India’s rural healthcare is not adequate or prepared to contain Covid 19 transmission, especially in densely populated northern states with the region coming short of doctors, hospital beds and equipment. Even the facilities for vaccination are scanty in the villages. The villagers often have to travel long distances to receive specialised treatment in the cities.
The second wave is at its peak in the country. While all attention of the administration, health department officials and healthcare providers are riveted on urban India, it is easy to overlook rural India with about 900 crore people (65% of India’s population). Neglecting rural India’s second wave will be a monumental error in terms of lives and livelihoods that will be lost. We hear that in some Northern states, every second or third rural household has at least one death due to Covid-19.
URGENT INVESTMENT NEEDED IN RURAL HEALTH CARE
The second and the third waves are known as greater killers than the first wave, as per the lessons learnt from the Spanish flu of 1919. As the human tragedy gets accentuated with the second wave, there is shortage of everything in Indian cities — oxygen, drugs, beds, ventilators, vaccines, even cremation space. Doctors and other Covid warriors are dying or quitting, exhausted, worn out, insulted or thrashed by desperate mobs. India’s urban healthcare system is overwhelmed under the weight of Covid, while rural needs are out of sight.
The media as well as the political class are preoccupied with the scarcity of hospital beds in the metros; none has commented on the impending catastrophe in rural India, where health infrastructure is as good as non-existent. Rural people, constituting two-thirds of the total population, have been neglected. The availability of rural hospital beds per 10,000 people is only 2-3. Also, the hospitals are devoid of trained manpower, ICU beds, specialists, tertiary care institutions or state-of-the-art ambulances. With ignorance and poverty prevailing in villages, gatherings are a common sight, be it religious events, elections or political agitations.
The disparity in healthcare services will exacerbate the loss of life in rural India. We need to act very quickly to prevent rapid spread and save lives by creating makeshift healthcare facilities to care for the sick in rural India.
Urban India, severely affected in the first and second waves, will have high levels of herd immunity. Protection by vaccination will take two doses plus two weeks — minimum of six weeks from start. Considering the supply problems, the low achievement of urban inoculation and hesitancy, vaccine-induced immunity will not protect rural India from the impending massive extension of the second wave in the next few crucial weeks.
We have a crucial few days before the rural component of the second wave becomes a major medical disaster—an opportunity to plan and implement an effective preventive programme to minimise its rural impact.
Right from the beginning of the pandemic in India, our greatest failure has been our inability to properly utilise a simple, readily available, cost-effective preventive tool—the social vaccine—to inform and provide specific education through effective communication strategy to all Indians and enable everyone to adopt Covid-appropriate behaviour.
This means a complete cessation of all gatherings, meetings and congregations, everyone wearing a fitting face mask, maintaining a physical distance of one metre from others, avoiding physical contact with others, practicing cough etiquette and frequent hand washing. Even now, this is the only tool that we can readily deploy to reduce rural spread and save lives.
This requires mobilising our entire population, initiating a massive publicity blitz by all influential people who hold sway over the public—politicians, actors, sportspersons, acclaimed medical professionals and administrators. Every TV channel in every Indian language should carry these messages repeatedly during prime time to drive the message home. Education of the public should be the responsibility of the district administration, gram panchayats, healthcare workers, civil society opinion leaders, teachers, voluntary organisations and philanthropic institutions. Mobile phones, which have a wide reach in rural India, can be utilised to spread messages and short educational video clips about Covid-prevention strategies in regional languages. This step will have a major impact.
A large number of migrant workers who returned to cities and towns after the first wave are migrating back to the villages— this migration is triggering multiple chains of virus transmission in rural India by the highly infectious variants of the second wave. Further urban to rural transmission should be quickly curbed by setting up temporary quarantine shelters and providing food for migrant labourers, where they can stay for two weeks before mingling with the rural folk. This period can be used to vaccinate this vulnerable group.
If urban India, with its numerous public and private healthcare facilities, faces a huge oxygen deficit, one can imagine the plight of rural India with its meagre infrastructure. Innovative ideas to make oxygen available to rural India would be a priority and a challenge. Large numbers of portable oxygen concentrators, to be deployed at hospitals and even homes when required, should be made available to each district collector. Uninterrupted power supply should be ensured to enable continuous functioning of life-saving medical equipment.
Mass vaccination will have to be deployed to prevent a potential third wave. For this to be achieved we need to be innovative on two fronts: one, overcome vaccine hesitancy and two, improve availability and equitable distribution of the jabs.
A comparison of the proportions of new infections, serious disease and deaths in those partially (one dose) or fully (two doses) vaccinated, with the same proportions in unvaccinated individuals, updated on a daily basis, can be conveyed to the public in easily understandable terms. This will inform the public about the efficacy and safety of both vaccines. This single step will help dispel vaccine hesitancy.
Equitable and efficient vaccination of rural masses demands concerted, decentralised action by gram panchayats; they should actively involve all stakeholders—healthcare workers, civil society opinion leaders, industries, teachers, voluntary and philanthropic organisations—and quickly organise inoculation camps in each village. While governments (State and Central) undertake to supply vaccines for this mammoth task, each village panchayat should ensure the smooth conduct of the inoculation programme without wastage.
Tough days are ahead. If we act quickly and on a war footing, we can still mitigate the impact of a major medical disaster in rural India.
(Dr Naresh Purohit is a Medical Expert and Advisor National Communicable Disease Control Programme. He is also Advisor to six other National Health Programmes. He is visiting Professor in five Medical Universities of Southern India including Thrissur based Kerala University of Health Sciences. (The views and opinion expressed in this article are those of the author)