A simple prescription to contain COVID-19 in rural Karnataka

A doctor and his team of volunteers spread across 160 villages of Karnataka adopt a simple method to contain the spread of COVID-19 in areas where public and private health care infrastructure is almost non-existent.

Dr Anil Kumar Avulappa, district convener of the DYFI who runs the People’s Surgical and Maternity Home in Bagepalli.

Zaheer Baig is an agricultural worker and migrant labourer belonging to Digavanettakuntapalli in Bagepalli taluk of Chikkaballapur district in south-eastern Karnataka. His family also runs a small grocery shop in the front portion of his house located on the main road of the village. As the second wave of the COVID-19 pandemic spread to the villages of Bagepalli between April and June, Baig and his friend, Khalandar Khan, an agricultural worker and a cadre of the Democratic Youth Federation of India (DYFI), could be seen in front of Baig’s grocery shop at 8 a.m. every day with a box of medicines. They had been provided basic training to monitor COVID-19 symptoms in the village.

Residents of the village (which has a population of 1,200) with fever, cough, body ache or other symptoms began to gather at Baig’s shop. Baig said: “I would first record their temperature with a [thermal] scanner, check their oxygen [saturation] levels with a pulse oximeter and note the first day when their symptoms appeared. If the patient had fever, I would immediately give him an initial dose of three medicines: Dolo 650, Cetrizine and Doxycycline, as prescribed by Dr Anil [Kumar Avulappa].” Poring over a notebook in which he has taken down the history of every patient in Kannada, Baig swiftly tallied the daily numbers and said: “Sixty patients were given the first dosage of medicines at Digavanettakuntapalli, and they have all recovered.”

At Naremaddepalli, located 10 kilometres from Digavanettakuntapalli, Mabbasha N.M., an agricultural worker associated with the Karnataka Pranta Krushi Koolikaarara Sangha (KPKKS), the State unit of the All India Agricultural Workers Union, and his team of three volunteers monitored COVID-19 symptoms among the 2,000-odd inhabitants of the village. Mabbasha said 100 people were given the first dose of medication.

C.M. Vemanna, a KPKKS member from neighbouring Jangalapalli, said: “Four patients developed severe symptoms even after they were given the first dose of medicines. After consulting with Dr Anil, I gave them a second dose of medicines consisting of steroids, which helped in their recovery.”

Baig, Khan, Mabbasha and Vemanna are among the 480 volunteers spread over 160 villages who have been trained by Dr Anil Kumar Avulappa to fight COVID-19 in Bagepalli and Gudibanda taluks, 100 km from Bengaluru. Avulappa owns and manages the 30-bed People’s Surgical and Maternity Home in Bagepalli. The residents of most of these villages in this arid and backward part of Karnataka are agricultural labourers, the majority of them either Muslims or from the Scheduled Castes and Scheduled Tribes.

Treatment advisory

Frontline visited seven villages coming under the purview of Naremaddepalli and Somnathpura gram panchayat limits in Bagepalli taluk to understand the efficacy of a simple technique devised by Avulappa to restrict the spread of COVID-19 in a region where public and private health care infrastructure is almost non-existent. There is only one Primary Health Centre for every two gram panchayats in Bagepalli taluk. In all these seven villages, volunteers who spoke to Frontline explained how they managed to contain the spread of coronavirus through the treatment advisory provided by the doctor.

Avulappa explained this in detail: “It is important to mark the first day when the patient starts to show COVID-19 symptoms and to begin treatment immediately with a five-day course of Dolo 650 (paracetamol, given twice day), Cetrizine (an antihistamine given once a day) and Doxycycline (an antibiotic given twice a day). On the seventh, eighth and ninth day, one should watch out for the danger sign: this could be an increase in the existing symptoms, the manifestation of a new symptom or breathlessness, in which case the patient should be given a dose of steroids (16 milligrams of Methylprednisoleone once daily).” This is the crux of Avulappa’s treatment protocol, which he calls a ‘syndromic approach’, initiated during the COVID-19 second wave. He says he adopted this approach from Dr Shankara Chetty, a reputed doctor of Indian origin based in South Africa.

Volunteer network

Avulappa managed to create the volunteer network for the community-led initiative last year when COVID-19 began to spread beyond urban centres. He realised that if the pandemic reached the villages of Bagepalli, it would be disastrous in view of the absence of heath infrastructure. It was at this point that the doctor, who is also the DYFI’s district convener, began to put together teams of volunteers drawn from the network of organisations such as the DYFI, the KPKKS and the All India Democratic Women’s Association (AIDWA), allaffiliated to the Communist Party of India (Marxist), in Bagepalli and Gudibanda taluks.

