By Govindraj Ethiraj
Mumbai: The number of COVID-19 cases in India is now slowing down a bit, with around 350,000 cases and fewer than 4,200 deaths every day. We know by now that on both numbers, there is considerable under-counting.
The number of cases at a national level does not also represent, or perhaps hides, what is happening in rural India. What we do know now, through anecdotal measurements, either in terms of the number of deaths or the field work of many organisations, is that cases in rural India are now much higher than ever?
What is the impact of COVID-19 on rural India? How do we put in place medium and long-term plans to improve the public health infrastructure in villages? I'm pleased to be joined by two guests today. Dr Pavitra Mohan is secretary and co-founder of Basic Healthcare Services, a non-profit that has been working primarily in southern Rajasthan. He is based out of Udaipur and was earlier a senior health specialist at UNICEF India. He has an MBBS and then an MD from the Delhi University and a masters in public health from the University of North Carolina, US.
I'm also joined by Poonam Muttreja, executive director of the Population Foundation of India. She was earlier the country director of the McArthur Foundation. She has a masters in public administration from the Harvard Kennedy School of Government. She has been speaking on many issues relating to health and other outcomes in rural India.
Tell us what has changed and what has not, in rural India, between the first and second waves?
Poonam Muttreja: The one big difference between the first and the second wave is, we responded [in the first wave]. Even though we weren't prepared, we took time to prepare and we declared a lockdown: unfortunately within four hours and that created its own problems. We were all made to feel we needed to change our behaviours, we needed to practice social distancing and laws were put in place as well as curfews and so on.
The big difference this time is that we are neither prepared nor do I get the impression that our government is serious about preparing for either the second wave or a third wave.
The other big difference is that young people are being impacted: they are 70% of India's population. And they are moving: migrants are mainly young people going back to their villages and taking the infection with them, so it has reached the villages. We kept asking last time: Will it reach the villages? And we were just very lucky that it didn't then, but now it has.
The third big difference is that for the first time, [during the first wave], our political leadership actually led the country into believing that we need to change our social behaviours, apart from the "thali bajao", that COVID-19 required. These [protocols] were spread by a leader in India whom people listened to, we have to admit that. Now we have the same political leadership doing rallies and allowing religious events like the big Kumbh Mela. So people in India who have seen these images on television, mainly rural, do not believe that there is a second wave or that there is a need to practise [COVID-appropriate behaviour].
Finally, our frontline health workers, especially the ASHAs, who were put into action, had the energy and enthusiasm to do it, but we let them down by not giving them any protection. So, many of them got COVID-19 or other health issues. They are demoralised, discouraged, sick and scared because they know what the second wave is. What we are hearing from the field in rural areas is that we have not developed any infrastructure to deal with any aspect of COVID.
You do a lot of work in southern Rajasthan. What have you been seeing? What has changed?
Pavitra Mohan: I think in the first phase, there was a small rise [in infections] in rural areas after the lockdown. Immediately after the abrupt lockdown, there was a very, very small increase, but after it was relaxed and many migrants started returning around May, we saw a small increase in the number of people infected. But then it kind of petered off by September and it never spread as much.
This time around, the sharp rise and the width [of the spread] is so much more. It's spreading much faster. It's affecting even deeper rural areas. We had hypothesised in the first phase that maybe if it comes to rural areas, it would not spread as fast and would probably not affect the remotest populations. But this time around, remote populations are affected hugely, both in terms of infection, but also increasingly in terms of severity and deaths.
One reason for this is that, as you said, the virus seems to be more infectious and causing more severe infection. The other significant factor is the movement between urban and rural areas, which continued and continues: that led to a significant spread. Thirdly, there was also, from the system's point of view, the inability to quickly look at some of the rising episodes of an influenza-like illness and to immediately ramp up testing. This led to a bit of complacency until it started causing deaths and hospitals started getting flooded.
This is also a huge wedding season in many rural areas, including the areas we work in. That plus the movement of migrants back and forth to attend weddings led to a faster spread this time. It's also epidemiologically a population that was neither vaccinated nor infected in the first wave. Thus, they were easy prey to the virus this time around. This led to high severity [of the disease] among the rural, and even remote rural, populations.
You run a chain of decentralised clinics. How have you been coping with the severity of the disease in this wave?
Pavitra Mohan: We were caught unawares and now, it is progressively increasing. We're nowhere near the peak, at least in south Rajasthan. There are certain places in rural areas, which seem to have been peaking. Maharashtra, for example, started much earlier and probably even in rural areas [there] the peaking has happened.
