A few weeks ago, 20-two-year-old Jyothi Bairapaka and Neelam Mounika were faced with one of the most challenging moments in their lives. Inside the isolation ward at Government Hospital in Khammam district, the two epidemiology students were seated with a woman who was suspected of contracting COVID-19 but refused to budge. The woman had worked at the home of a positive patient but declined to admit the fact. She was sobbing and pleaded for help and wanted to leave. Tasked with contact tracing, Jyothi and Mounika tried their best to connect the dots, but in vain. The shock came when the woman tested positive for COVID-19 two days later. The challenge involved in collecting data in an emotion-filled environment was not something classrooms and text books had taught them.
“Whatever information we collected turned out to be false. It was only after collection of intelligence by tracing phone location and call details that we could establish that she was indeed working at the home of the COVID patient. The bigger picture became clear then,” says Jyothi. Echoing similar views, Mounika says persons in the isolation ward were hardly cooperative. “They felt they were being blamed for the spread of the virus, maybe. They behaved like they have been jailed and we were going to harm them. Some were aggressive and on one of the occasions we both had to run away when a 75-year-old tried to beat us up,” she adds.
The two students, pursuing a Master of Public Health at the University of Hyderabad, are currently volunteering for the state government to carry out epidemiological fieldwork in Khammam district, as part of the containment strategy against the spread of COVID-19. They were roped in for active and passive surveillance on April 9.
Their role involved working with the WHO-Integrated District Surveillance Project (IDSP) by providing technical and desk-based support for contact tracing, line listing, spot mapping, and active and passive surveillance for Severe Acute Respiratory Illness (SARI) including COVID 19 and Influenza-like illnesses (ILL). They visited people quarantined at homes in containment zones every day with the Auxiliary Nurse Midwifes (ANMs), Accredited Social Health Activists (ASHAs), and medical officers.
Khammam district, which is in orange zone, has six of the eight positive cases discharged already. For a district bordering Andhra Pradesh, where a large number of COVID cases are detected, Khammam has done well to keep the numbers in single digits. The last positive case reported in the district was on April 21, and with the district inching towards being declared a green zone, Jyothi and Mounika hope they will be relieved soon. They are, however, not sure if they would land a government job after graduation.
*The curve starts plateauing*
After a sudden spike in positive cases of COVID-19 in Telangana, the last few days have seen such cases being reported in single digits. The number of positive cases in Telangana stands at 1,107 as of May 6, with 648 having been cured and discharged while 29 others have succumbed to the disease. The state’s recovery rate is 58.5 per cent. According to the Center, the doubling rate of COVID-19 cases in Telangana is one of the best, at 70.8 days.
As per the list released by the Ministry of Health and Family Welfare on May 1, only six of the 33 Telangana districts featured in the red zone. Nine districts are in the green zone and 18 are in the orange zone. As many as 22 districts have not recorded a positive case in the last 14 days, whereas, the districts of Wanaparthy, Warangal Rural, and Yadadri-Bhongir have not reported a positive case till date.
In the state’s fight against the pandemic, along with a large number of doctors, paramedics, nursing staff, health workers, sanitation workers, and law enforcers, the young volunteers of Epidemiology and Public Health, too, has had a role to play.
In April, when the pandemic was posing serious challenges, the Telangana government recruited as many as 10 graduates of the Master of Public Health (MPH) programme from the School of Medical Sciences and offered them contractual jobs in the positions of District Epidemiologist in different districts. Another graduate from the school was hired by the Assam government in the same position. They belong to the 2016, 2017, and 2018 batches. Four more students of 2020 batch are in the list of hopefuls.
Apart from Jyothi and Mounika, 13 other current students of the 2019-batch of MPH have been in COVID-19 surveillance duties on the ground for the last month. Shiva Shankar, one such student, volunteering in Jogulamba Gadwal district, says the hands-on experience he received during COVID-19 is enormous. The last positive case reported from the district was on April 24 and is currently in the Orange Zone. A district epidemiologist has been appointed here recently.
“We worked as the bridging block between different departments. Officials from health, sanitation, civil supplies, municipal office, district collectorate, police, and revenue departments are on the ground fighting the pandemic and we looked into inter-sectoral coordination. It is a great experience,” says Shiva Shankar.
*A sudden opening of opportunities*
For Dr. Monica Suhasini, an alumna of the UoH who recently landed a job as a District Epidemiologist in Kamareddy district, COVID-19 has not only been a source of knowledge and experience but also a boon, literally. “After graduation last year, it was very difficult for us to find a job. Even if we ask for a job, we were told that there were no such positions available,” says Monica. She worked as a field investigator in a project in Jogulamba Gadwal district earlier for a couple of months and then with an immunisation project in Suryapet district for seven months. “As I was unable to join back my work after Janata Curfew, I had to leave the job. Due to COVID, the government issued a notification for the role of District Epidemiologist in Kamareddy district and I applied,” says Dr. Monica, who now has a four-month contract with the government.
