is people returning from Bombay who have tested positive. The number of people returning from Bombay was higher than from other places, and positive bhi wohi nikle hein, Bombay waale. But, because immediate tracing is being done, community spread has not taken place. The percentage of samples testing positive is very low. If around 3000 people have returned to our block in the past month, only 9-10 people have tested positive. Cases could increase. Maybe. It is possible. But it has not happened yet.
People have just returned from far away. They are scared. Except for a handful of exceptions, no one is talking about going back yet. Right now, they are happy to be at home. The chances of the virus immediately spreading in rural areas do not appear to be high. As this first week of June progresses, we will get a clearer picture. It is possible that in two, four, or six days cases increase, but at this moment there is nothing noteworthy and there aren’t really many indications that this will happen.
Distribution of PPE and other medical gear has been decentralised and now upon asking we are being given what we need. Our doctors and medical staff have also begun to adjust to the circumstances. Khauf waali baat ab kam ho gayi hai. Fear has reduced now. This is also because in our district the number of cases is not very high. There were about 165 cases, out of which about 90 have recovered. The positive thing is that none of the patients needed oxygen or ventilator support. There have been one or two casualities, but these were patients who were already suffering from chronic diseases.
The way things have opened up, it does not feel at all that a lockdown had been imposed. Movement should have been controlled a bit. People are still returning, and since the lockdown has been relaxed, movement will only increase . The police were quite strict earlier, but now shops are open and people are moving around freely.
This outbreak does not appear to be ending soon. It is not as if, okay, we have controlled the cases and soon this will be over. It is going to continue for months. In our hospital we have opened up our OPD. We have distributed duties amongst our doctors such that they work alternate days. Our thermal scanning team also takes turns and works alternate days. By doing this we are making sure our staff can rest. Over the last two months our staff has cooperated well. Yahaan pe iss tarah ka kuchh nahi hai ki mana karein, aana-kaani karein ki hum nahi karenge, why has our duty been put here, and so on. There is nothing like this. Everyone is working well. In our block no medical staff has gotten corona. In another block a case emerged two day ago. A lab technician was found positive. He must have been doing his work in the field. In our district there have been three such cases of medical staff being infected. In the second case, it was a technician shifting samples from one hospital to another, and in the third case it was a pharmacist who was doing thermal scanning. Out of these three people two have recovered, and we hear that the third person will also recover in a week or ten days.
Recently, complete responsibility has been given to each village. ‘Nigraani samiti’ teams have been created by the state government at the village level. The village pradhan is appointed as the head, and aanganwadi, ASHA, and other frontline workers are part of the team and report to the pradhan. The potedarji, the person in each village who gives out ration and so on, is also part of these teams. In this way all village pradhans are actively participating, they are looking after people returning from outside, ensuring they get scanned, supervising and making arrangements for them to properly quarantine. We are in touch with these nigraani samiti teams and are sharing the latest guidelines with them. A new initiative by them is to stick posters on the doors of all those who have tested positive, are suspected cases, or have returned from outside. These posters have information about necessary precautions and what those who are quarantined and others should and should not do. As a result people are being made well aware. These nigraani samitis are a good initiative by the state government.
Update 09/06/2021
The worst phase of the second wave began around 15th April. In UP, gram pradhan elections took place on 15th, 19th, 26th, and 29th. Results were announced on 2nd May. People came to vote from all over, including from outside the state. There was huge crowding on voting days and during counting as well. People were mingling and the infection spread like wildfire. The virus reached every village - there was no village without cases of covid-19.
It was a very critical situation. There were too many cases, even the city hospitals were not prepared. Oxygen shortage was acute. For two weeks people ran from pillar to post but could not get the oxygen they needed. Those with co-morbidities suffered badly and there was a high death rate in this group. At our level we proactively marshalled what resources we could. Our block hospital was not authorised to admit covid patients, so we had oxygen cylinders ready and were giving half an hour to an hour of emergency care before referring patients to designated covid hospitals. But things went out of control, there were no hospital beds even in the cities.
In our block there were around 400 cases during the peak - that’s the data we have. Around 25 to 30 deaths occurred in our block, but the official count was 5 to 10. Public hospitals maintain death records, and all private hospitals have to inform the CMO of covid deaths. From these two numbers the death rate is calculated. We did not receive any instructions to hide casualties. But everyone wants to show lower deaths. We reported the covid deaths we knew of, we showed the deaths of the people registered on the portal, who were in the system, but, information regarding other covid deaths did not always reach us. Some slipped through the net. For instance, if someone went to a private hospital, then we don’t always know what happened to them. If they died, information about their death did not always reach us. Whoever has been entered into the government system (by being admitted in a government hospital), they were traced, but those outside of it were not always tracked. Information about some deaths reached us after a week or 15 days, and we did not always include them in the official count.
