Tamil Nadu Lockdown Diary: From enforcing COVID-19 quarantine to managing alcohol withdrawal symptoms, health workers in rural TN have their task cut out
In rural Tamil Nadu, a health sub-centre is the first institution from the primary health care system that anybody from the community would turn to,
Editor's note: This multimedia series documents the mechanics of how 12 districts in Tamil Nadu worked during the COVID-19 lockdown; told through the stories of healthcare workers, sanitary workers, district officials, other essential workers, administrators, locals and patients. The series resulted from three weeks of travel through the state.
Arivazhagan and Mr M* are two truckers from Sornavur Keezhpathy village. Both of them drive to different cities, as the occasion or work demands. In the last week of April, both of them made one trip each to Koyambedu Wholesale Market in Chennai. They were part of the hundreds of truckers and essential workers who ended up in institutional quarantine for weeks after, due to a COVID-19 outbreak within the Koyembedu market. A cluster which sent administrators across northern Tamil Nadu into a tizzy. Koyembedu Market was eventually shut down, after major delays, on 5 May.
Arivazhagan returned from Koyembedu on 27 April and was shifted to a quarantine facility only 4 days after. He however tested negative. Mr M wasn’t as lucky. He tested positive and was shifted to a COVID-19 isolation ward immediately after, where he stayed put for 14 days. Arivazhagan spent 10 days in a quarantine facility. Both of them have now finished their home quarantine as well. Arivazhagan has resumed driving loads to other cities, whereas Mr M doesn’t want to do that in the near foreseeable future. Mr N* says the same to this reporter. Mr N tested positive after returning from Koyembedu and was isolated for 14 days. “My wife was pregnant when I tested positive. She was also tested soon after, and thankfully, she tested negative,” says Mr N. After he returned home, he hasn’t stepped out much. “I won’t go back to Chennai ever again, at least not now,” he tells me. Like most clusters, the one emanating from Koyembedu created a lot of fear among, and about truckers.
The Koyembedu cluster turned everything around for districts which were all doing well. From double digits, cases moved to triple digits within days. Cuddalore jumped from 26 to more than 200 in the first week of May. Similar was the case with adjoining districts. After weeks of stability, this blow caught many unawares. COVID Control Rooms started facing the heat, as this sudden escalation needed deeper, widespread tracing and mapping. Some from Koyembedu had returned without informing officials, others had skipped past checkposts. Panic was spreading in the villages about these ‘Koyembedu returns’. People were not presenting themselves voluntarily, because of this panic.
While those at the district headquarters can try and break their heads about how to keep track of every individual who returns, the ones who can actually do it are those at the village level.
One set are panchayat officials and the other, more important players are those working at Health Sub-Centres (HSC’s). This is because a HSC is the first institution from the primary health care system that anybody from the community would turn to, for all medical purposes. This would be the first institution a symptomatic person would approach. And the institution which will have to keep track of how you are doing, till the virus leaves you. For example, when Arivazhagan returned from institutional quarantine facility, the village nurses from Sornavur HSC kept track of his progress by regularly visiting him and supplying him with zinc and iron supplements from time to time.
Tamil Nadu has 8682 such HSC’s.
Why is the role of HSC’s crucial, especially in the middle of a pandemic?
Across the districts that this reporter visited, all administrators, be it from the Revenue Department or from the Health Department, reiterated the importance of an effective HSC. Effectiveness isn’t just a measure of facilities available at the HSC, it is also about the interpersonal relationships that healthcare workers from the HSC develop over the years in the areas that they are working in. These interpersonal relationships are crucial in taking the populace into confidence, while planning towards managing a pandemic. Tracking a pandemic is a major task, but that doesn’t mean that those with other ailments or medical needs can be neglected. This is also where a HSC plays a crucial role. The role of a HSC is to make healthcare accessible to everybody, under all circumstances.
To understand how an HSC operates, here are some of the key players, explaining their duties themselves.
S Velankanni, 51
Village Health Nurse
I have worked here for 31 years. This HSC caters to 3,476 people, spread across 3 villages. After the lockdown was announced, we first planned on how to keep track of antenatal and postnatal mothers. We needed to ensure that they got their supplements on time, and we also had to plan for deliveries in the middle of a lockdown. After two ares within my HSC limits turned into containment zones, we told them not to travel out for anything. Instead, we went there to meet them and provide them with the supplements they needed. It would have been risky for them to step out.
Regular immunisation drives were obviously hit, but we figured out a plan around it. We would do only 15 children at at time, while taking all precautions necessary. We took at least half an hour with each child.
