The second wave of COVID-19 hit India at the end of March 2021. In April, Doctors Without Borders/Médecins Sans Frontières (MSF) sent doctors and nurses to work in Mumbai’s Jumbo Hospital that had a capacity for 2,000 patients. Teams also adapted regular medical projects to support patients receiving care for HIV (in Manipur), tuberculosis (TB) (in Mumbai), Sexual and Gender-Based Violence (in Delhi) and mental health counselling (in Jammu & Kashmir) while the country was locked down and hospitals were overwhelmed.
However, with a relatively small presence in India, MSF was not best placed to react to the initial devastating impact of COVID-19 in the major cities. MSF teams started looking to see where they could meet health needs outside of Delhi and Mumbai. In June 2021, MSF launched a small emergency response in Manipur to provide COVID-19 surge support in the city and its surroundings, following a call for support from the Ministry of Health in India.

LAUNCHING AN EMERGENCY RESPONSE

Manipur sits tucked in the northeast corner of India. Its capital, Imphal, is home to almost half of the state’s urban population, with numerous dialects, beliefs and ethnic groups in its territory. As the second COVID-19 wave swept through India, Manipur felt the effects too.

The MSF response aimed to assist those not able to access healthcare facilities due to cost, distance, stigma, and other barriers.

In order to reach people, cut off from the city’s health services and isolating at home, MSF formed mobile response teams comprised of doctors, health workers, and drivers who travelled several kilometers across the Imphal valley every day to visit people isolating with confirmed or suspected COVID-19.

Dawanga Tussi, a longtime driver with MSF prepares to head out for a day of home visits with doctors and health workers. Tussi has been involved in MSF’s work in Manipur since its early days, providing specialized care to HIV and TB patients. © Nikhil Roshan
With more than thirty different dialects in this culturally and ethnically diverse area, community health workers with different language skills and local knowledge play a major part in ensuring that MSF teams reach vulnerable patients from different backgrounds.

“We quickly realized that it was important to expand the catchment areas of MSF’s mobile response teams to the more rural areas outside of Imphal – where access to healthcare is more challenging,” says Luca Pigozzi, MSF’s Medical Team Leader during the emergency response in Imphal.

“We managed to expand our outreach and mobile response teams to neighbouring districts of Thoubal and Bishnupur and to establish collaboration with district hospitals and COVID care centres.”

MSF doctors, drivers and health workers discuss the day’s schedule and routes they will take to reach patients spread across different parts of Imphal valley, Manipur.
© Nikhil Roshan

MSF mobile response teams arrive at a home in Langthabal Chingkha, a village in the foothills that surround Imphal valley. MSF staff seek those who are most vulnerable and in need of care while remaining sensitive to the diverse ethnic and cultural mosaic of Manipur. © Nikhil Roshan
Launching an emergency response during a global pandemic presented MSF teams with enormous challenges, but for 26-year-old doctor Ashwin Krishnamoorty, working in a Mobile Response Team with MSF provided an opportunity to connect with patients and provide quality care free of charge.

“Working as part of a mobile response team, I have got a glimpse into the culture, understood better the overall healthcare situation here, and got to know the perceptions people have about COVID-19,” Dr Krishnamoorty said.

