The Jan Chetna Manch, Bokaro (JCMB) is an NGO that empowers low-income communities in areas of health, advocacy, livelihood, and land. With no guidelines or protocols in place, officials have been forced to use their discretion during the lockdown in taking care of expecting others, thus creating a lot of confusion on the ground.
For example, JCMB’s health centre, which works on nutrition and maternal and child health programmes, was put at risk because their supply of Personal Protective Equipment (PPE) was stuck in Jamshedpur due to the ban on inter-state transport.
“That we read about in the newspapers, it’s a little different in reality,” says Lindsay Barnes, the supervisor of health programme at JCMB
The fact that they are essential items is of little consequence.
According to Dr. Arun Gadre (a gynecologist who earlier worked in rural Maharashtra for 20 years) several COVID-19 tragedies were of the preventable kind. At JCMB, the staff has been shaken by several unusual preterm deaths recently.
JCMB’s last month report revealed five preterm births — an unprecedented jump from one or two a month. With transport banned during the lockdown, women from low-income brackets that the JCMB health centre caters to were unable to reach on time and some have consequently had stillbirths.
“We hardly ever experience such deaths here, so it is disturbing for us,” says Barnes.
Dr. Gadre believes it is important to understand that because ASHA (Accredited Social Health Activist) volunteers – the final frontier of the healthcare system in rural and tribal areas – have been redirected to COVID-19 related relief work, the people they usually care for are left to fend for themselves. He also worries that the APJ Abdul Kalam Amrut Yojana, which has come to a halt due to physical distancing norms, will cause serious problems in the future. This programme entitled mothers to free, hot, nutritious midday meals, injections, sonographies and home visits by an ASHA volunteer post-delivery to check for infections and lactational problems.
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JCMB has had to restructure its entire health programme due to the COVID-19 pandemic. They have begun to provide home-based care through their Community Health Workers (CHWs) instead, and are discouraging women from coming to the clinic for regular check-ups unless there is a serious problem.
A challenging restructure
According to their records, they cater to around 40 to 50 pregnant and recently-delivered women while strictly maintaining physical distancing and hygiene norms every day. Although they were originally involved with nutrition and immunization programmes, Barnes is hopeful this will reduce the complications in delivery and postnatal care that JCMB has witnessed during the lockdown.
While the Health Centre feeds the women 5 times a day, Barnes says the cost of delivery has increased during lockdown. Many women have additionally lost out on the subsidised delivery benefit that they get as JCMB is accredited under the Janani Suraksha Yojana.
A major change at JCMB is the nurse midwives’ routines as they now spend a lot more time washing everything. Even though they themselves don’t have the right PPE equipment after Bokaro had experienced one of the first COVID-19 deaths in Jharkhand, Kajol, a nurse midwife, and Purnima, a second nurse never complain and instead carry on with a smile and a cheery “Yeh toh hamara kaam hai,” (this is our job).
The lockdown has given rise to other practical problems as well, although the extent may vary depending on the region, culture, geography and previously disadvantaged groups. While the urban middle and upper classes have the means to access health care, delivery is still affected due to shortage of staff in private institutions. Some gynecologists have put in place a system of screening of contact history, says Dr. Gadre, and suspected COVID-19 positive mothers are sent to government hospitals for fear of being shut down. At the end of the day, doctors face the dilemma of ensuring that their clinics either remain open to cater to the majority or treat the odd infected mother and risk shutdown.
Amulya Nidhi, co-convenor of Swasthya Adhikar Manch and part of Jan Swasthya Abhiyan, a network working on health and healthcare, is careful to emphasise on the four pillars of any healthcare system. These include manpower or staff, infrastructure such as hospital buildings and services like ambulances or blood banks and supply of drugs, vaccines and so on. From the above examples it is quite clear that the foundation of our public health system is not strong enough.
Shishupal, the only male CHW at JCMB describes his normal day. during the lockdown. Despite having to pass through police nakabandis and other barriers, he finds alternative routes to do his job. While maintaining physical distancing norms and allaying the fears of villagers, he home delivers nutrition supplements and medication as part of the nutrition programme. The 400 malnourished children are checked for nutritional deficiencies only by observation, as making detailed lists of health indicators as he did prior to lockdown isn’t feasible anymore. He covers 2-3 villages a day out of the total 60, depending on the size of the village or the number of children.
With migrant labourers now returning to their home states in large numbers, it is important to spread awareness and educate communities against blind belief in rumours and stigma that cause panic and fear. However, the extent of the impact of ignoring other health concerns during the fight against COVID-19 will only come to light in the next few months.
Delivering a stillborn
With postnatal care being reduced and all other healthcare put on hold, especially in Primary Health Centres (PHCs), it has certainly affected previously marginalised groups such as Muslims, tribals and Dalits, lower-class women to name a few. Dr. Gadre said that in May in Pune a nine-month pregnant Muslim woman was unable to reach the hospital in time due to lack of transport and the refusal of several hospitals to admit her without a COVID-19 negative test. When a kind bus driver finally gave her and her husband a lift to a hospital that she was finally admitted to, she delivered a stillborn.
The lack of education and systemic oppression only deepens the marginalisation that these women face every day. Without immunization drives being carried out as usual, babies born before and during lockdown are at high risk of succumbing to many preventable diseases. In fact, in Indore, the immunization drives restarted only two whole months after the lockdown, says Nidhi.
However, while funds are pouring in due to the kindness of regular citizens and philanthropists, the government should be using this as an opportunity to strengthen the public health system.
“Corona is exposing the social health structure, the vulnerability, everything. All points that were hidden…they have become raw and bare,” worries Dr. Gadre. This is concerning because while we are aware that our public health system isn’t the strongest, it was still functional. Being compulsorily diverted to COVID-19 work, all other care has been put on hold, further burdening the public health system. If we destroy this ecosystem now it may take years to put things back in order and return to how things were prior to the lockdown.