The fact that the CPI(M) has a rich and long history of organised struggle in the region helped. Soon, a team of volunteers consisting of between three and five active members was in place in each of the 160 villages where Avulappa’s network extended. Of these, the majority were spread across the villages of Bagepalli taluk while 18 teams were set up in Gudibanda as well.

Avulappa conducted 14 training sessions for different sets of volunteers last year, explaining the nature of COVID-19 and the measures that could be taken to prevent its spread. During the first wave, Avulappa also began to use this extensive network to identify and treat a variety of ailments among the agricultural workers in the region. Most of these workers have small agricultural landholdings and subsist on wages earned through their participation in schemes under the Mahatma Gandhi National Rural Employment Guarantee Act. But the real benefits of this grass-roots network would become clear during the second wave.

“During the first wave, we focussed on vulnerable sections of the population such as senior citizens and people with comorbidities, but there was also tremendous indifference among the general population to the dangers of the virus. It was only during the second wave when a sense of panic spread in the villages as the number of casualties increased that they sought the help of the volunteers. At that point, I heard Dr Shankara Chetty’s approach.”

Using Chetty’s methodology as the basis for his protocol, Avulappa went ahead with its implementation by conveying the treatment protocol to his teams. Two non-governmental organisations, the Rotary Bangalore Spandana and the Right to Live Foundation (RTLF), chipped in by providing thermal scanners, pulse oximeters and medicines. T.V. Sridhar, the executive director of RTLF, told Frontline that his organisation was eager to help Avulappa because “what he did was completely unique and democratised the provision of rural health care”. Thus, each village centre (which simply meant the house of one of the volunteers) was equipped with these basic tools needed to monitor COVID-19 symptoms.

As COVID-19 cases started increasing in Karnataka in April, Avulappa’s hospital was overwhelmed with COVID-19 patients, but he managed to frequently address the volunteers through videoconferencing to clear their doubts. He also made time for teleconsultation with patients whose symptoms persisted. The field supervision of the initiative was managed by M.P. Munivenkatappa, the KPKKS’ State vice president; B. Savitramma, AIDWA State committee member; and Harisha Y.N, RTFL’s programme coordinator and DYFI district committee member. Every morning the trio would head out to the villages from Bagepalli to coordinate the initiative and keep track of medicines supply. “We would cross verify every patient’s symptoms after getting the daily list from our village teams,” Munivenkatappa said.

Each patient’s current medical history retained by the volunteers shows the effectiveness of Avulappa’s straightforward initiative. At Besthapalli, for instance, Kalpana, an anganwadi worker and AIDWA associate, produced a notebook in which she has maintained a record of 26 people from the village who required the first dose of medication. The data entered in the table include the person’s name, husband/father’s name, oxygen saturation level, temperature, age, date (when the symptoms first manifested), symptoms (of the patient), medication provided and recovery. Kalpana said all the 26 people in her list recovered after they were put on a five-day course of Dolo 650, Cetrizine and Doxycycline.

Dr Satyanarayana Reddy C.N, Bagepalli Taluk Health Officer, said: “Dr Avulappa and his team have done exactly what was needed by people in their homes at the village level and they did this at a time when villagers were apprehensive of visiting hospitals. Their work has had a great impact in restricting the spread of COVID-19.”

The success of this initiative can be gauged from the statistics provided by Harisha, who was responsible for tabulating the data received from the volunteers. She said: “From the first week of May to June 15, 1,288 persons were given the first dose of treatment. The symptoms subsided after three or four days for most of them. Only 43 persons required the second dose, but no one succumbed to the virus or even required hospitalisation.”

People’s initiatives

Avulappa’s initiative, which he describes as a ‘social consolidation strategy’, has demonstrated the effectiveness of a simple, people-led and grass-roots-based effort to challenge the pandemic when the existing health care infrastructure has proved to be inadequate. Munivenkatappa said more such people’s initiatives were needed as COVID-19 “had laid bare the failure of capitalism”.

Avulappa is now advocating measures to combat the (likely) third wave. “The third wave can be fought only if there is a massive extension of health care services to rural India. After the Spanish flu pandemic of 1918-1920, health care systems changed in the world; in Russia [Union of Soviet Socialist Republics], health care was made free; in the United Kingdom it led to the establishment of the National Health Service. After the pandemic ends, India should work towards doing away with corporatisation of health care and strengthen its public health care system,” Avulappa said.