The pandemic and the rural doctor

When I retired from my surgical career a few years ago, I set up a clinic in a rural town in Kodagu district. The clinic is small and sparsely equipped. The medicines used are few and inexpensive. I make up for this thrift with advice: about the food we eat, our environment, inactivity, genetic disorders and stress being the key factors that cause disease. I explain how they can be prevented. Patients listen politely, or with dismay, or amusement. Some follow my counsel. The pandemic happened at a time when I was truly enjoying my job as a general practitioner, seeing a marvellous variety of cases, and therefore having to update my knowledge.

When Covid struck, the Indian economy was still suffering from the effects of demonetisation; and Kodagu had not recovered from the floods of 2018 and 2019, with crops damaged, houses wrecked, and tourism – one of the pillars of Kodagu economy – yet to recover. When the sudden lockdown came in March 2020, we had one positive case in the district. The average citizen buckled under the resulting mayhem. The lifting of the lockdown, with frenetic attempts to return to work and an influx of people from bordering districts and states, led to a surge in Covid infections which reached 6,000 within a few months. The district hospital in Madikeri admitted proven cases and managed them efficiently. But having a single centre for the entire region was inadequate. The distance from my clinic to Madikeri is 70 km.

I spoke to the district health officer (DHO) at the beginning of the lockdown to find out if he had any advice. In view of my age, he advised me to shut my clinic, stay safe and send all suspected cases to Madikeri. Of the three doctors working in town, one tested Covid positive and stayed off for two months. I shut the clinic, opened the clinic, shut it again and finally decided to stay open. I lost about two months thus but continued to see patients at home. The gentle warning from the DHO aside, no one interfered with my work; nor did I get any guidelines. A large number of doctors in rural India have had to rely on their own resources to handle the pandemic. Our efforts are an essential part of the rural struggle to cope with a ‘never before' medical crisis that has claimed the lives of nearly three lakh Indians to date.

I read about Covid, listened to experts online and spoke to medical colleagues. Epidemiologists warned that for each clinically confirmed case, there would be several more cases, untested and many of them asymptomatic. I tried to work within the confines of this crucial detail and did some clinical detective work. It was confusing and frustrating. The best help at that time came from a friend in Pune (non-medical, from the armed forces) who sent me useful medical information and a supply of the medicines; he also alerted me daily about new developments that I might miss. The other source of help was my brother (also from the armed forces). He provided me with a stack of N95 masks, medicines and gloves. The role of these two army guys was far, more important and genuine than the showy praise from the Armed Forces with helicopters showering flowers over hospitals, and serenading medical staff with music, thus expending Rs 68 crore. The banging of thalis and lighting lamps to ring in good health was just as empty a gesture.

Early treatment with home quarantine is ideal for a majority of patients. I used Hydroxychloroquine (HCQ) as a preventive and therapeutic medicine in the early months of the pandemic and then switched to Ivermectin, which has proved its worth if started early. Independent medical teams around the world have used these drugs and made their data widely available. Towards the end of last year, the ICMR endorsed these drugs but did not follow up on their use. Doctors around India have been using these drugs with success and safety.

The Covid pandemic exposed clearly the errors made by our government, the most fundamental being to rely entirely on one set of advisers and then rushing into an ill-timed lockdown. The plight of migrant workers who bore the triple blow of hunger, joblessness and Covid is unforgettable. Those in power underplayed the ill-effects of their goof-ups; they concealed hard truths under a blitzkrieg of self-congratulatory exaggerations of India’s success in defeating the virus. That a second Covid surge was likely in April-May in India was foretold as early as January by experts in India and abroad. The government chose to be arrogant and ignorant; and we, the people, stupidly followed -- travelling, attending parties and weddings, forgetting to wear masks: The reprisal was swift.

In Kodagu, the cases have risen sharply. I shut my clinic yet again and now see patients at home, on the porch. My job is to clinically detect cases early, because if treatment is started by the 2nd or 3rd day of the onset of symptoms, the chances of quick and safe recovery are high.

We are learning every day. The disease has two phases. The first stage is when the virus multiplies in the body and it lasts for six to seven days. This is when simple treatment is most effective. The second stage is one of high inflammation said to be caused by a hypersensitivity reaction to the virus and it can be dangerous if not quickly detected and treated. Blood tests to detect inflammation are essential in those who have a persistent fever after five days of treatment, severe lung signs, extreme fatigue or low oxygen levels. They need steroids, a blood thinner and an antihistamine. A few will require oxygen and fewer will have to be admitted for critical care and more advanced drugs. Much of what I learnt is based on small and large studies by various doctors. Around the world, there are several doctors and doctor groups well worth learning from.

More than a month after the onset of the second wave in India, we are in ‘crisis’ mode. Rural India is facing devastation. It is never too late to rearrange our cache of knowledge and wisdom, to learn, and to share our learning. An effective network of healthcare providers in each area, treatment protocols, availability of drugs and the quick establishment of oxygen beds will do wonders.

And when the pandemic is no longer a threat, we must prepare to face the economic and the nutritional debacle that will follow.

(The writer is a surgeon and novelist)