Ojhauli is a nondescript village in Uttar Pradesh’s Gola tehsil, 50 km from Gorakhpur, the home district of chief minister Yogi Adityanath. In the past month, this village, with a population of about 4,500, reportedly saw 30 deaths preceded by Covid-like symptoms. However, there was no response from the nearest community health centre (CHC), located in Gola. On May 20, Neelranjan Ojha, a native of Ojhauli, reported the deaths to Himanshu Thakur, the district panchayati raj officer of Gorakhpur. Immediately after, a team of health officials arrived at the village and eight people were admitted to a Covid hospital in Gorakhpur.
State officials in Maharashtra have been similarly lax or late in responding to Covid cases in rural areas. Around 20 per cent of the state’s daily Covid tests are being conducted in Mumbai alone, which accounts for just 1.5 per cent of the population of Maharashtra. In rural districts such as Ahmednagar, Buldana, Satara and Beed, among others, where the positivity rate is 23-30 per cent, the number of daily tests is below 5,000. In the second week of May, a controversy also erupted in Beed after the district administration failed to add 240 Covid-related deaths to the state’s tally.
Such under-reporting is not restricted to Maharashtra alone. And as India grapples with the second wave, what makes the situation more dangerous is missing data. Government statistics do not give an accurate account of the devastation, which has led to an inadequate response. “In the absence of reliable Covid surveillance and data from rural India, we cannot be sure about the extent and severity of the pandemic,” says Dr Chandrakant Lahariya, a Delhi-based epidemiologist and public policy and health systems expert. “National aggregates may indicate a declining spread in urban settings, but it is possible the virus is still spreading in rural India.”
A May 7 report by SBI Research estimated that rural districts now account for about 48.5 per cent of new cases, up from 45.5 per cent in April and 37 per cent in March. But more than new cases, it is the death toll that is wreaking havoc in India’s villages. The 243 districts that receive funding under the Centre’s Backward Region Grant Fund accounted for 11 per cent of all Covid deaths in India in September 2020. That figure is now 16 per cent. And these numbers miss many cases from places like Ojhauli and Beed, which have fallen off the radar because of factors like inadequate medical infrastructure, a hesitancy to get tested and administrative apathy. For instance, between May 1 and 23, Maharashtra chief minister Uddhav Thackeray conducted four meetings to review Covid cases in the state, but only one of these, on May 16, focused primarily on rural areas. Thackeray took cognisance of the situation only after it became clear that around 70 per cent of the state’s new cases were being recorded in talukas with populations below 100,000.
The same day, the Union government directed states to improve rural medical infrastructure by strengthening access to resources such as beds, oxygen, testing kits and ambulances in primary health centres (PHCs), community health centres (CHCs) and sub-district hospitals, and by creating makeshift Covid care centres (CCCs). The guidelines also recommended that Rapid Antigen Test (RAT) kits be made available at all PHCs, sub-centres (SCs) and health and wellness centres, that community health officers and auxiliary nurse midwives (ANMs) be trained to perform rapid antigen tests and that accredited social health activist (ASHA) workers be tasked with active surveillance in villages.
Graphic by Tanmoy Chakraborty
While most states have started taking measures on these lines—some were doing so even before the directive went out—the task is immense. Even before the pandemic could place extraordinary demands upon it, healthcare in rural India was already crippled by poor infrastructure, a lack of manpower and policy neglect. There is a massive shortage of SCs, PHCs and CHCs, which form the creaky backbone of healthcare in the hinterland. According to the Union ministry of health and family welfare, India faces a 23 per cent shortage of SCs, a 28 per cent shortage of PHCs and a 37 per cent shortage of CHCs. As a Rural Health Statistics report released last year reveals, on average, each SC serves four villages; each PHC, 27 villages; and each CHC, 128 villages. To put it another way, one CHC is responsible for an area of about 596 sq. km, almost the size of Mumbai.
Even when it comes to new Covid-capable infrastructure, there has been a sharp skew in favour of urban areas. For instance, in Madhya Pradesh, there are 819 medical installations that offer Covid treatment. Of these, only 69 are in rural areas. Only 14 per cent of isolation beds, one per cent of oxygen beds and 0.54 per cent of ICUs are in rural areas.
The situation is similar when it comes to personnel. Although there has been a 40 per cent increase in the number of allopathic doctors in PHCs across India in the past 15 years, there is still a seven per cent shortage. More importantly, there is a 76.1 per cent shortfall of specialists at CHCs. “India has perhaps the largest network of PHCs and SCs. But there is an urgent need to provide personnel, especially grassroot workers, since they are the points of first contact,” says professor Sanghamitra Sheel Acharya of the Centre of Social Medicine and Community Health at Jawaharlal Nehru University’s School of Social Sciences.
This cripples even upgraded infrastructure. For instance, as per a directive issued by Uttar Pradesh chief minister Yogi Adityanath, four CHCs in each district are to be converted into dedicated Covid hospitals, with 50 beds, an oxygen concentrator and a team of doctors. One such is the Shambhunath CHC in Bah, 70 km from Agra. The CHC has 10 oxygen beds but no trained personnel to handle the supply of oxygen. It has a mandated strength of 21 doctors but only three are actually posted there. It has digital X-ray machines, but no radiologist, and the lack of a pathologist has shut down its pathology unit. As a result, no Covid patients are being admitted there. To address this shortage, the state government is looking to employ retired medical staff. The CM has announced a 25 per cent additional incentive on basic salary to doctors, nurses, paramedical staff and grade four employees on Covid duty. Medical interns, MSc nursing students, BSc nursing students, final year MBBS and Pharma students will also be posted on a daily honorarium, based on requirements. Neighbouring Haryana has also roped in registered medical practitioners (RMPs) and second year onward medical students to beef up manpower.
