The Scenario 

Covid-19 response model of Kerala (an Indian state) is well acclaimed. One of its components is the care for migrant workers. After Indian government declared lock down from 25^th March 2020, Kerala had 18,912 camps that housed over 3 lakhs migrant workers, as per the home ministry report on 8^th April to the Supreme Court of India. They were addressed by the administration as Guest workers. 

The state-wise percentage of migrant labourers residing in Kerala, according to Gulati Institute of Finance and Taxation (GIFT) is: West Bengal (20), Bihar (18.10), Assam (17.28), Uttar Pradesh (14.83), Odisha (6.67) and the rest of the states (23.13).  Poor economic conditions in their respective native places and high wage rate and better employment opportunities in Kerala have been the main reasons of migration to Kerala [1]. Apart from that, Kerala provides better social security to migrant employees than in other Indian states. Under the insurance scheme started in 2010, migrant workers are eligible to buy medicines worth INR 15,000 in a year, get inpatient treatment worth INR 25,000 in empanelled hospitals and can claim up to INR 5,00,000 for accidents and disabilities. Their children are encouraged to join Government School and considered at par with Kerala children with free education up to level 10^th standard.

In spite of these facilities, hundreds of migrant labourers were on the streets of a small town in southern Kerala demanding exemption from lockdown and arrangements for journey back home [2]. Following this, Government had revised the strategies. Instead of free supply of cooked rice from Kudumbashree (Government supported women self-help groups) kitchen, different menu suiting the workers for North and East Indian states were provided all free of cost. Counselling services were provided (24/7) in five languages- Hindi, Bengali, Odia, Assamese and Garwahli. Health care programmes were started. Apart from essential supplies, television, indoor games like carom board and chess for entertainment and even free recharge for mobile phones were some other facilities provided to them [2]. The revised approaches showed positive results, as there was prevention of flare up and spread of unrest in other parts of the state.

The officials from Labour and Health departments carried out checks in migrant workers’ camps and sites, with awareness campaigns in multiple languages. Accredited Social Health Activists (ASHA) and National Health Mission (NHM) officials were working as a link between guest workers and government health department. They were providing help to the sick [3], conducting campaign to maintain personal safety measures and contact tracing if any. However, individual medical checkup and care for the ailments to the members of a community was not envisaged by the government system. Hence our hospital provided mobile medical services with the help of police department.

Approach

This tertiary care centre provided mobile medical services to guest workers through 81 camps for 17 days from 3^rd April to 25^th April 2020 at 33 locations. This was provided at their place of residence as the policy of the government with the help of police department. These locations come under 10 police stations areas of Thrissur City and Kunnamkualam Rural police superintendent jurisdiction of Thrissur district of Kerala state. Medical team moving in an ambulance provided services including disbursement of medicines at every camp site. These services were provided to 3021 migrant workers. Police taking stock of living conditions and heading the welfare programs did contribute to their own attitude and approach which was appreciated as humane and supportive, unlike the traditional image of rough and harsh. 

Almost 90% of migrant workers knew Hindi the National language and 5% were Tamil speaking of neighbouring districts of Tamil Nadu. Remaining 5% (from Assam and Bengal) could converse only in their language. The health team managed essential communication with them in their language using Google Translate.

Health inspectors in the team working in corresponding areas identified camp sites and fever cases with IR thermometer. Social workers in the team provided mask to every worker and ensured hand rub hygiene procedure before the clinical examination. Those with signs of infection on clinical examination were given antibiotics. A few cases were suggested quarantine and the formal order were issued then and there by authorities and arrangements were made at the place of their stay itself. Their follow up were ensured by Health and Police.

Out of 3021 workers, 34 were diagnosed as Upper Respiratory tract Infection (URTI) and one case was Herpes. Three had TB and one had HIV. All TB and HIV cases were diagnosed early and were on current treatment. In all the visited camps, barring one in coastal region skin diseases were common (Table 1). None was diagnosed as COVID-19.

Information Gathered

In one camp, a migrant worker with cough was remaining unattended, being excluded by everyone. He was a long-term sufferer of bronchial asthma. Patient was reluctant to take prescribed medicines till he and others were assured it was not COVID-19. There were few cases trying to avoid or quicken the screening due to the fear of possible quarantine and further checkup. There were a few cases of alcohol withdrawal in the camp. Tremors, anxiety and depressions were encountered by them. A few tried to prepare homemade liquor with their own recipe and techniques. They were counselled by police authorities  and kept under watch, and no legal case was charged against them. A few of them complained empty feeling, sadness, sleeplessness and muscle aches especially of calf muscles. They were known to be workaholics doing overtime work most of the days when they were working. Reversal of sleep wakefulness cycle was observed in some, who suffered insomnia due to excessive day time sleeping. Nothing to do made them sleepy during the day. They complained of suffering from headache.

Members of medical team also suffer travel sickness and some developed symptoms of heat stroke. They were also under the pressure of procedures for personal protection. Among the team members behaviour at camp site varied. Most of them were compassionate and professional in their dealings. But one person was noticed to be keeping social distancing at a much longer distance than advised, negatively affecting communication. A consultant who was anxious about pandemic was noticed to be behaving unpredictably. Another doctor was noticed to be disposing cases very fast in an unreasonable haste.

