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How the staff of a primary health centre kept a village indoors and curbed the virus

P Anima | Updated on April 28, 2020 Published on April 28, 2020

Doctor is in: The primary health centre is the community’s first link to the medical system in panchayats such as Ranni Pazhavangadi in Kerala’s Pathanamthitta district   -  SPECIAL ARRANGEMENT

Seven people of Aythala village in the Ranni Pazhavangadi panchayat in Kerala tested positive for Covid-19 in March. Here’s how the staff of a primary health centre successfully contained the infection

* The staff at the primary health centre tracked down 18 families in the village who had come in contact with Covid-19 infected persons.

* The PHC staff played multiple roles, including of investigators, in a bid to trace all contacts

* An effective network on the ground helps healthcare workers to contain the virus

When the phone rang at 2.10am, Dr Abitha Mole VO knew there was trouble. The caller confirmed her worst fears. Swab samples from five residents of Kerala’s Ranni Pazhavangadi panchayat had been sent for a Covid-19 test. The results were all positive, G Vinod Kumar, the health inspector at the primary health centre (PHC) in the area, told Dr Abitha, the medical officer at the centre.

Since that March 8 call, cell phones have not ceased to ring in the affected panchayat in Pathanamthitta district in southern Kerala. Work intensified soon after the call, but, almost two months later, the PHC staffers are still on their toes. Their days stretch well into the night, and some haven’t been home in weeks. For the anxious residents of the panchayat — of which Aythala is a ward — the PHC is a one-stop solution to their health queries. “We get calls from residents even at midnight,” Dr Abitha says. “We walk around with a book and pen in hand, prepared to jot down any information,” Vinod Kumar adds.

The efforts have led to success. Aythala was one of the early hotspots of Covid-19 in Kerala where the health authorities successfully contained the spread of the virus. Seven members of a family were found infected in early March. Three of them were visiting from Italy. All seven, including two senior citizens, have recovered. There haven’t been any new cases since then.

For the healthcare workers of the PHC — the smallest entity in the country’s gigantic health system — it is the triumph of an effective containment strategy. But, more so, the pandemic showcases how a well-oiled and well-run health machinery at the local level, where field officials assiduously build a network with the community, helps in gathering information, creating awareness and meeting exigencies head on. The Ranni Pazhavangadi PHC, one among the 460-odd in the panchayats in Kerala, is the community’s first link to the health system.

The number of Covid-19 infected persons in the country, in the first week of March, was under 40. Seven of them were in Aythala, a village with 440-odd houses and a sizeable non-resident Indian population. The country was still a fortnight away from a lockdown and the district administration’s plan to track down over 1,200 people who came in touch with the patients had few blueprints.

Core team: The staff at the PHC had to call each person in quarantine twice a day and check on their health   -  SPECIAL ARRANGEMENT

The 25-member PHC with a medical officer, health inspector, nurse, clerk, junior health inspectors (JHI) and junior public health nurses became the nucleus of action on the field. If the district had to stop the virus in its tracks, the PHC staff had to keep a village indoors. Could they do that?

“The network created by a PHC in the panchayat is strong,” says AL Sheeja, district medical officer (DMO). “They liaised very well with major hospitals. They wasted no time when information was passed on to them. They tracked down people (suspected Covid-19 cases) and sent them for sample collection,” she adds.

Route map: In the beginning, Dr Abitha (right) and her team had to attend to the medical and non-medical needs of families who were kept in quarantine   -  SPECIAL ARRANGEMENT

Dr Abitha remembers how it started. At 10am on March 6, she got a phone call from the physician at the taluk hospital nearby. A couple had come to him with fever and enquiries revealed the patient’s brother and family had come from Italy. The family from Italy had visited a private hospital in Aythala the day before with symptoms of fever. The physician passed on their contact number to Dr Abitha who instructed Augustine KP, JHI for Aythala, to contact them.

The family, however, did not admit to the illness. Dr Abitha called them, this time with proof of the medicines they were prescribed at the private hospital. The family slowly opened up, and information trickled in.

For the healthcare personnel, work had begun. The district health department was informed and Dr Abitha, along with Augustine, visited the family to convince them to give some swab samples. The results — positive for Covid-19 — were known a day later.

With confirmed cases in a panchayat of over 23,000 residents, the PHC staff began their work early on March 8, with a meeting with collector PB Nooh. DMO Sheeja divided her staff into teams of five to trace those the infected persons had been in touch with. Dr Abitha and her staff, tasked with tracking down the contacts of the infected family in Aythala, sought the services of an elected member of the ward, Boby Abraham, who was a local and knew the villagers well.

Abraham dialled the guests from Italy and gently probed them about who they had met. “We drew up a list of 18 families who had interacted with the infected persons. There were 79 primary contacts and 103 secondary contacts. Forty persons were classified as high-risk individuals,” Dr Abitha says.

