Exploring the Escape Plan
The world took an unforeseen turn in March 2020. Social or rather physical distancing became the formula for survival for the social animal, and handwashing was considered one of the primary precautions to survive the pandemic. As the Coronavirus disease (COVID-19) is reported to transmit rapidly through the infectious respiratory droplets, the efficient management of the battle ground in this fight, i.e hospital space, becomes critical in surviving the pandemic. Besides COVID-19, hospitals are also at a high risk for the transmission of other diseases, as this is the site where a patient’s illness interacts with the hospital staff and visitors. This story looks at the infrastructure and implementation of hand hygiene, in a Government general hospital (associated with a medical college) located in one of the most arid and COVID-19 affected regions of Andhra Pradesh.
Kadapa, Andhra Pradesh
A person washing her hands
“Handwashing is one of the key cornerstones of COVID-19 prevention. Now more than ever as we embrace the new normal and live with COVID-19, hand hygiene needs to become an integral part of our daily routine and our lives, as we live through this pandemic, and beyond, to protect us from diseases.” - Dr Poonam Khetrapal Singh, Regional Director, WHO South-East Asia Region (World Health Organization, 2020)
Reference:
World Health Organization. (2020, October 15). Handwashing an effective tool to prevent COVID-19, other diseases. who.int. Retrieved February 13, 2022, from this link.
A brother and sister playing in the corridor connecting the inpatient and outpatient blocks
Hospitals, the critical space for fighting the virus, demand greater care in management and hygiene, to save all the lives involved. If necessary precautions aren't taken, the exchanges between patients, healthcare staff and visitors could lead to Healthcare-associated infections (HCAI) which can develop either as a direct result of healthcare interventions such as medical or surgical treatment, or from being in contact with a healthcare setting (National Health Service, n.d.).
Hand hygiene is one of the key methods to prevent HCAIs (Mathai et al., 2010). This has been a primary and essential tool to keep oneself free from potential pathogens (harmful microorganisms) and be healthy, as hands are our foremost modes to physically interact with the world we inhabit. In this regard, there are dedicated guidelines prescribed by national and international organizations to the healthcare providers on when and how to use alcohol-based hand rub and/or washing hands with soap and water in healthcare facilities, as they care for multiple patients and come into contact with infection sources. If these protocols are strictly followed, HCAIs arising from medical interventions can be minimised.
Yet, only the compliance by healthcare providers in hand hygiene practices isn't adequate to reduce the infection burden. It must be done by all the stakeholders as hospitals are a potential site for transfer and spread of pathogens on everyone’s hands, or else, face the widespread deadly pandemics like in the case of COVID-19.
Reference:
Mathai, E., Allegranzi, B., Kilpatrick, C., & Pittet, D. (2010, April-June). Prevention and control of health care-associated infections through improved hand hygiene. Indian Journal of Medical Microbiology, 28(2), 100-106. Link
National Health Service. (n.d.). Healthcare associated infections. england.nhs.uk. Retrieved January 14, 2022, from Link
Patients and attendants seen leaving the Government General hospital, Kadapa after their checkup
“To improve the quality of healthcare and make medical education accessible to all the eligible students of the region”, reads the vision statement of the Government General hospital, Rajiv Gandhi Institute of Medical Sciences (associated with a medical college), in Kadapa, Andhra Pradesh.
It is located in Putlampalli village, 7 kilometers away from Kadapa city and was established in 2006. Recognised as a tertiary-level care hospital that promises to provide highly specialised medical care involving advanced and complex procedures performed by specialists in cutting edge facilities, it has a total capacity of 750 beds and 1500-2000 patients frequenting its inpatient and outpatient blocks every day. Since this hospital is situated in a chronically drought-affected district in Andhra Pradesh, where 19 of the past 23 years were drought years (District Disaster Management Plan n.d.), the importance of hand hygiene in this institution is especially significant. Further, a study suggests that hospitals in drought-prone areas have poor preparedness, response and recovery capacity (Wijesekera et al., 2020)
During the current COVID-19 pandemic, the hospital was one of the two dedicated government institutions providing medical assistance to the infected persons in the district headquarters. The facility becomes the default health centre for many district residents who cannot afford private hospitals. Therefore, it becomes more important that this state institution is equipped to provide safe infrastructure alongside medical assistance to the poorer sections of society. The maintenance of hand hygiene and an infrastructure that supports it plays a significant role as chances of contracting the virus are higher when compared to a non-covid hospital.
Reference:
District Disaster Management Plan. (n.d.). kadapa.ap.gov.in. Retrieved January 14, 2022, from this link.
Wijesekara, N. W. A. N. Y., Wedamulla, A., Perera, S., Pesigan, A., & Ofrin, R. H. (2020, April). Assessment of drought resilience of hospitals in Sri Lanka: a cross-sectional survey. WHO South-East Asia Journal of Public Health, 9(1), 66-72. Link
A handwashing station without tap fixtures on the upper floor of the inpatient block
The hospital derives its water from protected sources i.e., through bore and municipal water supply. Another source of water includes the Penna River. Despite the drought-prone nature of the region, the hospital does not face any shortage in water supply especially after a tank near the hospital was dug deeper last summer.