Similar is the story of Dr. Nikitha Reddy, another alumna of UoH who recently took over as District Epidemiologist in Nagarkurnool district. She says, “No one knew the role and purpose of epidemiologists before the pandemic. There were no government jobs available and one had to settle for health-related projects with NGOs. It is mostly like social work and you cannot expect a remuneration sometimes.” After graduating in June last, she was struggling to find a job.
As a District Epidemiologist, Dr. Nikitha says she is in the process of understanding the disease from the ground level and assesses the number of cases, identifies the cause, and plans how to contain the same. Along with fever surveillance in the district, the role also involves learning about clusters and working out an action plan to proceed further. This involves active surveillance through household surveys conducted by ANMs and ASHAs and also passive surveillance by collecting information from registered medical practitioners (RMPs) and pharmacies in and around containment zones.
Dr. Monica adds that active surveillance by ANMs and ASHAs will continue till the last case is discharged and the district moves into a green zone. The last case reported in Kamareddy district was on April 2. The District Epidemiologist reports the status on the ground to the IDSP and the Directorate of Public Health daily.
Admitting that public health experts and epidemiologists are not very ‘popular’, at least in India, Dr. B R Shamanna, a Professor of Public Health at the School of Medical Sciences in UoH, says, the discipline of epidemiology was never given its due importance in India till COVID pandemic emerged.
Epidemiology is the basic science behind Public Health and is very critical while looking at instituting control measures during a pandemic, be it the distribution, determinants, or identifying the risk factors. This involves more planning and quantitative science, he says. “The detection, management, treatment, and care comes later. Only when you identify the problem, can you address it. And that is done by the Epidemiologists,” adds Dr. Shamanna.
Stating that India’s public health infrastructure is weak, Dr. V Ramana Dhara, a Professor at the Indian Institute of Public Health in Hyderabad, hoped that with COVID it would be given a kickstart. Most of the Primary Health Centres in the country may not have enough staff, funds, or medicines, forget about a public health staff as an outreach worker, he says. This absence of an outreach worker was either due to lack of funds or unwillingness on part of people to go to PHCs to work.
In the aftermath of COVID pandemic, he says, epidemiology and public health are the disciplines to look forward to. “There is a lot of potential for exciting work. I hope more institutions start teaching Public Health. But, primarily the graduating students have to be recruited somewhere. Unless they know there are jobs they would not come forward,” he says. He hoped the Center and State governments start filling up the vacant posts.
IIPH and UoH are the two leading institutes offering a MPH programme in Telangana, since 2013. Any graduate from non-medical background is also eligible for these courses.
A public health expert is a jack of all trades, and epidemiologists play a crucial role in not only the determination of the spread of disease, but also in aspects like containment, mitigation, prevention of disease, and promotion or restoring people’s health.
“It is a very exciting field. It is multi-disciplinary,” says Dr. Ramana Dhara. The discipline comprises Statistics, Math, Social Science, Anthropology, Behavioural Science, Occupational Science, and Artificial Intelligence, etc. “You can do investigations into epidemics, health problems, and publish scientific papers. There is a lot of potential for exciting work. And everything has a tangible result,” says Dr. Ramana Dhara, adding that such investigations lead to conclusions and prevention of diseases from recurring.
Agreeing with him, Dr. Shamanna says Public Health broadly looks at social determinants of health, which means it is not the virus or organism that is in focus. “We look at all other things that come as baggage-behavioural factors, environmental factors, and health system-related factors, management factors. It is not just about the Genetics and Biology,” he adds.
Dr. Shamanna has been holding a series of webinars, to let people understand what is COVID-19, how it evolved, and the expert understanding. That in epidemiology is called the natural history.
Meanwhile, the students of Master in Public Health (MPH) who are volunteering with the state government in the wake of COVID-19 pandemic are required to submit their reports to the department on their return to university. With the information collated, they will also make a presentation and the findings will be published. These will be used as case studies in the syllabus in the future.
According to him, how long should the nation-wide lockdown continue to flatten the curve is a million-dollar question. “The very reason we are pursuing flattening of the curve is to build our capacity or the system’s capacity to address the severe or critical people who may land at the hospital. But at the same time, the longer you take to flatten the curve, the more economic implications it will have. In Dr. David Nabarro’s words, first we have to protect lives, then regain livelihoods of people, and living thereafter is about adjusting to the new normal,” adds Dr. Shamanna.
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