Table 1: Details of camps conducted

TB: Tuberculosis, ATR-HIV: Antiretroviral Therapy for HIV, Skin diseases frequency: + ~ 10%, ++~20%

In spite of providing all essentials and possible recreations free, most of the migrant workers were keen to return to their village and unite with family. Urge to return to place of familiarity and comfort of family of origin appears to be innate and universally seen. Perhaps at least a generation of stay may be required to assimilate to a novel and foreign culture and environment.

After lockdown of the Nation, there was daily briefing by Chief Minister of Kerala in visual media. Thrust in campaign was for wearing masks, hand washing and keeping social distance. The camp observations showed that the messages reached even migrant workers who are living in remote areas and speak different languages. This shows the efficiency of public health system and commitment of grass root level workers. 

Alcohol and tobacco use among migrant workers were not uncommon. Withdrawal symptoms of some and illicit liquor distilling were hence expected. Excessive use of intoxicants during Pandemic is highlighted as a matter of concern [4]. But withdrawal syndrome was not considered with the seriousness it deserves. A workaholic in workless times can experience withdrawal symptoms. Thoughts like ‘dread over looming time off, guilt over not doing anything “productive”, inability to stop thinking about work, compulsive checking of work-related matters, restlessness, irritability, and difficulty relaxing, obsessing over cramming leisure time with structured activities, depression etc. 

Work Withdrawal Syndrome (WWS) is an offshoot of workaholism [5]. Symptoms and signs of WWS were seen in some. Their anxiety about families at home place, limited amenities at their normal place of stay and crowed sleeping areas has not minimized their dedication for hard work. They were working well to the value of the wages received; perhaps these wages are beyond imagination at their home place. 

The diagnosis of TB, HIV and Herpes demands a periodical and effective health checkup and follow up policy among guest workers. This should be an eye opener to heath administrators. The widespread occurrence of skin disease should also attract attention of health care workers since many may be contagious. 

Since the health workers are the frontline warriors in this fight their apprehensions and over protective behaviours are not matching to their profession which they adorn. It is worth to note that majority of the medical team were working hard and restlessly to provide healthcare to the lockdown stranded fellow men of our country.

This study highlights the need for repeated such camps, follow up programmes, extreme care to the diagnosed cases and similar medical camps even after lockdown among the guest workers.

Summary of View Points 

• The guest workers were keen to return to their village and unite with family. Urge to return to place of familiarity and comfort of family of origin appears to be innate and universally seen. The facilities provided at their work place were not enough to think them stay back

• After lockdown of the Nation, thrust in campaign by the government was for wearing masks, hand washing and keeping social distance. The camp observations showed that the messages reached even migrant workers who are living in remote areas and speak different languages

• The diagnosis of TB, HIV Herpes and skin diseases demands a periodical and effective health policy for guest workers. This study highlights the need for repeated such camps, follow up programmes, extreme care to the diagnosed cases and even such medical camps even after lockdown among the guest workers

Acknowledgment

The authors wish to express their sincere thanks to management of Jubilee Mission Medical College & research Institute, especially Fr. Tijo Mullakkara, Asst Director. The service of medical team of this institute is gratefully acknowledged. The corporation of various departments of Kerala government especially police, health and local bodies are also acknowledged. They also thank Ms. Mridula Vellore, Research Assistant (Scientific writer) of Jubilee Centre for Medical Research for her support in editing the paper.

1. Saikia, Dilip. “Migrant Workers in Kerala: A Study on Their Socio-Economic Conditions.” Journal of Economic and Social Development, vol. 11, no. 2, 2015, pp. 29–43.

2. Shanker, Arnimesh. “Rotis, Mobile Recharges, Carrom Boards—How Kerala Fixed Its Migrant Worker Anger.” The Print, April 2020. https://theprint.in/india/rotis-mobile-recharges-carrom-boards-how-kerala-fixed-its-migrant-worker-anger/403937/. Accessed 29 April 2020.

3. “Covid-19 Scare in Kerala: Migrants to Aid Health Service Delivery.” The Times of India, March 2020. http://timesofindia.indiatimes.com/articleshow/74606930.cms?utm_source=contentofinterest&utm_medium=text&utm_campaign=cppst. Accessed 29 April 2020.

4. Clay, M.O. and Parker, M.O. “Alcohol Use and Misuse during the COVID-19 Pandemic: A Potential Public Health Crisis?” The Lancet Public Health, vol. 5, no. 5, May 2020, p. e259. https://doi.org/10.1016/S2468-2667(20)30088-8.

5. Hoffman, Ronald. “Vacation Time Is Here—but Do You Suffer from WWS (Work Withdrawal Syndrome)?” Dr. Hoffman Wellness Blog, August 2014. https://drhoffman. com/article/vacation-time-is-here-but-do-you-suffer-from-wws-work-withdrawal-syndrome/. Accessed 15 August 2014.