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Afrida Shaikh asks whether I can imagine a job where suspected covid-19 patients cough, sneeze and possibly vomit on me nearly every day. It sounds like something out of dystopian fiction. “We get shouted at, sometimes abused after this happens. People don’t realize that nasal swabs deal with a sensitive area, a throat swab can cause people to cough or gag, and this makes them very angry," says the 22-year-old.

A phlebotomist and swab technician with Thyrocare, she conducts approximately 100 covid-19 tests every day—in homes or at camps set up by the Brihanmumbai municipal corporation (BMC) in Mumbai hospitals. This entails collecting nasopharyngeal and oropharyngeal swabs from patients—the youngest patient she has swabbed was an infant, only two days old, whose mother had tested positive for the coronavirus before she delivered.

“It’s no small feat to convince children between the ages of 3-10 to let me swab their mouths and noses. We are wearing PPE (personal protection) kits, they can’t even see our faces, it’s terrifying for them," she says. “I joke with them, ‘Let me see if you have brushed your teeth! Oh look something is running around in your nose!’—and haste khelte eventually I get the tests done," says Afrida.

Over the last three months, she has lived out the same routine every day—all while wearing a mask, face shield, gloves, coveralls, head cover, rubber boots and gloves, sometimes for hours. She gets ready early in the morning, leaves her home in Mumbai’s Dharavi, where she lives with her parents and three siblings, and spends the day collecting samples across the city.

The financial capital has one of the highest number of coronavirus cases in the country—approximately 70,000 on the date of publishing and over 4,000 deaths. Afrida has been part of the process of making this data available.

The novel coronavirus has shone the spotlight on professionals who would otherwise have gone about their day’s work sequestered among the country’s employed multitudes. But as physical distancing norms clear the streets, they are conspicuously visible, battling the pandemic.

Yet, even within this community, there are warriors who remain unsung—swab technicians like Afrida who perform the first-mile task of the World Health Organization’s most consistent mantra: test, test, test.

According to a 2018 study by staffing recruitment firm TeamLease Services, India had 95,000-125,000 phlebotomists. Of these, some have had to step up to the challenge of covid-19 testing. Thyrocare, the lab with which Afrida currently works, has 80 swab technicians. CORE Diagnostics, headquartered in Gurugram, Haryana, has 48.

“For covid-19 sample collection, our technical and quality team provides the swab technicians with two-day training as per ICMR (Indian Council of Medical Research) guidelines. The training covers the aspects related to proper protection against any possibility of infection, capturing the required information and collection, packaging and transport of the swab samples," says Zoya Brar, CEO and founder, CORE Diagnostics, which has been conducting covid-19 tests since 27 March, once it got approval from ICMR.

A high-risk operation

Towards the end of March, there was fear of a cluster outbreak when a woman from Delhi, who eventually tested covid-positive, attended a wedding in Mubarakpur, Haryana. Asif Ali, 24, who is from Baghpat in Uttar Pradesh and works as a phlebotomist with e-pharma and diagnostics startup 1mg, was part of a team of doctors and technicians called in by the state government to conduct tests in the village—contact tracing is key to stemming the spread of the virus.

“The people nearby began to threaten us when we set up the camp. They accused us of spreading the virus, even showing up with sticks and lathis when we tried to explain things to them," says Ali. The testing had to be done under police protection.

“Still, the risk of conducting tests in people’s homes is much higher—you don’t know anything about where you are going, every surface could potentially be high risk," he adds.

This is the work Radhe Shyam, 32, who works with CORE in the National Capital Region, has been doing over the last few months. “Patients usually treat us like we are the ones who are already infected, when it is they who are suspected cases—they throw documents at us, they throw the cash at us," he says.

As he travels through the scorching heat on his scooty, Shyam carries glucose in his bag, often eats lunch in the shade on the side of the road between collections, is sometimes out completing forms and patient data till 2am, and returns home to a separate floor, isolated from his wife and children lest he pass on any infection . “My son and my daughter used to sleep next to me every night. They cried a lot when this began—now we only speak on the phone, and twice we have spoken on video chat," he says.

Swab technicians endure the compromise that comes with being a front-line worker during the pandemic; and they too have had to face the discrimination meted out to healthcare practitioners, particularly during the initial days. Shyam even had the police show up at his doorstep—the neighbours had complained he was infected. “My wife showed them the ID card and explained what I did, told them I was not infected. I risk infection every day and make sure that people who needed it were tested for the virus, so this was really disheartening," he says.

