Most primary health centres bordering Bengaluru, India’s tech capital, are shut through the day. For a resident of north Karnataka, the average distance to the nearest hospital is 5km, or more. That’s the experience of most residents of rural India—and it’s among the reasons why tracking and preventing the spread of the covid-19 virus is harder outside of metros, which are themselves overwhelmed by the more deadly second wave.
“The highly virulent strain that’s taking so many lives in the second wave has 100% intra-familial infection rate and 3-4 times higher transmission efficiency than the previous strain of the virus,” explains virologist Dr. T Jacob John. “One person infects several others, and we’re noticing that if several people in one village get infected, the virus spreads to neighbouring villages in no time.”
An SBI Research report on rural spread, published last week, concluded that between March and May 2021, the percentage of rural districts with covid-19 cases across India rose from 36.8% to 48.5%.
In Bihar, for instance, in the second wave, 76% of the state’s total reported cases are from rural areas. About 89% of Bihar’s total population is in its villages. Dr Sahajanand Prasad Singh, a Patna-based surgeon and national president-elect of the Indian Medical Association, says the creation of village isolation centres had prevented rural transmission during the first wave last year. “During the first wave, people returning to their villages in Bihar were quarantined for two weeks in isolation centres. This has not been done properly this time. Rapid antigen testing has to be started with speed and scale in rural areas followed by immediate treatment of positive cases. Block-level ICUs and small oxygen facilities have to be created. Many hospitals in far flung areas are still without oxygen,” he says.
The IMA has started an Aao Gaon Chale initiative to rope in doctors for rural service. Ever since the programme was launched in 2004 in Gujarat, various state IMA branches across the country have adopted 1040 villages, benefiting over 20 lakh people.“IMA has close to 5 lakh doctors and 50% of them practise in cities but hail from rural areas. These doctors have been asked to work for their villages in whatever way possible—supplying testing kits, sanitizers etc,” Singh adds.
India’s public health spend is a little over 1% of GDP, one of the lowest in the world, according to the National Health Profile 2019. There has been no significant increase in public health expenditure for the past 15 years. The recently released Commitment to Reducing Inequality Index 2020 report by global charity Oxfam revealed that India’s health budget is the fourth lowest in the world and the country spent less than 4% of its budget on health, a third of what the world’s second poorest country Burundi did. The survey ranks India 155th on the health spending index and has found that just half of its population has access to even the most essential health services.
Attributing the wild spread of the virus in the second wave to the absence of a timely lockdown at the start of April, Dr Dhruva Chaudhry, member of The Lancet Commission’s Taskforce on Covid-19 in India and head of pulmonary and critical care medicine at PGIMS Rohtak, says: “We didn’t talk about ‘flattening the curve’. Everything happened this time in a span of just six weeks. Cases exploded in Haryana in April with 37% positivity and 15,000 new cases every day at peak. The younger generation particularly has been hit this time.”
Going to patients’ doorsteps
The key, he says, is to treat people where they are. “We don’t know how many covid-19 care centres are functioning in villages. The time is now to create field hospitals and operate a fleet of mobile medical units. We have started these initiatives in Haryana. Deploying medical students and trainee lab technicians to boost primary surveillance and home care services will go a long way in rural regions, particularly when 40% of the medical workforce is ill. As we prepare for the third wave, it’s also crucial that we start setting up covid-19 surveillance centres in every state,” says Dr Chaudhry.
In Uttar Pradesh, covid-19 cases have been reported from a third of the villages. Hundreds of bodies found buried on the banks of the Ganga in various districts of UP recently have highlighted the issue of a possible massive rural spread in the state.
“Testing has to increase massively in villages where people often hide their symptoms. Vaccine administration is a huge challenge too. We have requested the government for spot registration and vaccination in villages so that a large section of the state’s population is immunized soon,” says Dr Ashok Rai, head of the covid-19 taskforce of IMA’s Uttar Pradesh unit.
Dr. John says the first step should be creating awareness about symptoms and the importance of wearing masks among the rural population. “Masks provide 80% protection from infection. We need more education about symptoms. We must use all effective means of communication—television channels, radio, print and community awareness campaigns.”
Even states like Kerala with high social indices are struggling to prevent the rural spread. “We have a decentralised approach in Kerala’s health system. We were a model state for the country during the first wave, but then we relaxed. Today, many rural pockets are without oxygen beds and medicines,” says a doctor at Ernakulam’s district hospital.
In Karnataka’s remote areas along the Western Ghats, a large number of tribal populations are testing positive. Kodagu, Hassan, Chikkamagaluru and Uttara Kannada have reported an increase in cases in the past week. Karnataka’s revenue minister R Ashoka says deputy commissioners have been instructed to increase testing in every village. “We have launched mobile clinics for villages. In the absence of medical facilities, we have no choice but to go to their homes and test and treat them,” he says.
Ashoka who is also the vice-chairman of Karnataka State Disaster Management Authority said special teams will be formed to conduct on the spot and door-to-door testing for symptomatic patients in rural and semi-urban areas. “We are doing everything we can to break the transmission chain. There are not many testing centres in rural areas. Special teams, including doctors, auxiliary nursing midwifery/anganawadi workers, will visit every house in the rural areas. These teams will identify symptomatic patients and conduct rapid antigen tests on the spot. Final year medical students have been roped in to contain the rural spread,” he said.
The first job, says Dr H Sudarshan, who has worked with tribal groups in Karnataka’s Chamarajanagar district for more than 35 years, is to educate rural folks about the importance of vaccination. “That’s not an easy job. They believe that a common cold, cough and fever can be treated with home remedies. How do we convince them about the dangers of this virus and its variant? It will require consistent and concerted effort.”
Dr. John points to India’s success in controlling polio and HIV/AIDS and says that can be replicated for covid-19 too. “We can’t let people die due to poor planning,” he says.
The writers are journalists and co-founders of Antardhwani, a think tank based in Bengaluru.