However, many handwashing stations that are supposed to be the primary cleaning spaces for patients display no functional taps with water, soap, or alcohol rubs.
A patient washing her plates in an unclean handwashing basin
The handwashing stations with functional taps embody dinginess. This setting repels the patients and the healthcare staff alike, with one blaming the other about the way they’re maintained.
A functional handwashing station with no soap or sanitiser
On an average, around 350 people from various parts of the district can be seen on any floor, either in the outpatient or inpatient block but each floor has only two handwashing stations present, amounting to a mere total of twelve taps. Out of these, only a few taps are functional. The limited functional stations thus bear the brunt of the workload, with no hand hygiene supplies, which results in dejected patients who now have to bring their own supplies.
An attendant carrying a water bottle, as she does not trust the hospital’s water supply
The luggage of a family whose member was admitted at the hospital
“We come from a village that’s very away from this place. We bring our own soaps and sanitizers, and drinking water. There is hardly anything here. Even if there is anything, we don’t know how much we can depend on the hospital for our safety”, exclaims a caregiver.
Stacked footwear of the many visitors that come to this hospital from the surrounding villages
Subbaraju Aavula, a patient, went on to say, “Ever since Covid, we have all been very scared of going near a hospital. Such is the life that the places which give life are places of horror now. Everybody is telling us that we should wash our hands regularly to be safe from this virus. But, how should we wash our hands if there are no facilities?”
Disabled toilets are reassigned for staff and locked down for any public usage
When it comes to accessibility, disabled toilets are shut down. They are either locked or converted into staff toilets.
When asked about this, Malathi¹, a head nurse tells me, “Disabled toilets are locked because there is no use keeping them open. I have never seen disabled people using them. It is only normal people who use and dirty them. It’s just an extra burden for the sanitation workers to clean these toilets. So, we just converted them into staff toilets. And patients here don’t even care whether there are facilities or not!”
¹All interviewee names of nurses are changed
A nurse on her round interacting with the patient
Hand hygiene promotion material and activities are largely absent across the hospital.
“In our time, there was a lot of communication between patients and nurses. Whatever we learnt in our classroom, we used to tell patients in our rounds. But, nowadays, there is hardly any knowledge sharing happening!”, Mary, another nurse, continued, “Without this, how can we make the present situation better?”
The poster of rights and responsibilities for patients hung in a corridor of the hospital
Another healthcare worker says, “The patients who come here are illiterate. They have no awareness. They don’t know how to keep their surroundings clean. If we keep one soap near a handwashing station, it will be gone by the evening. They spoil the toilets. If it’s a public space, they just don’t care about keeping it clean.”
A nurse filling out the paperwork.
However, despite the staff’s cynicism and resignation about such a state of things, they have many suggestions to turn around the hospital in terms of infrastructure and stakeholder behaviour.
In an interview with Rosy, a staff nurse, she enthusiastically ideated that, “Every patient bed should have a small dispenser installed just like the saline stand, so when we go for rounds, we can ask the patients to use them. This would definitely increase the frequency of handwashing. And every ward entrance should have sanitizer dispensers stationed. We can even put wall mounted sanitizer dispensers where every handwashing station is there. This way soaps also wouldn’t go missing.”
Another nurse Subbalakshmi added, “In the neighbouring district government hospital, they keep playing audio clips of safety measures to be followed during the times of COVID including when and how to wash your hands, exactly like a lift voice speaking in the background. I think that if people keep listening to something, they would start following it some or the other time. And these medical college students also can conduct some skits or awareness programs.”
When asked why these suggestions aren’t translating into actions, Subbalakshmi dejectedly replied, “Who would listen to us?”
Discarded face mask outside the hospital building
Hand hygiene is a simple, cost effective way to prevent the spread of infections. During the current pandemic scenario, it is one of the best defences the public has got besides physical distancing and masking. Since a healthcare facility is a high-risk setting, handwashing facilities here for patients and visitors alongside healthcare personnel constitute a critical prevention and control measure against COVID-19 and various other infections.
A WHO study indicates at any given time the prevalence of Healthcare-Associated Infections varies between 5.7 percent and 19.1 percent in low-and-middle income countries and between 3.5 percent and 12 percent in developed countries (World Health Organization, n.d.). Infections acquired in these facilities are thus a major global health problem.
Therefore, it becomes vital to minimise such avoidable infections for all parties involved, so as to avoid the dangerous risks of unsafe and unhygienic patient care, which could even lead to the public health infrastructure crumbling.
Reference: World Health Organization. (n.d.). Health care-associated infections FACT SHEET. who.int. Retrieved January 14, 2022, from this link
About Devi Divija Singal Reddy
Divija is a Master's student in Public Policy and Governance from Azim Premji University, Bangalore. Her research interests centre around public health and gender in India. She loves to photograph and is keen on integrating it as one of her research mediums.
This story was produced as part of Water Seeker Fellowship 2021, a collaborative inititative of Living Waters Museum and Social and Political Research Foundation.