As far as COVID-19 is concerned, I moved to the HSC after the onset of the pandemic. I have been here for more than two months now, and I have visited my family only on a few occasions. This is to ensure that I am here at all times and can keep track of any emergency. The work marked out for us is to coordinate with officials from the panchayat and mark the houses with people who are quarantined. After this, monitor everyday for symptoms. We keep the communication channels open always. We are constantly talking to them, and reassuring those who are positive or under quarantine that they will be fine.
I know these villages like the back of my hand. The people here have known me for decades as well. They respect me. Developing this rapport is crucial, as people listen to me only because of this. So if I tell them that quarantine is good for them, even the most adamant of people will listen to me. We have had cases where people tore out quarantine stickers and refused to cooperate. Eventually, locals from the village also help us to make people see reason.
Harikrishnan, 46, Senthil Kumar, 47, Shankar, 47 and Pichai Muthu, 47
Formerly Domestic Breeding Checkers, now COVID workers
(Harikrishnan, representing the four)
Earlier, we used to survey our areas to keep a check on dengue breeding grounds. Now, we have two roles. One is to coordinate with the health inspectors and ensure that all containment zones are sanitised everyday. The second is to track people who are returning back to the village from outside the district. Our networks are widespread across the villages we work in. On an everyday basis, while we are sanitising containment zones and areas around the village, we keep a check on people who have returned. Even before many of them return back, we receive calls about it. This helps us visit the place immediately and mark it, if there is an individual who has returned from a red zone. Panchayat officials provide us lists, but more importantly, we are directly connected with the people. Many are also scared, so they themselves come to us with information.
More importantly, we make sure that the HSC’s are fully sanitised as these are nodal points for all medical activities. Patients coming in need to be safe, as well as those who are working here. So, here at the HSC, sanitising activities are more intensive.
Dr Karthikeyan, 39
Medical Health Officer
While services at the primary healthcare level weren’t hit, one major problem has been that patients weren’t able to access tertiary services like they could before. Patients with non-communicable diseases (NCDs) travel for check ups or scans once every three to six months. This was affected during the lockdown.
Otherwise, our COVID-19 duties have been to carry out house-to-house surveys and check for ILI (influenza-like illness), particularly so in containment areas.
M Sankar, 55
Block Health Supervisor
I am regularly talking to those quarantined in institutional facilities from this block. Let me tell you, at times managing them is really difficult. Some of them would tell us to let them go as they were missing their wives and that their wives would take better care of them. One person even attempted to run away. At times they are soft, but they can get really frustrated and aggressive. We also lose our patience at times, but ultimately we have to communicate to them why they have been quarantined.
M Renuka, 56
Sector Health Nurse
Since our block is a Universal Health Coverage Block, we provide 12 services. These are antenatal and postnatal care, regular health monitoring of children under 5 and adolescents, family welfare services, treatment for minor ailments, mental health support, ENT and ophthalmology services, trauma care, geriatric care, tracking non-communicable diseases and palliative care. Catering to patients dependent on us for these services during the lockdown was a challenge, but we managed to pull through.
From March, we have been making regular announcements regarding COVID 19 across our HSC limits. Some are through recorded messages which we play across the village. We also travel across villages during surveys, and a lot of time during this is spent on answering queries related to COVID-19.
V Deepa, 27
Mid-level Health Provider
I keep track of all patients with non-communicable diseases. This includes those with heart disease, diabetes, cancer, autoimmune diseases and kidney conditions. During the COVID-19 lockdown, I had to ensure that all such patients received their medication. There are 156 such patients under me, and I’ve been tracking their progress and supplying them with the requisite drugs from time to time. We home deliver these medicines.
I also refer people who display mental health problems. What I noticed during the COVID-19 lockdown is, though many were affected due to loss of income, what really was an issue was alcohol withdrawal. Initially it was very bad. Since Pondicherry is also close by, access to alcohol is very easy. A sudden stop set a lot of people into a frenzy. People tried selling illicit liquor here too. We had to intervene and get the police involved to stop it. We tried to educate people about the various instances where illicit liquor killed people in surrounding districts. It is not like they didn’t know but this sudden unavailability seemed to have made people do all this. We told wives of many of these men to keep vigil. They have to or else they’ll only suffer, if their husband drinks illicit liquor and dies.
K Gunavati, 32
Women Health Volunteer
My usual duty is to keep track of anybody showing symptoms of non-communicable diseases in our area. I do this by regular blood samples collection and testing. I also help Deepa (quoted above) refer mental health patients. I conduct a survey where I ask questions based on their work, sleeping habits and behaviour. Based on their responses or mannerisms, we refer them to the psychiatrists who visit every week.
I also counselled people to not let the lack of alcohol worry them during the lockdown. But what I noticed is after a month, many told me they were feeling better after they stopped consumption of alcohol or tobacco. They told me that coronavirus has made them forget alcohol.
*Names withheld to protect the identities of COVID-19 patients
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