There is no denying that the official death count was much lower than the real number - this was done. The reason for showing a lower death count was the idea that the actual number would cause a lot of panic in the public. But in any case, these things find their way to the media. Some rumours were also spread - for instance that 50 people have died in x village, even though no such thing had happened.
The peak phase lasted until around the first week of May. It was very difficult, very challenging. Everyday we had meetings, and everyday we were pulled up for the things that were lacking. Simultaneously we had to increase testing and vaccination. There was a point when our own staff contracted the virus. At that time we had to take care of them while also continuing our work with lower manpower. Everyday we were receiving pressure from the CMO to maintain the facilities in the field.
Testing was never discouraged, in fact we were asked to do as much testing, as much sampling as possible. In our block only our hospital is conducting covid tests. We have about 5-7 lab technicians (LTs) and assistants (LAs) and they go out into the field and collect test samples. During the peak we have even done 1000 tests in a day. It does not take too long to train LAs and LTs. Once they are instructed on how to do their job, they are able to do it. Bahut jaada train karne ki zaroorat nahi padti. Ek baar train ho gaye toh ho gaye. In this critical phase we trained 10 new LAs and LTs and created 5 new teams. In some villages people would refuse to get tested. Thats when our sampling numbers would fall, but on the whole we were asked to carry out sampling on a large scale and we have done it well. From 15th April until now 7884 RTPCR tests and 6746 antigen tests have been conducted in our block for early detection. Cases have reduced drastically, but sampling is still going on.
The situation is much better now. There are only 3 to 4 cases per day. Severity is also falling - our hospital was receiving emergency patients from around the block, these patients have stopped coming in the last 10 days. Currently out of a total population of 2,85,000, 32 people are in home isolation and 3 people are hospitalised.
Vaccination is being pushed in a big way at the moment and is taking place in two groups - 18 to 44 and 45+. So far 7000 to 8000 people have been vaccinated in our block. We haven’t really faced vaccine shortages. There were one or two days when we ran out, but supply was quickly fixed. In our block atleast, there is virtually no vaccine hesitancy. Ever since the second wave has come people are very keen to get vaccinated. There is a per-day quota and all names are registered in advance through the COWIN app. In the beginning we had to deal some small obstacles, like people insisting that they be vaccinated first, but now things are fine. We have also received directions that from 1st June onwards anyone can walk-in, register, and get vaccinated.
There is a lot of discussion about the third wave. We are preparing for it. After hospitals got overwhelmed during the peak of the second wave, the government is now of the view that only critical patients should be referred to bigger hospitals, and others should be treated at the block level itself. So secondary level care facilities are being planned for our centre. Our hospital is 30 bedded and we have been asked to stay ready to be designated as a covid hospital. We might be expanded to a 50 bedded facility in that case. We have received 5 oxygen concentrators and there is a possibility we will get more. There are also plans to set up an oxygen plant. This is all in preparation that if there is a ovid patient they can be given treatment at the block level. If things progress well then within a month we should have all the facilities set up here. We won’t have ventilators, but we will have everything else. I personally think the government should also start vigorous awareness campaigns in rural areas, this is required.
Practice mein saari cheezein aa nahi payi hein, lekin planning mein hein. Now is when the work should start and everything should be set up. When problems come everyone is alert, they start planning - this should happen, that should happen. But once the problem passes, their focus shifts. Take the case of an oxygen plant being set up in our block - there was a lot of planning and discussion about it, but I’ve noticed that for the last 10 people have fallen silent. Nothing is being done.
I can’t say whether the government is to blame or those administrators who have been given this responsibility. But, abhi log dheele padne shuru ho chuke hein. In the beginning it looked like everything will be done quickly, but now it looks like, kisi cheez ko thande baste mein daal dena, that kind of situation. This is not about one level - it is at every level of administration and government. Particularly at the local level I will say that there is an atmosphere of premature celebration. People are congratulating themselves on handling this crisis very well. There is an attitude that if it happens again toh tab dekha jaayega.
One thing I can say - if the third wave comes suddenly, we are not prepared. If arrangements are not made now, we will be caught unawares.