Ali was even asked to vacate his room in Gurugram in late March because the landlord was worried he would infect the family. He was eventually provided accommodation by the company until the lockdown eased and he could return home.

Paying the bills

When Thyrocare invited candidates to train for covid-19 testing, Imran Irfan Shaikh stepped up. “If we all step back, then how will this work?" asks Imran, who cleared the interview, underwent the training and started collecting samples as early as 1 April. Since then, he has tested the staff at Mumbai’s Arthur Road police station, suspected covid-19 cases in homes across the city and patients at special medical camps and covid-19 hospital wards.

For him, a degree in pharmacy had been unaffordable. Imran grew up in a chawl on Kherwadi Road in Bandra East, Mumbai; his father, a tailor, wanted his eldest son to be part of the “medical field" some day. “Mere dost bekaar the, uss samay, tapori type (I wasn’t around the best company at the time, my friends were rowdy)," says 22-year-old Imran, recalling life at 15, when he took up his first internship at a lab in Mumbai, where he would learn to draw blood and collect samples. Eventually, he went in for a BSc in medical laboratory technology (MLT) from the Yashwantrao Chavan open university—honing the skill of blood collection—and became a full-time phlebotomist.

For many like Imran, circumstances do not permit the years of training and residencies needed to complete an MBBS. Shyam, for instance, was a ward boy in a Delhi nursing home by the age of 16. He needed to support his mother, who was working as a part-time domestic help. “My father would often drink and we had to help out my mother, she raised us single-handedly," he says. Eventually, he completed a diploma in MLT and, after training in a lab, took to this line of work.

It is this “service to the nation", as Afrida describes it, that pays the bills. A common story among young phlebotomists is that they are part of the first generation within their families to receive an education, mostly at great financial cost to their parents. Today, phlebotomists, never really accorded recognition as serious professionals in the field, play one of the more significant roles in tracing the spread of coronavirus.

When the nationwide lockdown was imposed on 25 March, 28-year-old Santosh (this is how he introduces himself) , a phlebotomist with CORE, left Bengaluru to return to his village in Karnataka’s Bidar district, where his father works as a farmer, earning an additional 400 every month as a newspaper delivery man. There was no work at the time—all the samples he would collect had to be flown to Delhi for assessment and flights had been stopped.

A month later, with CORE starting testing, Santosh left his family and moved back to Bengaluru, where he collects both blood and covid-19 samples, depending on the need. “My parents really did not want me to go, they begged me to stay home till this subsided, they were worried," he says. Santosh sends 5,000 home every month.

Lasting memories

The virus has been a terrifying reality for most and it is the uncertainty of its impact that is often overwhelming, even as physical symptoms wane. Some of the connections forged during this time, Imran says, transcend the professional, turning into enduring personal relationships.

He narrates an incident from Mumbai’s Saifee Hospital, when he had gone to collect samples from the covid-19 ward. “There was a man who had been testing positive repeatedly for two months, he just begged us out of desperation, ‘please mujhe negative result de do, mera kharcha nahi ho paa raha (please ensure a negative result, I can’t afford the expense),’" says Imran. “But none of this is in our hands. We calm the patient down and explain the procedure to the best of our abilities, and often, that leads to a lasting connection and a lot of love," he says.

The patient runs a toy shop in the city—he gave Imran and a colleague his card and told them they could always stop by and take home any of his toys for free.

*****

“The world is changing, ma’am," Afrida tells me before heading back to a medical camp in Saifee Hospital. “It may be a male-dominated profession but we are no less," she adds. She believes it is her sensitivity that has given her some of her most enduring memories as a swab technician.

As the lockdown steamrolled finances and work, Afrida has been helping out with expenses—the family manages on her earnings and her father’s savings. Though phlebotomy entails a fixed weekly income, the new paradigm works differently—they are paid per sample collected, the rate varying as price points for covid-19 testing are regulated.

Returning to her work, the young phlebotomist may be as uncertain as the rest of the world about what the future holds but there is no doubt about her commitment. “We are covid warriors, and we will win, no matter the risk and backlash," she says, echoing the views of her colleagues as they dodge dread and droplets.

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