Around the time of the Janata curfew on March 22, Dr. Prashanth N. Srinivas
realised that a wide swath of infection in India would eventually affect rural and
far-flung areas and should be addressed at the primary healthcare centre (PHC) level.
Success in stanching an infection depends on what you do in a street, a ward, panchayat
or taluk, that is, in a community.
At that time, (as now), research and guidelines from different sources were pouring in: the Journal of the American Medical Association; the New England Journal of Medicine; The Lancet COVID-19 resource; Military Medical Research (a publication from Springer).
In addition, there were inputs from the U.K’s Public Health; technical guidance from the World Health Organization and India’s Ministry of Health and Family Welfare, the COVID-19 pocket reference book.
The problem is that all this information has to be processed and adapted to local primary health care centre needs. That takes time, a luxury doctors don’t have when people with respiratory ailments start coming in. It’s a problem Prashanth is well aware of from his rural post. The 40-year-old public health researcher at the Institute of Public Health, Bengaluru, lives and works at the Institute’s field station at B.R. Hills in southern Karnataka. After MBBS, he worked as a clinician for four years, and transitioned to public health research. His wife, Tanya Seshadri, is a specialist in community medicine. She works in B.R Hills at the Vivekananda Girijana Kalyana Kendra’s (VGKK) Tribal Health Resource Centre as a community health consultant.
Embedded in a community setting, Prashanth got calls from local health workers, NGOs and others. The IPH field station at B.R Hills is in a forested area with tribal populations at the junction of three states: Karnataka, Tamil Nadu and Kerala. The team at the station conducts fieldwork including household surveys among tribal and other forest-dwelling populations at multiple locations in this area. The early days of COVID-19 saw anxious reactions from health workers and others affected in these areas. People were unsure of how many people were quarantined locally and whether the disease would spread in the community. Most importantly, clear guidance on what to do had not yet percolated to the remote rural primary healthcare system.
Nobody was giving instructions to grassroots health workers on what things to keep ready. What you should have for an eventuality of transmission in a village.
Prashanth followed some of the updates on news and social media and discussed them with clinician-turned-biologist Sudheendra Rao. It appeared that there was no practical, actionable resource for immediate use at primary health care level.
“Nobody was giving instructions to grassroots health workers on what things to keep ready. What you should have for an eventuality of transmission in a village. What do you need in terms of your own safety, because health workers’ safety is the most important thing in highly infectious epidemics,” says Prashanth.
He also asked other public health colleagues for resources relevant to a rural primary health care setting that is easy to refer to and check the preparedness of a PHC. He found none. Colleagues such as Dr. Giridhara Babu who were busy supporting the early response in cities in fact suggested he start creating one.
Thus was born the idea of a resource that would be useful for rural PHC doctors and health workers, which eventually evolved into a COVID-19 preparedness checklist. The document is focused on telling what to do if you’re a PHC health officer or doctor.
The PHC along with the Sub-Health Centre is the building block of India’s healthcare system. Every cluster of villages in India has a PHC. A PHC serves 20,000 people in hilly and tribal areas and 30,000 people in the plains; there are about 25,000 of them in India.
In an epidemic or public health crisis, everything comes down to what you can do from a PHC. You can reach India’s vast population only through this nationwide network. Not only is training and sensitisation necessary for ASHA, anganwadi workers and other primary health staff, the different departments should roll out training modules for preparedness, Prashanth says.
“Are we monitoring positivity of COVID-19 among frontline workers in various public services, for example, the police? We need a system where if a policeman has mild flu-like symptoms, he or she must have a clear idea of whom to consult, how to organise isolation, and how to get testing done early so that his or her contacts can also be tested and quarantined if needed.”
