The last few weeks have witnessed a significant spike in Covid-19 cases in India taking the total number beyond 13 lakh. With two states, Kerala and West Bengal, already accepting the fact that community transmission has started, and a significant spike in infection rate in rural areas following migration of people for more than a month, among other reasons, the question arises whether the existing healthcare infrastructure in rural India can handle the pressure.
The Indian Medical Association (IMA) reportedly said community transmission in the country has started and that the spread of the virus to villages is a ‘bad sign’.
Though the association distanced itself from the statement two days after, there is no denying that it is a bad sign. According to a KPMG report of 2015, “about 80 percent of doctors, 75 percent of dispensaries and 60 percent of hospitals are present in urban areas when 72 per cent of India’s population lives in rural areas”.
Though members of the medical fraternity who gave views for the report were divided over the preparedness in villages, statistics and reality show that there could be a serious crisis ahead. IMA, however, has claimed that the medical fraternity is fully prepared and that clusters are in urban metros and not in the countryside where open spaces are the rule.
The rural healthcare has three tiers — sub-centre, primary health centre (PHC) that is the referral unit of six sub-centres and community health centre (CHC) that is the referral unit for four PHCs. Lack of infrastructure, medicines, doctors, nurses and hygiene is nothing new in these units. In some remote areas, people have to travel for kilometers to avail of decent healthcare service.
In April this year, the president of the International Institute of Rural Reconstruction (IIRR), Peter Williams, pointed out that “it would be quite a short-sighted measure for governments to focus their attention on cities”.
But in most of the states in India, the focus was on cities as initially, the majority of the cases were reported from urban settlements. “We cannot handle the pressure if cases shoot up and come to the villages,” said a doctor who is posted in Nadia district in West Bengal. He, and many others, spoke to the correspondent anonymously.
“Whenever a person comes to us with symptoms of Covid we isolate him or her or refer to the district hospital. We do not have ventilators here,” said the doctor.
Another doctor posted in the same district said those who tested positive in the district were migrant workers and none of the locals got infected. “We are hoping that cases will not go up as migration has ended. No one can hide as our team is on the lookout,” he added.
West Bengal was the second state after Kerala that admitted to community transmission in a few areas, something that the Centre has been denying. Last month, Goa too admitted to community spread only to retract its statement a week later.
Eminent physician Dr Sukumar Mukherjee, who is in the core corona management team of the West Bengal government, said whether rural healthcare can take the pressure will depend on the situation. “In West Bengal, the infection rate is increasing but the cure rate is also improving,” he told this correspondent in the end of June.
When asked in the perspective of the current situation, he sounded alert saying cases have been reported from villages and 50 districts in the country have been affected. He added that lockdown is a way to stop community transmission.
Pranab (name changed on request), a resident of Amtala in South 24 Parganas, said there were several cases in nearby villages and that has affected general healthcare. “About three persons in my family were suffering from coughs and colds and I was worried. But there is no testing facility near our village. The nearest is ESI Hospital (around 13km) or there are private options, which are expensive,” he added.
There are some natural hurdles, like difficult terrain in several places of the North East. Dr Kaling Jerang of East Siang district in Arunachal Pradesh said though his district “is easier in every sense in Arunachal with motorable roads reaching everywhere, many interior districts will have problems”.
Dr RV Asokan, secretary general of IMA, said when it comes to rural healthcare in this pandemic situation, various factors come into play. For instance, physical distancing is possible in villages as there is less congestion there than in cities. Also, the quality of air is better in rural areas, ensuring a better respiratory system.
Initially, only six metro cities (Delhi, Mumbai, Kolkata, Chennai, Hyderabad and Ahmedabad) were affected and the Indian Council for Medical Research (ICMR) was confident that villages would not be affected. “It is not about the quality of healthcare that is available but the quality of health,” said Ashokan.
He said the percentage of cases as against the population count is slightly higher in the North East. The cases in the region have risen fast in the last few weeks with Assam leading the seven sisters with around 27,000 positive cases.
According to Jerang, there are no cases in the rural areas of Arunachal Pradesh so far and “these areas are safe”. In Meghalaya too, not many cases were reported from outside the city in the beginning. In April, a village in East Khasi Hills was sealed after one positive case was detected, a primary contact of the first Covid patient in the state. Now, Mawngap and Laitkor on the outskirts of the city have been declared containment zones. Neighbouring Assam has several cases outside its capital town of Guwahati.
General healthcare has also taken a hit especially in rural areas as the number of health workers remains constant. Rupali, a resident of a village near Diamond Harbour, said she could not find a general physician when she was suffering from dysentery. “I was scared to go to a hospital but private clinics are closed in our village. So I did not go to a doctor and took some stipulated medicines,” she added.
A doctor in Arunachal Pradesh pointed out that the limited medical staff in the state have been engaged in pandemic management. Several doctors this correspondent spoke to in Assam, West Bengal, Odisha and Arunachal Pradesh said most of the doctors and healthcare workers are engaged in fighting the pandemic but hospitals are providing emergency services.
But nothing much has changed for the villages where there is hardly any infrastructure to tackle emergency patients. A recent report in a local daily in Meghalaya said a PHC in South West Khasi Hills has been running without a doctor after the one doctor there went to Shillong to pursue higher studies. The state of affairs in most of the PHCs is the same with many running with one or no doctor.
Some states, however, have shown alacrity. The best example is Kerala. Among those in the eastern and north-eastern zones, Odisha is “prepared”. When asked whether the rural healthcare system in our country can take the pressure of the pandemic, a doctor in Odisha’s tribal-dominated Keonjhar district gave hope.
“No healthcare system is sufficient enough to take the pressure of pandemic, especially of this type where you need social distancing, special PPEs, ventilators etc. But the rural healthcare in India has handled all this pressure,” she said.
Talking about Odisha’s preparedness in rural areas, the doctor said 17,451 temporary medical centres have been created at gram panchayat and urban local body levels with an accommodation for 8,04,441 persons. In the temporary centres, migrant workers were provided accommodation, food, personal hygiene kits for men, women and children, and free health check-up.
And yet those living in rural pockets have misgivings about the reliability of the healthcare system. “Many cases have been reported from villages surrounding ours and if more come up, there will be a problem as there is no facility here or in any rural area. So patients have to be sent to cities where beds are limited,” was Pranab’s apprehension.
Dr Pradip Mitra, who is heading the Bengal corona team, allayed fears saying there are enough beds and ventilators not only in the city but also on its periphery. “Districts are equipped too. There won’t be any problem,” he said.
A senior doctor, however, shared his deepest fear. “Enforcing lockdown and other measures like social distancing, hand hygiene etc looks like the only hope for us. In a worst case scenario my own feeling is there could be a complete collapse of our healthcare systems notwithstanding the preparedness that we have done so far. Lack of human resource and infrastructure is very acute; only a few seriously sick Covid patients might bring down the whole system,” he said.