Doctor Ashwin Krishnamoorty examines Khanenbam Tabashana (65 years old), community health worker from Lilong during a visit to Standard Robarth Higher Secondary School’s Community Home Isolation Centre (CHIC) in Lilong. Patients in isolation stay in basic conditions in the school buildings. © Nikhil Roshan
Doctor Ashwin Krishnamoorty examines Khanenbam Tabashana (65 years old), community health worker from Lilong during a visit to Standard Robarth Higher Secondary School’s Community Home Isolation Centre (CHIC) in Lilong. Patients in isolation stay in basic conditions in the school buildings. © Nikhil Roshan
Doctor Ashwin Krishnamoorty goes over drug prescriptions issued to the Gangmei family. A worrying trend seen in the pandemic has been the overuse of antibiotics. MSF doctors often urge patients to curb such use. © Nikhil Roshan
Doctor Ashwin Krishnamoorty goes over drug prescriptions issued to the Gangmei family. A worrying trend seen in the pandemic has been the overuse of antibiotics. MSF doctors often urge patients to curb such use. © Nikhil Roshan
MSF staff put on PPE and use sanitizer before entering the home of a COVID-19 positive patient. © Nikhil Roshan
MSF staff put on PPE and use sanitizer before entering the home of a COVID-19 positive patient. © Nikhil Roshan
Doctor Ashwin Krishnamoorty examines Rakesh Samurailatpam, a 31-year-old travel agent working in Bangalore. He came back home to Imphal when the second wave of the pandemic hit and has been working from home. He remarked that while his business would recover in due course, many small businesses relying on tourism had been badly affected with some even having to close down. © Nikhil Roshan
Doctor Ashwin Krishnamoorty examines Rakesh Samurailatpam, a 31-year-old travel agent working in Bangalore. He came back home to Imphal when the second wave of the pandemic hit and has been working from home. He remarked that while his business would recover in due course, many small businesses relying on tourism had been badly affected with some even having to close down. © Nikhil Roshan
Doctor Ashwin Krishnamoorty examines Khanenbam Tabashana (65 years old), community health worker from Lilong during a visit to Standard Robarth Higher Secondary School’s Community Home Isolation Centre (CHIC) in Lilong. Patients in isolation stay in basic conditions in the school buildings. © Nikhil Roshan
Doctor Ashwin Krishnamoorty examines Khanenbam Tabashana (65 years old), community health worker from Lilong during a visit to Standard Robarth Higher Secondary School’s Community Home Isolation Centre (CHIC) in Lilong. Patients in isolation stay in basic conditions in the school buildings. © Nikhil Roshan
Doctor Ashwin Krishnamoorty goes over drug prescriptions issued to the Gangmei family. A worrying trend seen in the pandemic has been the overuse of antibiotics. MSF doctors often urge patients to curb such use. © Nikhil Roshan
Doctor Ashwin Krishnamoorty goes over drug prescriptions issued to the Gangmei family. A worrying trend seen in the pandemic has been the overuse of antibiotics. MSF doctors often urge patients to curb such use. © Nikhil Roshan
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MSF mobile response teams visit as many as 11 households in a single day.

They provide in-person examinations, hygiene kits containing items like soap for handwashing, and share health education messages around good hygiene and infection prevention to minimize the risk of COVID-19 spreading.

As a core part of the intervention, MSF set up a 42-bed High Dependency Unit (HDU) for COVID patients at Little Flower School, a private convent school near Imphal airport.

It received patients suffering from severe COVID and provided high flow oxygen and non-invasive ventilation. Some patients were referred directly by MSF’s mobile response teams.

“After we started working outside of Imphal, we noticed immediately that our HDU was filling with people who came from areas with more vulnerabilities,” says Luca.

Dr Ashwin Krishnamoorty recalls an 80-year-old patient who was admitted to the HDU.

He recovered and before discharge, he prayed for the wellbeing of the doctors and thanked them for taking care of him, with his hands joined and tears in his eyes.

“It somehow made me sit up and notice the patients, and the impact our work has on them.”

A young couple speak over the phone to their elderly relative who has been admitted to MSF’s high dependency unit (HDU) in Imphal. Entry into the red zone – the section of the HDU with COVID-positive patients – is restricted to MSF nurses and doctors. Caregivers and relatives are provided with a space at the visitors’ section where they can speak to their loved ones over the phone via video chat. © Nikhil Roshan

Caregivers and relatives are provided with a space at the visitors’ section where they can speak to their loved ones over the phone via video chat. Doctors and nurses assist elderly patients inside the red zone who often struggle with the technology. Though relieved by the service, the couple were visibly anxious about the fate of their loved one.
© Nikhil Roshan

NURSES AND COMMUNITY HEALTH WORKERS

The contribution of local nurses and community health workers has been invaluable. By acting as translators, they enabled doctors to communicate effectively with their patients.

Doctor Reanna Irani is grateful to them and recalls – “One nurse – I was very impressed with her. She is from Imphal. When a patient is upset, distressed or disoriented – she pats them gently on the head or hand and plays calming music for them.

I found it so kind and important for patients who are in great distress – they worry about their breathing, pain, they are not sure what will happen.”