The PHC staff visited each of the 18 families the same day, educated them about the virus and instructed them to stay in. When the villagers saw the healthcare workers, they volunteered information. One had interacted with the infected people briefly; another had received gifts while the third directed them to the domestic helper who worked at the house.

From then on, the PHC staff ceased to be just the point persons for health in the panchayat. They even turned investigators. “The infected persons had visited a supermarket in Aythala. I watched the CCTV cameras and identified several contacts. All of them were kept in quarantine,” Dr Abitha says.

Keeping people in quarantine, though, was easier said than done. Families had gone into isolation abruptly and their needs — medical and other requirements — had to be taken care of. In the first few days, the PHC staff had to step in and deal with sundry needs, from providing the families with water to even making arrangements for animal feed. Often, they supplied essentials to the households in quarantine. Many needed medicines and the staff delivered them at their homes.

“The only way we could keep them inside was by minimising their needs,” says the doctor. But the challenges were many, and most of them had little to do with the health apparatus. Among the secondary contacts were students appearing for examinations. “Getting them to the examination centre was tough,” recalls Dr Abitha. The PHC did not have a vehicle, nor did the panchayat.

Finally, a panchayat member ferried the students in his four-wheeler. At the examination centre, healthcare workers had to ensure that the students in quarantine sat separately.

At the PHC, the staff was split into teams. Each of them had to call every person in quarantine twice a day and check on their health. While five members of the infected family were hospitalised, their aged parents in Aythala fell ill. Neighbours pitched in with food and care. The senior citizens later tested positive for Covid-19 and those who attended to them went into quarantine, too.

“The initial days were difficult. But soon a system was put in place. The district administration instructed us to just take care of the medical needs. The rest of the work was directed to the panchayat. But the calls would still come to us since we were the ones in touch with the people,” says Dr Abitha.

Residents in quarantine battling anxiety were directed to counsellors. Within days, the administration provided the PHC with a vehicle and so did an NGO. Volunteers pitched in to deliver medicines. Checkpoints were installed at the bus stops and additional healthcare workers from the district deployed.

Looking back, Dr Abitha stresses the importance of early intervention. Within hours after the results were out, the PHC team was able to track down the families who had come in contact with the positive cases. “That helped, and the fact that we were able to get information,” she points out.

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For a field official seeking to unlock channels of communication with a community, work at the ground level is crucial. Half way through a conversation with BLink, junior health inspector Augustine puts the call on hold. He has to first attend to a call from an Aythala resident who has queries about the state government’s immunisation programme. Aythala and three other wards in the panchayat are under the JHI’s charge.

His association with the residents has been carefully built over the past six years. His “eyes and ears” and the foot soldiers he inevitably turns to are the Accredited Social Health Activist (ASHA) and anganwadi workers. Channels of information are kept alive also through the ward health sanitation committees. The committees comprise, apart from a health official, the ward member, ASHA and anganwadi workers and representatives from Kudumbashree, the state’s poverty eradication and women’s empowerment programme.

The ASHA, anganwadi and Kudumbashree workers — all women — keep an ear to the ground. “Our routine meetings every month are a great source of information. At all the health-related events, we put out one request — please share information,” points out Augustine. At every event after the pandemic broke out, the PHC staff had urged each of these local-level workers to inform them about people who had returned from countries abroad. “We assured them that we would take it forward, but to give us a call and let us know,” Augustine says. Apart from the intricate network of sources on the ground, junior health inspectors were guided by the medical officer at the PHC.

“If the doctor observes more than a couple of cases of fever from a locality, we are alerted and instructed to follow up,” he says.

Augustine attributes the panchayat’s success at containing the pandemic to this efficient network. Aythala was gripped by rumours to begin with and panic spread when the first five people were hospitalised for testing. The next day, the PHC staff along with the ward member, visited the neighbours of the suspected family, in a bid to assuage their fears. “We visited 28-29 households that day,” Augustine recalls.

At every household, the staff had one message to give: Do not isolate the family suspected to have the infection. “We also collected phone numbers which came in handy when the test results came in,” says PHC health inspector Vinod Kumar.

For healthcare workers who play multiple roles — from spearheading immunisation campaigns to creating awareness and training — investigation is also a part of the job. “Even when there is a case of typhoid, we trace the source of the infection through questions we ask a patient. So there is an element of investigation in our work,” Vinod Kumar says.

The health officials stress the importance of a strong system at the grassroots. “The network is already in place, one just has to adapt it to the latest emergency,” he adds. None of them though discounts the crucial part played by responsive and responsible citizens. “People in the panchayat are educated, and once guidelines were given, they adhered to them and reported those who did not,” Augustine says.

Panic in Aythala has eased. As the healthcare workers try to get past what has been the most challenging days of their career, their eyes are firmly on the future.

“The dengue season will begin soon,” Vinod Kumar notes.

It is another day at work.

P Anima

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Published on April 28, 2020
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