Health Response in Disaster Situations - An ode to our medical fraternity (An on-ground experience during Kerala floods)

If you can keep your head when all about you   

    Are losing theirs and blaming it on you,   

If you can trust yourself when all men doubt you,

    But make allowance for their doubting too;   

If you can wait and not be tired by waiting,

    Or being lied about, don’t deal in lies,

Or being hated, don’t give way to hating,

    And yet don’t look too good, nor talk too wise:

If you can dream—and not make dreams your master;   

    If you can think—and not make thoughts your aim;   

If you can meet with Triumph and Disaster

    And treat those two impostors just the same;   

If you can bear to hear the truth you’ve spoken

    Twisted by knaves to make a trap for fools,

Or watch the things you gave your life to, broken,

    And stoop and build ’em up with worn-out tools:

If you can make one heap of all your winnings

    And risk it on one turn of pitch-and-toss,

And lose, and start again at your beginnings

    And never breathe a word about your loss;

If you can force your heart and nerve and sinew

    To serve your turn long after they are gone,   

And so hold on when there is nothing in you

    Except the Will which says to them: ‘Hold on!’

If you can talk with crowds and keep your virtue,   

    Or walk with Kings—nor lose the common touch,

If neither foes nor loving friends can hurt you,

    If all men count with you, but none too much;

If you can fill the unforgiving minute

    With sixty seconds’ worth of distance run,   

Yours is the Earth and everything that’s in it,   

    And—which is more—you’ll be a Man, my son!

                                                                - From ' If ' by Rudyard Kipling (1943)

    The month of August 2018 will be etched permanently in the minds of Kerala people. Such was the disastrous effects of the rains and flood which created havoc in the state. It was unprecedented, unimaginable and unexpected. Life was suddenly in jeopardy. Barring the three districts of Thiruvanathapuram, Kollam and Kasargod, all the other districts were in water literally.

Satellite images of Kerala state before and after floods

    Everyone was unprepared. Those people who are trying to play politics in this difficult situation have to understand the definition of disaster first i.e. an event or calamity or destruction which cannot be contained or treated by its own resources. Be it any political party which holds the power, this was an unprepared call.

This was nature's mayhem. We had many pitfalls, we weren't able to predict the calamity in the first place plus our people weren't even aware how to respond in this crisis. The state lacked the experience, but what the world saw after the floods were a remarkable story altogether. Most of the news feed available is being told through the eyes of a rescue member or through a news anchor. 

    I would like to share my small experience with you all. I would like to share how our health system coped up with providing health care and support during the floods. I would like to tell my experience though the eyes of a health care provider.

The notice posted reads as "It is from this Hospital that doctors and staffs are offering services to all flood relief camps under the Taluk. All the staffs including doctors are working 24 hours a day. Please cooperate." 

    One thing to understand is before, during and after the floods - the health infrastructure and manpower in our government sector was static. The numbers haven't increased but the efficiency have. The doctors and staff have worked really hard to provide services in the most remote areas. Help had poured in from sectors especially volunteers and medicines. I had also the opportunity to mingle with many people who worked directly in the flood hit areas. They all had different stories to tell, but all had the compassion to work more and more in-spite of relentless effort.

    Best part of the whole mission is to witness coordination everywhere. Initially, there were hitches since this calamity was one which the health sector hadn't faced before. Many hospitals were under water, and in most institutions, the electricity was down. Hospitals were frantic in not knowing what to do with the sick patients. As an emergency physician, I know how difficult it would be for seriously ill patients like those having chronic kidney diseases on regular hemodialysis, even if they miss one session of dialysis. 

    I felt very happy when I heard the news of a pregnant lady in labor was airlifted and treated at a navy hospital, where she delivered a beautiful baby. I mean to say, this is where everyone has a role and even though how minuscule, it may be, it should be seen as humanity at its best. It emphasizes the realization that God resides within all of us as universal compassion and friendship. The hashtags used in social media such as #WeWillOvercome, #StandwithKerala and #CompassionateKerala are few examples.

A pregnant lady with rupture of membranes had been airlifted and evacuated to INS Sanjivani.

    My original intention was to accompany the medical team and see their work style. The health system works on a tier level according to my understanding. At the top level is the district medical officers. Under him, there are many nodal officers which are mostly the top doctors in different community health centers and under them are the other doctors and staffs.

All those doctors who have concomitant administrative role were in regular touch with the local self government people also. This is a calamity in which the health care providers are also affected i.e. they might be in flood hit areas and are unable to come for work. But fortunately, there were plenty of selfless volunteers including doctors, staffs and students who helped our health sector and kept the light shining. 

    On a personal note, I could understand that the categories of patients that need attention are five fold:

    1. Those requiring urgent treatment at the time of floods.

    2. Those who require treatment of dermatological conditions after the floods.

    3. Those who require specialist care.

    4. Those who require their regular check up and medicines.

    5. Those who require attention for vector borne diseases.

    I had joined my friends to participate in the relief work. My first task was to report at the control room at the local community community health center (CHC). They were well organised. There was a control center in which the nodal officer along with other staffs sits and maintains registers, receives calls, allocates teams and task. The flow of doctors and other staffs varied from time to time. Teams are allocated by the nodal officer. I was entrusted with a team which consisted of myself, two interns, one junior health inspector, one junior public health nurse and one pharmacist. Since I had my own vehicle, medicines were loaded into it after sorting in the CHC.