A nurse checks on the workings of an oxygen concentrator at MSF HDU.
© Nikhil Roshan

Nurse Heshu Komuni attends to an elderly ailing patient at the MSF HDU on her night shift. Bedside patient support by locally trained nurses and nurse aides was an important part of the response. © Nikhil Roshan

Doctors and nurses at the MSF HDU kick start into action as a new COVID-19 patient is wheeled in. © Nikhil Roshan

Doctor Ankita Lakshmanan and her team meet Nanjam Rajan Meitiei at a primary school in Oksu village. Rajan is self-isolating with his wife here at the insistence of village elders. © Nikhil Roshan
Some people, who don’t have the space to isolate themselves at home, must move away from loved ones to stay in community centres until their isolation period is over.

The high demand for beds in hospitals has meant that some hospitals only accept patients referred by a medical doctor. MSF’s mobile teams are able to provide these referrals when they meet people in need of additional care during home visits.

Fields in Lilong awaiting rain. © Nikhil Roshan
Fields in Lilong awaiting rain. © Nikhil Roshan
Foothills on the way to Oksu village in East Imphal. © Nikhil Roshan
Foothills on the way to Oksu village in East Imphal. © Nikhil Roshan
Doctor Ankita Lakshmanan examines Ibema Leima, a 36-year-old mother of two. She is self-isolating with her husband Nanjam Rajan Meitiei at a former primary school in Oksu village, in East Imphal. © Nikhil Roshan
Doctor Ankita Lakshmanan examines Ibema Leima, a 36-year-old mother of two. She is self-isolating with her husband Nanjam Rajan Meitiei at a former primary school in Oksu village, in East Imphal. © Nikhil Roshan
Since she tested positive for COVID, Ibema Leima 36, and her husband Nanjam Rajan Meitiei, 48, have been self-isolating without their children in a former primary school classroom with a mud floor and bare wooden walls. © Nikhil Roshan
Since she tested positive for COVID, Ibema Leima 36, and her husband Nanjam Rajan Meitiei, 48, have been self-isolating without their children in a former primary school classroom with a mud floor and bare wooden walls. © Nikhil Roshan
Nanjam Rajan Meitiei shares a photo of their two sons, aged 12 and 2, on his phone. The couple have had to leave their children in the care of a relative in order to self-isolate as per the strict directions of their village elders. © Nikhil Roshan
Nanjam Rajan Meitiei shares a photo of their two sons, aged 12 and 2, on his phone. The couple have had to leave their children in the care of a relative in order to self-isolate as per the strict directions of their village elders. © Nikhil Roshan
Fields in Lilong awaiting rain. © Nikhil Roshan
Fields in Lilong awaiting rain. © Nikhil Roshan
Foothills on the way to Oksu village in East Imphal. © Nikhil Roshan
Foothills on the way to Oksu village in East Imphal. © Nikhil Roshan
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MSF wrapped up its emergency response in the Imphal valley in mid-October 2021 after no new patient admissions and an apparent decrease in the incidence of COVID-19.

During the intervention, MSF was able to provide surge capacity to a health system overwhelmed with severe and critical COVID-19 cases.

Doctors, nurses, health workers and outreach coordinators meet at the MSF high dependency unit at the end of a packed day. It is a chance to debrief on the day’s challenges, successes, to support one another and to look ahead. © Nikhil Roshan
Vulnerable and remote populations outside Imphal could access treatment of severe COVID and a referral pathway to treatment of critical COVID.

High-risk patients were identified early and referred to the appropriate level of care.

As much as possible MSF tried to ensure that in the relationship between the healthcare provider and patient, the person behind the patient was recognised.

Beyond that, the relationship between MSF and the communities it served was also of crucial importance.

The 42-bed High Dependency Unit (HDU) that was set up admitted a total of 265 patients with bed occupancy rates reaching 97% during peak periods in July.

Patients with severe COVID received evidence-based quality clinical care.

The MSF mobile medical teams that visited state run isolation centers in rural areas and provided care to patients in their own homes, carried out more than 600 patient examinations. They referred (and transported) 222 patients to the MSF high dependency unit. In addition, around 1,200 patients with mild to moderate COVID were treated in their own homes.

The MSF outreach team made up of doctors and nurses, visited 54 villages in remote and rural areas with a high burden of COVID, and distributed 660 hygiene kits. Engagement with the community was essential to better understand local knowledge and perceptions about COVID. By establishing a feedback loop with communities, MSF could try to find ways to increase access to testing and treatment.