In a recent case of panic brought on by the lack of testing facilities in Melghat, a tribal area in Amravati district, a 25-year-old labourer who had symptoms similar to COVID-19 was shunted from one hospital to another, before he died in Amravati. Tests showed he did not have COVID-19 but had died of complications resulting from rheumatic heart disease, which could have been treated in Melghat.
The case has brought into tragic focus the urgent need for testing facilities in the rural areas, especially those that have migrant labourers who work in big cities.
Distress signs
Ajay Tamhane (name changed to protect identity), a daily-wage worker, came home to Zatal village, Melghat, in February, from his work site in an Odisha coal mine. A month later, he reported cough, cold and high fever, and complained of chest pain. On March 21, his brother took him to the Sub District Hospital (SDH) in Dharni, where he was put on pain-killers and intravenous fluids, and then discharged.
But by the next day, his condition turned critical: he had developed severe cough with hemoptysis (nose bleeding), cold, fever and breathing difficulty. News of coronavirus had reached his village by the time, and his brother took him back to the SDH.
The medical officer suspected that Tamhane had COVID-19 symptoms as he was struggling to breathe, and the oxygen level in his blood had dropped to 50% (95% is normal). The nearest referral centre with testing facilities was in Amravati, 150 km and four-and-a-half hours away. But as his condition was worsening rapidly, doctors at SDH referred him to the local MAHAN Trust Mahatma Gandhi Tribal Hospital (MGTH), a charitable hospital, and the only one in the area with an internal medicine physician, apart from other specialists and an intensive cardiac care unit (ICCU).
There, despite being put on a ventilator, his oxygen levels did not improve, and his respiratory distress seemed to be increasing.
The doctors took his travel history, and decided to refer him for coronavirus. Government rules mandate that suspected cases with respiratory distress should be referred to the designated district hospital in Amravati. Though, the patient’s oxygen levels increased to 70% and he was feeling better, the doctors called for a government ambulance and shifted him there.
At Amravati, Tamhane was put in an isolation ward, but he died the next day. His COVID-19 test was negative.
Need for testing facilities
At Melghat, doctors had been monitoring Tamhane constantly. His ECG indicated he had rheumatic heart disease with heart valve issues. He also had pulmonary oedema (swelling) and Acute Respiratory Distress Syndrome (ARDS). The ventilator support at Melghat had subsided his pulmonary oedema and ARDS and his oxygen levels had hit 96%.
“If his corona-negative status could have been diagnosed in Melghat, he would have received ICCU care in Amravati and could have been saved,” said Dr. Vipin Khadse, medical officer at the SDH, nodal officer for COVID-19 in Melghat, and volunteer doctor at the MAHAN Trust. “He was stable in our setup but according to the government mandate, every ARDS patient has to be sent for coronavirus testing. If coronavirus cases do indeed come to Melghat and, let’s say, we get a hundred patients a day, who can we refer them to?”
Hard times
Dr. Ashish Satav, chief medical officer at MGTH, and one of the doctors who attended to Tamhane, said villages in Melghat — which has a population of 3 lakh, 84% of whom are tribals — are congested, and homes are often small, without ventilation. Poor hygiene is another issue, leading to increasing cases of rheumatic heart disease in young people. Dr. Khadse said, “People here often don’t clean themselves well after defecation. Streptococci bacteria migrate to the throat, and their colonies move through the blood to the heart.”
In his 22 years at Melghat hospital, Dr. Satav said he has handled over 3,000 critical cases. Heart attacks are common among the tribals and “over 60% of deaths are due to infectious diseases here,” he said.
Dr. Satav said doctors are reluctant to take up posting in Melghat due to poor living facilities. Of the three hospitals in the area, few have expert physicians or trained staff, while one, run by an NGO is non-functional, with doctors being called back for coronavirus duty.
The trust’s 30-bed hospital has received five cases of respiratory distress in as many days, two of whom have been sent to Amravati for testing.
Getting there isn’t easy either, especially for the poorer residents. “These are tribals who earn ₹4,000 to ₹5,000 a month. They have to negotiate forests and mountains to travel outside for treatment and prefer to be treated locally,” said Dr. Satav. “Even if the government does put money into their account, they have no idea how to operate those accounts; they are not literate. I have patients coming to me with ₹1 or ₹2 in their pocket, and it’s difficult to convince them to go to Amravati for testing.”
An added problem is that the two government ambulances do not make return trips from Amravati, and patients’ relatives have to spend up to ₹10,000 to hire private ones.
Yashomati Thakur, State Women and Child Development Minister and Guardian Minister for Amravati, and the principal secretary, Health, did not comment on the issue.
Bleak future
As nodal officer for coronavirus, Dr. Khadse is tasked with looking out for COVID-19-positive cases, in the area, conduct a surveillance of migrants from cities like Pune and Mumbai, trace their contacts, isolate them, and follow up with the home-quarantined.
“We need testing facilities here,” said Dr. Satav. “A PCR machine to test for coronavirus costs ₹20 lakh, which hospitals in the area cannot afford.” There have been no cases detected in Melghat yet. If there are, for Dr. Satav and his colleagues the future will be a hard trial.