So he issued an open call on Twitter for tools that primary healthcare workers, doctors and frontline workers, in rural and marginal areas can use instantly. Immediately, 15 people—from IPH and other leading institutions including Public Health Foundation of India, The George Institute of Global Health, SWASTI, Mysore Medical College, Indian Institute of Science, jumped in. Prashanth created a Google document and everybody pitched in. An unwritten rule was the document would be editorially maintained by Prashanth and Tanya, while others could bounce off ideas, bring in emerging material from WHO and elsewhere and review or comment on the draft.
A conceptual map was drawn up and six main domains marked for PHC and sub-centre preparedness. They are: 1. infrastructure, equipment, supplies and documentation, 2. health worker safety, 3. patient care, 4. biomedical waste management and disinfection, 5. health information, outreach and communication, 6. monitoring and reporting.
Guidelines, for example, from WHO, project a number of likely scenarios and advice for each. They are revised as new evidence comes in. A PHC doctor or health officer, already burdened with uncertainty and relentless spread of infection, may not have time to go through all of that. Furthermore, guidelines leave a lot to fallible human memory and, in the daily tide of calamities the administrator may forget to do things that are important. That’s where the value of a checklist comes in.
“Improper wearing of a mask is not only uncomfortable but also predisposes one to infection,” says Prashanth. He was often being asked by frontline workers like forest guards and others for masks but people were often wearing it improperly or neglected other measures for personal protection assuming that the mask would completely protect them.
Working furiously on the Google document, they had the first version of the checklist in 48 hours, and early versions were shared with state government officials by March 28. As the resource kept improving the final version in the form of a checklist with additional notes was shared with various national and state government authorities by April 6.
They devoted an exclusive section for Preparedness at the community level (including frontline workers and fieldwork) which guides frontline workers on health information, outreach and communication; screening and referral; health worker safety; community-based infection control measures; suspect, contact and community-based quarantine; monitoring and reporting.
The first version had too much text. After discussions with Dr. Sudarshan of VGKK there was a suggestion that it be whittled down to essentials. While the full resource can still be used by trainers at district and state level, Dr. Sudarshan felt the final version must be a simple-enough checklist any PHC doctor can use to assess the preparedness of their facility for local COVID-19 outbreaks.
By the time Prasnath’s open call came up, the National Health Systems Resource Centre, the technical support institute with the National Health Mission of the Ministry of Health and Family Welfare had asked the rapid evidence synthesis team of The George Institute for Global Health for help with training for community health workers. The rapid evidence synthesis programme of The George Institute is primed to answer questions from government decision-makers.
As the pandemic progresses, “we need decisions to be based on the research that comes out. Also, we must make sense of it,” says Dr Soumyadeep Bhaumik on methods for the evidence synthesis programme. As there was not much on COVID-19, Bhaumik and colleagues fell back on past epidemics such as Ebola, SARS, and MERS for material and looked at websites of multinational agencies such as CDC, for training resources. Collecting and collating information, they created a document in three days, and named it “Frontline health workers in COVID-19 prevention and control: rapid evidence synthesis.” It was sent to the National Health Systems Resource Centre.
It was at this time that Bhaumik saw Prashanth’s message on Twitter and immediately got in touch. He offered his document and both, along with others, got working. Their overriding concern was putting themselves in the shoes of a PHC doctor or health officer. It helps that they come from public health backgrounds. It also helps that they’re stationed in public health centres.
If we had a system to identify and track transmission at smaller scales and rapidly take measures to contain it locally, say in a ward, village or taluka, then in principle we would not need a big-bang nationwide lockdown.
Public health works at the population level and its responses too are at population level: how the infection is spreading, who is infected, what are the characteristics of the epidemic in terms of who will be affected, how will they be affected, what factors influence the spread, how to address the low-level, moderate and critical infections, who should be quarantined and how, how to deploy the health workforce to respond to the needs of the moment, and so on.