Control room at CHC Mannar

Sorting out medicines itself is a tedious task. The pharmacist available was placing medicines name wise in different cardboard boxes. The medicines available ranged from ORS packets to NSAIDs to even glucometer strips. Also, at these times, it's difficult to get specific medicines. But the medicines were in surplus. Some were sample medicines whereas others were all mixed up. There was plenty of Doxycycline tablets available since it was the only remedy for prophylaxis against leptospirosis.

Sorting medicines and getting ready for camp visit

Once the medicines were loaded into my vehicle, we set off to our destination. We turned right from CHC Mannar into the main road and travelled for two kilometres and then turned left at Koickal junction to go to Budhanoor, which was around 8 to 10 kilometres far. We had one house visit where an very old man in his 90s was lying very sick. He was all crouched up and with noisy breathing. All his family was with him. It was then I understood, the local PHC was affected by the floods and the doctor concerned was also in a flood affected area. So, there was no immediate doctor or help available in the vicinity.

He was critically ill according to my assessment and needed immediate care. But the relatives were all hesitant to take him to CHC Mannar owing to his old age. I said at least we could help him to take food by putting a nasogastric tube. Relatives expression's weren't much convincing. We left the house to move on a place named Koipally where there was a camp, housing around 40 inmates. Most of them had left to check whether water levels have receded at their houses. 

    

Houses still inaccessible in Budhanoor due to high water levels even after the rains have stopped. The electric posts standing tell us that there used to be roads through the stagnant water.

At the Koipally camp, after some discussion with the local people in-charge we started setting tables and chairs for conducting OP clinics. Majority of the people had complaints of itching and excoriation over their lower extremities, which is mostly a consequence of spending a lot of time in muddy water. We supplied tubes of Clotrimazole to them. Clotrimazole cream supplies were adequate now. What I learnt from the JHI (Junior Health Inspector) was previously, they used to give the cream in small amounts smeared in a white piece of paper, due to scarcity. Other complaints mostly were related to chronic illness. We managed patients with the limited number of medicines we had. The people at the camp were very friendly and even offered us to join them for lunch. But we had many more camps left to visit.

Beaching powder for disinfection - a scarcity to be addressed.

Next, we made similar visits to other camps which were located at a primary school, church hall and a social auditorium. Also we made a house visit, where there were 4 newborns and their mothers. All were fine. Notable diseases were a child with breathing difficulty and few fever cases. All those people who lost everything are very happy, especially to see us. To them, its a feeling that the government is taking care of them. For us, its a similar feeling to offer our services and see them smile.

Trucks distributing food at flood affected areas.

Next day, again we started our day by visiting the CHC, Mannar. This time, we went to Kadampoor to open the PHC (Primary Health Center). We got reports that the water levels have receded. When we reached there, everything was in shambles. Pictures can tell more than words. Therefore, I am posting photos below. In short, it can be described as 'total loss'. From the marshy smell, to the leeches and weeds, the place couldn't no longer be called a PHC.

Water didn't require keys to open the gates. The gates reeled in front of the fury of the floods.

Leeches were a common sight. But fortunately, we didn't see any snakes or alligators.

Medicines were spewed everywhere in and out. A Diclofenac gel tube seen amidst the Salvinia (African paayal) weeds.

Plenty of questions but no answers. Staffs standing wonder-struck seeing the pathetic situation of the PHC.

Staff members cautiously treading through the slippery path to the PHC. You can also see salvinia weeds (african paayal)  encroaching the health center compound.

Was it the floods or mob violence that created havoc?

Refrigerators and furniture all suffered the same fate.

All non human too suffered the same fate.

Renovation, Reconstruction, Rehabilitation. I am waiting.

Some volunteer organisations came forward to ensure willingness to clean the premises. We are very thankful to the people around who just came out of no where to offer help.

Next, we made a visit to Pandanad, which was one of the most badly affected areas. We turned right on our return from Mannar junction towards Parumala and so on. We just came to know that the roads have become viable from today. The images which we saw were not soothing. Road transport services both public as well private hadn't been reestablished yet. The road was full of dried up mud, which spreads as dust once vehicles traverses by. The people were wearing masks. Most of them were involved in cleaning their houses, drying their clothes and furniture and maintenance work. I could see people pushing their two-wheeler's to the service centers all clad in thick mud and dust. I could see despair and hopelessness in the eyes of the people. It would require years to steer back things back to normal for many households.

Sanitation workers taking a much needed break for lunch.

Potential respiratory problems due to rampant dust will be an emerging problem soon.

Vehicles clad in mud is a common sight in these areas.

Metal fences also bore the wrath of the floods.

Motor bikes mounted on pick-up being taken to service centers.

Everything from A to Z needs to be dried up in the sun.

Clothes getting dried up in the scorching sun.

Stories which tell you how we battled against the mighty floods. Unsalvageable boats in the background . 