The severity, we started seeing, at least till two weeks ago, it was much more among those who were relatively better off in the rural areas, not in the remoter areas, though the infection had started spreading there. But now, increasingly we are seeing that even the remote populations and tribal populations are being [severely] affected. What we had done last year was to equip our clinics with protective measures. For example, we shifted all our clinics outdoors because it is so much easier to prevent infection there than indoors.
We had ensured that we had oxygen concentrators in each of our clinics. This was right after the first wave and this is something we had been advocating since last year. If you see some of our writings, [we wrote] that all primary health centres and community health centres need to have oxygen, not just to deal with COVID, though we thought that COVID would be an opportunity to strengthen the availability of oxygen and the health systems. But that did not happen. So, unfortunately we are now seeing this rampant [crisis over the] procurement and transportation of oxygen [and concentrators]. Since last March, we had been pushing for it. We did procure oxygen for our clinics and now, of course, oxygen concentrators, which are easier [to deal with] in these times when there is a lockdown and it is difficult to refill cylinders.
Our second measure was to rapidly look at protocols, etc. Now we are working to set up COVID-care centres with the district administration to deal with the immediate prevention of deaths due to severity.
Many people from rural India also go to cities for treatment because urban hospitals have, say, specialised healthcare, doctors and intensive care units with equipment. How do you then respond to severe cases in rural areas?
Pavitra Mohan: We should have learnt from COVID to develop more decentralised, simple technologies and appropriate care rather than the fanciest care. If you look at ventilatory care, even in America, nine out of 10 would probably not survive that. A lot of our focus has been on intensive care and hospital-based care. But what we are learning from epidemiology elsewhere, as well as India, is that a lot of care and prevention of deaths could happen at homes, at smaller health centres and, at the most, at block-level centres.
Two main things we are seeing even in severe cases: One is that there is a lot of care that is possible at home. But in hospitals, there are two things that can be made available at the most decentralised units: oxygen, and then if you really need it, at the next level, BiPAP or CPAP, which are not as expensive as ventilators. Of course, a small proportion would require ventilators but that cannot be made available everywhere.
We need to look back and see that if we strengthen our peripheral health centres with the basics, we can actually get it right nine out of 10 times and we need not rely on hospital-based care for preventing the bulk of deaths.
We are talking about response, but there's also a problem of measurement: It is quite clear now that we are severely under-counting cases because tests are being denied for various reasons, including logistics. So if you don't know what the number of cases are, the number of deaths, how do you then respond in terms of medical infrastructure and so on? How and where do we even begin to address this, particularly in some of the largest states in India?
Poonam Muttreja: What we have to do is start doing surveillance immediately and I believe that the ASHAs played a really good role in surveillance earlier. They quarantined people who had symptoms and so on, and they did a very good collection of information.
I think now, given the severity of the situation, we can't just leave it to ASHAs. We could get this AAA going, they are our three aces right now: ASHAs, ANMs, and Anganwadi workers. We make a team of them and they do the surveillance but we must protect them with PPEs and all the COVID-19 appropriate equipment. We must train them online and do that quickly. I know that NGOs and many of us have the capability. We can get together and do it at scale and the advantage of [inter]net is you can do the training at scale.
We also need to do testing. We have no testing facilities in most rural parts, so I would like to suggest that every MP and MLA in India ensures that his or her constituency immediately gets testing facilities. They all pool in their funds, MPLADS funds, and the MLA funds, and it should be the responsibility of the MLAs along with district-level planning.
You cannot plan at this point of time for the villages of India from Delhi or from Patna and Jaipur. You have to do it from where Pavitra Mohan is and others in the community. So I would like to suggest that we immediately start with either the collector or the district magistrate (DM). It's not the prime minister who can decide and work on this, it is the DM we need for the villages.
I think a lot of other things should be postponed and the focus should be here, and we should involve the panchayats, especially in implementing social distancing, and appropriate social behaviour. We have the material. By "we", I mean a whole bunch of NGOs: and PFI definitely has as much material as is needed. We can make it available in every regional language. We immediately have to involve NGOs across the country, who have to collaborate. And for that, the government has to [put in abeyance] the FCRA rules (at least) by six months at least, as they are becoming a bottleneck in the working of NGOs.
What you heard from Mutreja is the top-down view. How are you seeing it bottom-up? Do you see this kind of participation from the local MLA, the district collector or the district magistrate?
