“1030am sharp - outside the municipal office” read the message the night before. A casually dressed man greeted me that morning, ushering me into the ambulance. We were a team of five - two doctors, one medicine dispenser and two support staff. We drove a few minutes to the screening camp location, which changes each day. Two local residents of the ‘chawl’ (ultra dense housing units of lower middle SEC), and two ASHA workers (government social health activists - always women) awaited our arrival.
The other doctor and I opened the sealed boxes given to us, donning the layers of PPE clothing provided. Whilst doing so, the team set up an effective assembly line behind us, like a well oiled machine. On my table in front of me was placed a large cardboard box - filled with various tablets and medicines, to treat any minor symptoms and complaints. It comprised pain relief, broad spectrum antibiotics, antidiarrheals, indigestion therapy and some decongestants. Obviously missing was cough syrup, however it did have a few strips of Hydroxychloroquine.
My colleague, Dr. K, was a recently graduated prosthodontic surgeon, who had also volunteered for this camp out of a sense of duty.
It had been ten years since I had last formally seen patients but when the message to volunteer came - I felt I had to say yes.
The least I could do is take a medical history, cannulate or administer drugs. My wife and I discussed the risks. It was the right thing to do. This is my generation’s time to step up.
At the Surveillance Camp - Two Hours, 290 People
The assembly line was structured as follows. The ASHA workers measured each individual's blood oxygen level and heart rate via a pulse-oximeter. Next the person’s forehead temperature was scanned. These recordings were registered and then I saw the person, taking a brief history, reviewing the clinical data. If concerned, and suspected a positive case, or felt that a second opinion was needed, my medical colleague would take a more detailed history (it helped that she was fluent in Marathi) and the drug dispenser then handed over the required medicines. This effective process saw a person through in under two minutes and ensured that various people saw the person to arrive at a collective decision.
The system was culturally contextual, economical, effective, scalable and efficient. However, improvements could be made. Here are a few suggestions that could be easily considered.
The Limitations
In the course of two hours we saw 290 individuals! A loudspeaker system was set up in the chawl and announcements were made for our arrival; requesting people to come and get screened. This was the first weakness - the entire system relied on self-declaration. Whilst we covered a larger number of people, we had no idea how many people chose to, were unable to or were forced to stay away. We already know there is a stigma associated with this disease, something I have written about on many occasions, and this could easily lead to individuals not reporting for fear of being identified.
The second change would rely upon the results of the clinical review. Around 15% of individuals at the first pass, had non-specific symptoms of COVID-19. The majority had flu-like complaints or a dry cough and sore throat for 4-5 days. All of these were reviewed and sent away with symptomatic treatment, recommendation to drink hot water with ginger and turmeric, and download the government app for contact tracing and symptom checker (Aarogya Setu). Roughly fifty people could have potentially been sufferers (carriers unknown) and my task was limited to providing relief, reassurance and advice on symptom progression. I would like to consider the possibility of installing a process for testing patients on-site; setup for us to “test, test, test” as advised by the WHO and numerous national public health experts.
The third concern was in relation to a suspected/ probable case. We had three individuals who were most likely suffering from an active infection and asked to report to a government centre. However the level of empowerment we had was limited. We recorded the event by highlighting the person’s name - in the record book, noting their address, and giving them the details of the nearest testing centre. But, they were then left to their own and therein lays my biggest fear. Will the person actually go right away (if at all), how many people has he or she already infected and more worryingly how many more will they infect? A problem which would be resolved by leveraging the digital infrastructure the government has worked so hard to put in place - the app.
Clinically, all three individuals were young (less than 40 years old) and had symptoms of a dry cough, head cold, tachycardia and sweating. Of the three, one young man in his early twenties, also had the classical loss of smell (and taste) known as anosmia. This highlights the anecdotal importance of each of us understanding that we are each susceptible to the infection.
The impact of this entire morning’s effort seems lost if the three cases (at a minimum) were not tested, and if positive, isolated, treated and contact traced. Visiting the front line taught me important lessons of the city’s public health response. It has the best of intentions for its citizens. I came home with a deep sense of respect for the regular front line workers, the #CoronaWarriors, and impressed by the managerial efficiency of the screening units - being able to process large volumes of people every hour. In a city of 20M+ individuals, one which already has the highest caseload in the country, with an incredibly dense urban population, many of which are living in cramped conditions with little or no financial support - these small changes could be the difference between flattening the curve or losing to the virus.
Join me next week as we continue our journey ‘From the Frontline’; in an episode where I will face an agitated patient, caught between the regulatory tape, and left to fend for himself.
(Dr Marcus Ranney is a business professional in healthcare and technology. He has volunteered to help with COVID-19 pandemic in Mumbai)
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