* Any views expressed in this opinion piece are those of the author and not of Thomson Reuters Foundation.
Srinath Reddy is a cardiologist and epidemiologist, and President of PHFI. He is the author Make Health in India: Reaching a Billion Plus.
Soon after the novel coronavirus touched down in India on January 30, concerns were raised as to whether weak rural health systems would manage to mount an effective response, should the virus gain easy passage into the villages from the urban entry points. Until July, that danger appeared distant as the virus was spreading mostly in large cities and neighbouring towns. However, it became apparent in August that the ratio of rural to urban cases had started to rapidly increase, with 24% and 43% cases reported from rural and semi-rural districts.
Levels of rural development vary across India, between and within states, with urban-rural connectivity being an important factor determining the extent and speed of viral dissemination. The states in southern and western India, in general, have better levels of rural development. Kerala has a seamless urban-rural continuum. It is not surprising that the states with higher levels of rural development and connectivity are exhibiting rising viral infection levels ahead of those with less developed rural regions.
The spread of the virus within and between the rural areas is expected to be slower than in the cities. Crowd density is lower, people commute shorter distances to work and meet less people, while there are more open areas for farm work and social gatherings. The risk of severe infection is also lower due to the lower prevalence of co-morbidities like cardiovascular disease, diabetes and obesity than in urban areas and ambient air pollution levels too are lower. However, these advantages are offset by the paucity of health services which creates barriers for timely testing and treatment.
Rural primary healthcare has been prioritised for several decades in health planning but has been poorly delivered due to inadequate public financing and inefficient management. While rural India has two-thirds of the population, it has only a third of country’s qualified health workforce. Around 65% of hospital beds are in urban areas. However, it is an individual state’s capacity that will determine the strength of the response rather than the aggregate national profile. Some states like Kerala and Tamil Nadu have high quality primary health services but in general rural healthcare has suffered from inadequate infrastructure, insufficient health workforce and undependable referral linkages to higher levels of care. Public health initiatives for prevention and containment as well as clinical measures for case detection and treatment face major challenges in such resource constrained settings. A major source of strength for rural healthcare are the Accredited Social Health Activists (ASHAs) who are not a formal part of the health workforce but are an incentivised ‘volunteer‘army of healthcare enablers and social mobilisers.
Detection of COVID-19 cases, in rural areas where primary healthcare facilities are not well functioning, must be enabled by ASHAs, Auxiliary Nurse Midwives and Anganwadi Workers (the troika of rural primary care), supported by young citizen volunteers. Symptom based syndromic surveillance for COVID-19 symptoms, based on a simple checklist, can be carried out through home visits by such teams. Mobile medical vans can be sent for testing periodically but symptoms and close contact history can guide home isolation policy till test results are available. Home care, with supportive primary health services should be possible by equipping the primary care teams with thermometers and oximeters. Schema for emergency transport to oxygen equipped sub-district hospitals or even urban intensive care units can be pre-planned as contingency measures, by these teams in consultation with district health authorities. Even as these mitigation measures are mounted, containment must also be pursued by strictly limiting urban to rural transport to essential needs.
For all of this to succeed, public trust needs to be built that a responsive and caring health system is available, not just to meet testing targets set by some government agency but to provide comprehensive healthcare in an efficient and empathetic manner. Persuading rural residents to wear culturally strange face masks is a task that can only be achieved by local influencers and not by shrill urban electronic media. Local community leadership is essential to build trust, eliminating fear and stigma. Countering COVID-19 in rural India is not just a challenge for India’s health system but a call of duty that both central and state governments must respond to with competence and commitment.
