London School of Hygiene & Tropical Medicine

“Tribal communities in southern Rajasthan in India have amongst the highest burden of malnutrition in the state as well as the country, and a huge burden of morbidities as well as preventable mortality. In areas where they exist, AMRIT clinics are the only facilities run by qualified health providers, with the next facility located at least 15-20 km away. When the pandemic and lockdown began, a major challenge was continuing health services, and also ensuring the safety of our health workforce of physicians, nurses and health workers. The other health facilities were shutting down the regular outdoor services and focusing on COVID-19 alone. As we were practically the only providers in the area, cutting down on their work even in the face of the pandemic was not an option.

“Faced with resource and space constraints, our response included using masks (multilayered, reusable ones), social distancing, and rigorous hand hygiene. We also shifted the consultation area into the open to further reduce transmission risk. The sense of fear everywhere also affected our nurses and health workers, who were under constant pressure from their families to return home. Speaking to them regularly, clearing their doubts as well as fears with scientific knowledge as it became known, was and still is an important part of our work. These discussions, carried out through online sessions as well as in person, have clearly boosted their confidence.

“Halting of all public transport and marked restrictions on travel made it very difficult for patients with chronic conditions, most commonly tuberculosis, diabetes and hypertension to visit the clinics. We listed out these patients and our nurses and health workers made home visits to deliver their medicines. Being close to the communities, we were also able to identify their urgent needs. Very soon after the lockdown began, there was a severe shortage of food. Our field teams identified the most vulnerable families for whom we, together with the government, mobilised food rations quickly. In the early days of the pandemic, there were also a lot of rumours circulating in the communities that created a panic like situation. We trained our health workers, who conducted telephonic counselling of community members, responded to their questions, and allayed their fears.

“Training of the physicians, nurses and health workers has always been an important part of our work. While we have not been able to conduct in-person training since the lockdown began, we have shifted to online platforms to continue the agenda. We have been using individual assessments (using apps such as google docs), and on-job mentoring and support.

“Our work also includes running daycare centres that provide nutritious food and a caring environment for young children. While these were closed from the time the lockdown began, our workers prepared hot cooked food for the children and delivered it home in small tiffins. In areas with extreme food scarcity, the food has ensured the availability of nutritious food and will likely protect these children from slipping into malnutrition.

“We have seen that following evidence-based protocols, adapting them rapidly as more knowledge becomes known, honest communication with the team, and supporting them helps in ensuring continuity of services. In times when the number of patients across many health facilities has dropped, the AMRIT clinics are seeing even more patients- nearly 25 per cent more than those seen in similar periods last year. There are now more patients of tuberculosis, severe malnutrition, women seeking contraception, and many more conditions. With the rainy season on, we are also seeing and managing more and more cases of malaria.

“In the last five months, my organisation and I have been writing extensively, sharing findings from the ground with the external world, and advocating the cause for strong primary healthcare systems especially in the midst of the pandemic. Our writings include the challenge of tuberculosis and why it needs continued focus, the incidence of COVID-19 in the migrants returning from cities to rural areas, food availability in tribal areas, the situation of childhood nutrition and actions needed, and more. These have been published in well known online portals in the country. My training in epidemiology has been vital in researching and analysing issues, and in documenting these in a scientific manner.” 

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