COVID-19 in rural India ‒ a public health perspective
A tribal village checkpost displaying COVID-19 prevention guidelines in Ushirpar village, Gadchiroli district (Credit: Jitendra Shahare)
Given the restricted influx of international travellers and low population density in rural India, the cases of COVID-19 infections have so far remained low. However, the exodus of migrant workers from urban India returning to their native villages is set to change this dynamic soon.
In this Q&A with Vanshika Singh, public health researcher Yogeshwar Kalkonde, who is part of the non-governmental organization SEARCH in Gadchiroli, Maharashtra, takes us through the peculiar challenges posed by the COVID-19 pandemic for those at the fringes of healthcare ‒ the rural Indian population, and elaborates on measures to alleviate these systematically.
Do you think the healthcare infrastructure of rural India is appropriately equipped to handle the short and long-term implications of the pandemic?
The primary health centres are the peripheral goalposts of our country’s health response system in rural areas and their role in the context of the pandemic will be to prevent the spread of the infection and avoid the hospitals from getting overwhelmed with patients. India has not, in practice, endorsed primary care to be the foundation of overall healthcare as a value system, and the fault lines in our public health systems are emerging all the more with the COVID-19 situation.
The lockdown posed a significant challenge to accessing healthcare in rural areas. This includes care for maternal and child services, infectious diseases, non-communicable diseases as well as emergency and elective surgical care. All of these were affected to various extents. The need to have medical care closer to villages is prominent now more than ever. Patients with chronic conditions such as high blood pressure and diabetes often seek care from a distant district or a taluka centre and the lockdown has forced them to stop their treatments, potentially increasing the risk of mortality in the short term.
The impact of the pandemic on rural India will emerge in multiple phases. The first phase was that of an extended lockdown, the second phase was of migrants being allowed to travel back to their homes in rural India. The third phase will start when travel increases as the restrictions are gradually removed.
What are some of the lacunae that you identify in the existing systems? And what should be the modus operandi of the primary healthcare centres in response to the pandemic?
That’s a very valid question. With technology majorly driving healthcare, it is easy to believe that the one with maximum technology can deliver the most. That is not entirely true. My own foray into public health has made me appreciate the power of the simple ‒ often that which is easy to implement can deliver the most in limited settings. The Health and Wellness Centres (HWCs) under the Ayushman Bharat Yojna are supposed to take healthcare closer to villages and these centres are gradually being set up. If we had well-functioning HWCs a priori in rural areas, we could have averted problems related to discontinuity of healthcare care in a significant way. So there is power in decentralisation. When you decentralise, people get power.
Having said that, as the lockdown eases, we are all expecting a surge in the number of COVID-19 positive cases in the rural areas, and if that happens, the strategy would have to be to manage these cases mostly at the primary centres and promptly transfer those needing a higher level of care to appropriate centres in the district. We now know that 85 percent of cases are mild and about 15 percent will need hospitalization. Those with mild-to-moderate symptoms, which is a majority of the patients, can be handled at the primary care level.
As we go to subsequent stages in rural India, the response to COVID-19 will be needed at two levels: preventive care and medical treatment. The preventive care will require working closely with village leadership, tracking those who are at higher risk, testing these individuals, tracing contacts and quarantining. If there is a significant number of symptomatic cases then we will have to see how the preventive services implemented through primary health centres will work.
The secondary and tertiary care health facilities such as the rural hospitals at taluka places and district hospitals are already flooded, and creating additional facilities and managing ventilators exclusively for COVID-19 will be extremely challenging for them. So the real test of rural healthcare lies ahead as we go forward in the pandemic. There is definitely an opportunity in this challenge: an opportunity to strengthen rural primary health care systems which will go a long way in improving the health of the rural folks well beyond this pandemic.
The reason that they had left their homes in the first place was to look for greener pastures as employment was not easily available in villages and many people are not keen on going into agriculture. Also, what we often forget is the periodic rural-to-rural migration, since it is only the urban-rural migration that gets highlighted in light of the pandemic. In this season, many farmers and farm labourers had made it to farms of neighbouring states for work, and upon return had to be quarantined with appropriate food and accommodation. While this first phase was reasonably managed at some places, many smaller villages didn’t have such provisions and the farmers returning from other villages had to be quarantined for 14 days outside the villages in open farms with the barest minimum facilities.
The kharif season will absorb some if not all migrants into farming, but many will not be willing to settle in for these jobs and might want to return to the city once the situation settles back to the new normal. Whether the industries will be viable enough to accommodate them by then, only time will tell. Some of the migrants have gone through a very traumatic experience of traveling back and are not keen to migrate in the near future. So overall, the pandemic will significantly increase economic and social hardships in rural areas.
The Government of India has several schemes to provide for livelihoods in rural areas, MNREGA (Mahatma Gandhi National Rural Employment Guarantee) being an important one among them. Central and state governments will have to pay special attention to rural areas so that employment opportunities are increased, and so the need for migration will be less at least in the short term.
Gadchiroli did not have any case until a few weeks ago but now has about 40 cases of COVID-19 as of now, all among migrants who returned from Mumbai.
SEARCH works with a community of around 100,000 people from 130 villages in Gadchiroli. As soon as we realised that COVID-19 will be a long-term risk, we launched a three-point program to enable the communities to tackle this.
The first aspect of this was to create awareness using culturally appropriate material and gently nudge the people into self-propelled action. Also, since 40 percent of the Gadchiroli population is tribal communities, we produced jingles and educational videos in the indigenous tribal language, Gondi. We need to further work towards a more sustained source of reliable information that is relevant for the particular needs of these marginalised communities.
SEARCH has worked with the villages to create local committees that have been trained in what to expect in the coming six months or so, and for them to take appropriate action at the community level. This was done before the wave of migrants came in, and an on-ground translation of this strategy was the quick assembly of quarantine facilities within the villages by these committees once the migrants came in.
The local committees worked together with their respective gram panchayats to set up check posts and distribute masks and hand sanitisers and promote behavioral modifications through social distancing and frequent hand washing. We also trained these committees to have a surveillance system in place to know what the course of action should be if they suspect a person has symptoms of COVID-19, and then prepared them to know where to take the patients, based on referral systems that are in line with the guidelines issued by district collectors of the region.
To bring this a full circle, we are keeping a tab on the local action and on how many such preventive practices have been implemented in their villages, so as to give this as a feedback to the communities in a data-driven manner.
An internist and a neuro-immunologist by training, Yogeshwar Kalkonde is currently associated with the Society for Education, Action and Research in Community Health (SEARCH), a non-governmental organisation based in the rural district of Gadchiroli, Maharashtra. As a Wellcome Trust/DBT India Alliance intermediate fellow and the program lead at SEARCH, he spearheads the development of healthcare delivery for chronic and non-communicable diseases in rural and tribal areas of Gadchiroli.
Vanshika Singh is a senior research fellow pursuing neuroscience, and finds her muse in the art of communicating science to a wider audience as a freelance science writer.