However, adding manpower has not been easy, as seen in West Bengal. Though the state government has given district magistrates and chief medical and health officers full authority to recruit medical staff, the drive has faltered because of low remuneration. “When private hospitals pay doctors Rs 500 per hour, the government pays a monthly salary of Rs 40,000. If we want to recruit 50 doctors, we get only 25 applications,” says Dr Manas Gumta, secretary of the Association of Health Service Doctors. The situation is similar in Bihar. In September 2020, the state government appointed 3,186 doctors as general duty medical officers and added 929 specialists in August 2020. Yet, 4,149 specialist posts and 3,206 general posts remain vacant. The state also faces an acute shortage of lab technicians (though the health department took the unconventional step of training ANMs to conduct Covid-19 tests last year).
State governments have also been taking steps to enhance surveillance in rural areas to prevent a repeat of the situation in urban areas, where medical infrastructure crumbled under surging Covid caseloads. “Our fragile rural infrastructure does not have the capacity to cope with the kind of Covid wave we saw in urban areas,” says Dr Bhavani R.V., a poverty and social protection specialist. To beef up surveillance and testing, almost all states have roped in ANMs, ASHA workers and anganwadi workers, with many introducing mobile testing units in rural areas.
Graphic by Tanmoy Chakraborty
Nonetheless, cases are being missed, particularly because rural screening is heavily dependent on rapid antigen tests. Adding to the trouble is the fact that test results are not easily accessible. “If someone has been tested, they should be able to access the test reports,” says Sandhya Gautam, director of Seher, a unit of the Centre for Health and Social Justice. Experts also caution against overdependence on test results to identify those who need treatment. “Since tests are not widely available and can give false negatives, a person’s exposure history and clinical symptoms also need to be factored in when making decisions on isolation and treatment,” says professor K. Srinath Reddy, president of the Public Health Foundation of India. As a model to follow, he cites the Haryana government’s Sanjeevini Yojana in Karnal district, which provides a comprehensive multi-component programme of assisted and monitored home care and assured emergency transport to advanced care facilities when needed.
When it comes to monitoring cases in home isolation, several states, including Gujarat and Maharashtra, have done poorly. Aside from checking in via phone calls, there is no system to monitor infections, or even to ensure that patients are being isolated. To bridge this gap, the Bihar government has launched an application to be used by ANMs and ASHA workers for online monitoring of infected patients in home isolation. Prime Minister Narendra Modi has asked the Bihar government to share the details of the app with the Union health ministry so that it can be adopted across the country.
Government efforts have also been facing resistance from rural populations, primarily because of a lack of awareness and misinformation about Covid. There is a fear of social stigma and forced isolation if one tests positive, with many refusing to report symptoms to avoid forced hospitalisation. Horror stories from hospitals—of shortages of beds and oxygen and disturbing images of poorly maintained facilities and news of deaths—have only worsened these fears. “People are reluctant to be tested or to visit hospitals,” says Dr P.K. Kundu, former director of the Calcutta School of Tropical Medicine. “They are scared of being quarantined. There’s a trust issue with health centres and medical institutions, particularly in rural areas.” ASHA workers like Hiramani Mandi of Keshiary block in West Bengal’s West Midnapore district say this trust deficit has left them unable to convince people to get themselves tested.
The reluctance to seek institutional help has also resulted in high death rates in villages. For instance, in Punjab, the mortality rate is 2.3 per cent in rural areas as against 0.7 per cent in urban areas. State government officials say around 83 per cent of patients in rural areas report to hospitals only when the disease has progressed to advanced stages, leading to increased fatalities.
Fear and mistrust are also fuelling the under-reporting of cases and deaths in rural areas. And while there are ways of corroborating deaths in urban areas—say, by comparing figures against records from cremation grounds and graveyards—there is no such option in rural areas. The fear that the families of those who might have died of Covid might be forcibly quarantined also leads villagers not to report suspected cases. Amid allegations of under-reporting, Rajasthan chief minister Ashok Gehlot has ordered an audit of deaths in the state. He has told district administrations to pay for the transportation and cremation of bodies of Covid patients.
Experts emphasise the need to create more awareness and trust to make rural citizens active participants in government initiatives to fight Covid-19. Gautam says panchayats will have to play an active role in disseminating information and encouraging people to take institutional help, as seen in states like Himachal Pradesh. “Combating the pandemic effectively in under-resourced areas calls for an all-of-society approach,” says Prof. Reddy. “Community engagement is vital. Local bodies, women’s self-help groups and youth volunteers are key resources. That will also help to build capacity for an effective and equitable multi-sectoral response to a third wave.”
Such a model, however, requires government machinery that responds quickly to the spread of the virus. Going by how long it took the Centre to issue guidelines to the states to check the rural spread—coming six weeks after the second wave began ravaging the country—the situation on the ground is not encouraging. As Dr Lahariya points out, this is a measure of India’s pandemic response—insufficient and slow.
Graphic by Tanmoy Chakraborty
—With inputs from Ashish Misra, Romita Datta, Amitabh Srivastava, Rahul Noronha, Kiran D. Tare and Rohit Parihar
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