A clinician who is treating a patient may think about a ventilator if his individual patient travels far up the creek, while a public health expert thinks of preventing people going that far. Working without the information they need in the midst of an outbreak and figuring out the magnitude of the problem on the run, as it were, these experts try to find ways to minimise mortality at population level and perhaps also trace the untraceable path of SARS-CoV-2, the virus that causes the coronavirus diease.
By zeroing on the infection at source, in the ward or street, they might just be able to avert a run on beds, ventilators, and ICUs that the tertiary hospitals provide.
“If we had a system to identify and track transmission at smaller scales and rapidly take measures to contain it locally, say in a ward, village or taluka, then in principle we would not need a big-bang nationwide lockdown. But we were caught unawares and insufficiently prepared so we had to resort to a national lockdown,” says Prashanth.
It’s because we don’t have the ability to trace contacts (as Kerala is doing) in every state and respond at local, smaller scales that the lockdown was the only possible solution—justifiable or not considering the number of migrant workers and workers in the unorganised sector—to break the chain of transmission.
Public health experts say the lockdown period and extension should have been used to build up PHCs and train health workers. Ideally, the guidelines and the checklists should have been handed down to the panchayat level even before the lockdown came into effect. But things have not panned out in this way.
“In a pandemic the main rule is, don’t play safe. Always think of the worst case scenario and act,” says Bhaumik, “if you don’t think like that the consequences will be so devastating that we will not be able to beat it. It’s better to overdo than to under-do. It’s okay, we might overdo something that will help kill it but if we don’t do enough, we cannot go back and redo it because it has already spread. The main thing here is not whether community transmission is happening but the extent of it. This is something the world learnt during the Ebola outbreak.”
Researchers say that while there are many guidelines, at the time there was no checklist that could guide local action on the ground. “Our idea was to provide something practical. They have used all other guidelines. But we have packaged it into practical managerial tools relevant to the PHC,” says Bhaumik.
By taking the syndrome approach, anyone reporting flu-like illness is treated as if they could be a case and containment is done with minimal disruption to the community at large.
“Careful home-based or community-based isolation and follow-up may result in recovery for a large proportion of the affected whereas those who progress to severe acute respiratory infection (SARI) may require care at tertiary hospitals,” says Prashanth.
The researchers put in tools for each of the six domains that the health officer or doctor at the PHC can easily use by marking.
They were aware that while COVID-19 is spreading, the other diseases didn’t take a holiday. The entire health workforce was engaged in coronavirus disease tracing and surveillance. Regular immunisation took a back seat. Health workers could be falling ill. They also realised that this was not going to be a short term job, but may span months. At district level and in rural areas, significant public health infrastructure is being turned into dedicated COVID-19 hospitals.
All of that, they thought, meant there would be a surge on top of the overload at a PHC. “A PHC has to prepare for regular illnesses and also for COVID-19. Migrant workers are coming back and they will not go to a tertiary hospital but to a nearby PHC,” says Bhaumik.
“That was the motivating factor for us. That became clear as we were writing the checklist.”
There were obviously debates when they were hashing out tools. When one suggested seasonal, small ailments can wait, others shot it down. You cannot keep a diabetes patient in limbo. When some suggested some group work such as a game as a stress-buster for health workers, Bhaumik argued against it saying that ran counter to social distancing.
There was no formal division on the lines of domain expertise. Everyone could come in on anything and suggest, tweak or fine-tune a tool. Or provide a new hack for the much-maligned PHC.
They could foresee that health workers themselves would face stigma, maybe outright rejection from the community. So, they devoted a section for that, including what tools would be beneficial as psycho-social support.
The researchers are aware of what a checklist can do and cannot do. It’s just that: a checklist, not a panacea for the epidemic. But it is important and useful. Checklists help to ensure a “reasonably functioning health system,” to be put to use. They save time and lives.
Now, they are working on a checklist for urban PHCs as well as translations into regional languages. Even this they want to winnow down further and present as just tools such as how to disinfect consultation rooms and other steps, without burdening a PHC doctor or health worker with too much material.