I was impressed by another venture by the health department. It was regarding how monitoring is done in the flood relief camps by the health care providers. This is a very big lesson to be learnt and must be extended to all camps. This is an android based application and the health care providers input the data. I am posting few screenshots of the app here. This method of using technology for the betterment of care should be encouraged.

The application is called KoBoCollect.V1.14.0a

                                  

 
                                
 

                                

 


The data is entered and which is later sent into the main server, which could be a useful tool in monitoring health parameters. This tool should be made compulsory for each camp visit team.

I would like to suggest a few steps which can be very useful in disaster situations based on my experience witnessing Kerala floods:

    1. During the impact period, the entire health set up in our state was crippled. There was no back up. I saw wonderful rescue missions done by airlifting. So, since our health department is not equipped with such sophisticated logistic support, we had to entrust the job to the army and specialized forces. Also, its high time we invest in transport medicine specialty. We need to set up camp as a mobile clinic, with necessary items which can be deployed immediately. Mobilization and preparedness is a key area which we should focus upon. Also, in areas whereas our trucks and vehicles cannot go, the civilian doctors and health care staff will find it difficult to reach. The initial 24-48 hours is very crucial. We need to identify key large hospitals which can take in large volumes of patients or deploy army doctors along with mobile team to flood/land-slide affected areas.

This shrub can tell the story of the aftermath i.e. how high had water levels risen. The color differences explains it all.

    2. One of the unhealthy and unnecessary complaints that arise is common people's abuse. Since our society is not versed in disaster education or preparedness, they seem to forget that even health care people are humans and they too get affected like them in such disasters. This sort of abuse destroys the spirit of health care providers in spite of their maximum deliverance. It's reasonable for the common people to get angry since they have lost everything, but expecting all care at the time of impact is unreasonable and not justified. We need to educate the people on this sensitive issue.


    3. Next, we need a dedicated sorting facility of medicines at the district or nodal officer level. Because medicines are being dumped at many places, which are not only limited to hospitals but also Panchayat offices and camps. Medicines are costly and so should be carefully sorted and distributed according to need. Lots of drugs which include necessary and unnecessary ones were seen for  distribution. Auditing is also required, which is help to monitor drug distribution. Much applaud must be given to the Kerala Health Department in ensuring smooth supply of medicines, in this disaster.

    4. Logistics need to be improved. Our CHC's and government hospitals are not equipped with necessary vehicles. The best method to recruit large ambulances which can carry staff as well as medicines which can act like a make-shift mobile clinic in such instances. Also, major institutions such as schools and colleges should voluntarily deploy their vehicles for transporting medical supplies in places of need. Also, medical students who come from different institutions should try to bring their own vehicles when they come for voluntary work. If they come in buses, the concerned hospital have to rent ambulances from outside to transport them to the affected areas and would be an extra burden to them.

A bus from Trivandrum Medical College parked outside the CHC, which brought volunteers for flood relief work.

    5. Monitoring and surveillance is an important aspect which can be simultaneously performed while treating patients at flood relief camps. Because it helps us to keep a track on fever cases, review through their incubation period and take important decisions. Also more focus can be given to risk population such as pregnant ladies, newborns and under-5 pediatric age groups. At the initial one week after the water levels had risen, the most common reported cases were of intertrigo and skin infections. But later on, there has been a rise in the number of leptospirosis cases which is a concern. And this corresponds with the incubation period i.e. 7-12 days. We are yet to confirm how much the doxycycline prophylaxis have been successful, but proper awareness and treatment strategies have been advised to the public.

    6. Kerala is a state with many medical, nursing and pharmacy colleges. The student population can be made useful to participate in flood relief guided by their teachers. It is an untold truth that true learning occurs when you go into the community. Without any disparity, be it from government or private sector, all students and teachers should be made useful in an organised manner and with better coordination.


To summarize, the health response seen during the Kerala floods of 2018 is one of the triumphs of our health department. We had battled Nipah virus outbreak and are also striving hard to overcome this recent disaster also. The poem which I had posted in the beginning of this articles is a wonderful piece of work by Rudyard Kipling. Now, witnessing the unity and dedication shown by the common people of Kerala, I feel that this is the best example of humanity, recently seen in our country. In that context, I would request the reader to replace the word "you" in the poem with "Kerala" [Kerala, representing the person addressed in the poem] and read it once again.

Sunny clouds in the backdrop of receding water levels.
'Nature always wears the colors of the spirit' - Ralph Waldo Emerson.

    Thanks for reading!☺

    KP

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Dr. Krishna Prasad G
MBBS, DNB (EM), MRCEM (UK)
Emergency Physician
Sree Gokulam Medical College and Research Foundation
Venjaramoodu, Thiruvananthapuram


Special thanks to Dr. Jebu Thomas, Dr. Jeny Augustine, Dr. Arjun James, Mr. Vivek (JHI, Budhanoor PHC) for their relentless and compassionate service of which I could be a part of.
Also thanks to Dr, Tessy Jose and Dr. Riya Varghese for extending their valuable time for camp visit.
Also thanks to all the staffs of CHC Mannar and PHC Budhanoor for their wholeheartedly support.


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