Pavitra Mohan: I would like to say that there is a lot of mistrust right now between the public systems and the communities that they're supposed to serve. It stems partly from the abrupt lockdown last year and the forced quarantine etc., which has left a lot of fear in the minds of the people and distrust of the public systems. That is something we need to break, both for the short-term and the long-term. In the short term, you talked about testing: people are just so afraid of testing at the moment or of assisted home care because they feel like they will be quarantined, taken away, etc. This is something that we really need to work on quite urgently and seriously.
Even the way we started the vaccination, people had some misgivings initially, which is normal for any new vaccine that is introduced, especially which is injectable and which is being given to every adult. But in many places we saw that people were almost coerced into taking the vaccine [with the threat that] otherwise they would not get their old-age pensions or their name would be removed from the ration card. That led to a lot of mistrust, which needs to seriously change. Things have to be dealt with with more seriousness than is visible right now.
There is, of course, a firefighting kind of an approach right now: say, how can we quickly make some oxygen available somewhere. But engaging with the communities and working with and motivating the frontline staff: that seems to be lacking at the moment and needs to be really ramped up.
I think it is clear that we have to focus more on prevention than cure. Just pumping in investment or getting fancy new hospitals is not going to solve the problem, at least not immediately. Any thoughts on how we can begin to do that, particularly in the context of rural India?
Poonam Muttreja: Again, I'd like to say that we can make an example by getting our political leadership, local MPs and MLAs, to participate, involving the panchayats and [encouraging] decentralised planning in terms of priorities. If we need oxygen, which primary healthcare centre does it go to? Which are the places where there are doctors who can manage the machines?
There's no point sending machines, equipment and medication to a primary healthcare centre which has a missing doctor. So community health centres too can be operationalised and it will be good for the long term, as Pavitra also said, we need oxygen regardless of COVID. We need facilities to have better equipment, better infrastructure, and we need to ramp up our 108 or 104 emergency ambulance systems: we have this across the country and let's use those for COVID patients to transport them.
As Pavitra also mentioned, home care is still a very good first option for many people, but how do they do it? I would like to see the ramping up of online medicine, where doctors can give people online advice on how to deal with the situation. Not just doctors, nurses can do it, NGO staff members, we have large numbers across the country, can do it. You don't have to be a doctor and I believe we don't have the doctors. So we may as well invest in our three frontline workers and others.
Finally, vaccination. The only thing that will save us from COVID in the long run and in the mid-run is vaccination and we need to ramp up our vaccination in rural areas: that is the only way. I think we are capable of doing vaccination in rural areas: if you remember pulse-polio [vaccinations], in one day, we did crores. We covered the whole country in two successive years. So let's go back to our own capability and management. I know this government says nothing has happened for 70 years but polio did happen and we eradicated polio, we eradicated smallpox. Can we just do what we did then?
And finally, we must have greater collaboration between whatever private sector exists: the government, the private sector and NGOs have to work together in collaboration and I do believe that local district-level coordination will help.
As you look ahead, what's your wish list when it comes to improving the quality of healthcare, especially in rural India?
Pavitra Mohan: I have a long wish list and I think we need a whole programme to probably discuss that. But to begin with, there needs to be a philosophical and technical shift: to focus on decentralised primary healthcare [rather] than the hospital-based system that we are increasingly creating. We have to move from specialised to more generalist care. We have to move from specialists to doctors, and doctors to nurses, and nurses to community health workers. We have to spend our time and energy in developing strong primary healthcare teams at the front. We need to support them, we need to mentor them. We have to move away and also have a greater belief in the public system.
I think over the years there has been not only an under-investment [in public health systems] that is only a reflection of the dwindling belief in the public system. And we know from this epidemic, especially in rural areas, that ultimately if anything is being done it is being done only by the public systems, whether it is surveillance or ramping up some facilities. A lot is possible and we know this from states such as Kerala and some districts where public systems are stronger and could respond quickly [to the pandemic].
Thus, we have to have greater belief in public systems, more decentralised care, more support to the front and primary healthcare teams, which includes the primary care physicians, the nurses, the ANMs etc, which used to be the case earlier. Even in cities, we know how the public hospitals did ramp up their services rapidly to be able to cater to a large population and without incurring any expenditure. We know that many people are indebted to and being exploited by private hospitals. I have no qualms in saying that. Of course, private hospitals have played a role in managing a large number of people who could afford it [but they] have also shown the exploitative side of the private sector.
Even as a medical fraternity we really, really have to take a sit back and figure out how we promote rational care. There has also been a simultaneous epidemic of promoting irrational care during this pandemic.