Mumbai: It was past 10 pm when S H Mehdi, BAMS, saw off the last of the day’s 250-odd patients and settled down to speak over the phone. “Chaaron taraf fever phaili hui hai. (There are febrile patients across the region.)”
Each of his patients that day in Sarai Rasulpur village of western Uttar Pradesh’s Khatauli block in Muzaffarnagar district was running a temperature. That day alone, he urged almost 100 to get tested for Covid-19. Perhaps 10 would make the journey to Khatauli town, 8 km away, he told Article 14. It had been this way for four weeks.
Nearly 1,500 km east of Khatauli, in West Bengal’s Birbhum district, ‘doctor’ Vishnu Salui said the last week of April was his busiest in 13 years of medical practice in Tarachi village, home to a large community of the Santhal tribe. Salui does not have a degree in medicine, but he saw 50 patients everyday, sometimes more, all reporting flu and diarrhoea, typical symptoms of Covid-19.
“Seven out of 10 I could cure, the rest I recommended a Covid test,” Salui, a paramedic, told Article 14. The nearest testing centres are in Mallarpur and Rampurhat towns, 7 km and 18 km away. “Those who were really ill or needed oxygen went to get tested,” said Salui. Most did not—going for a test would incur a day’s loss of wages.
In Uttar Pradesh, a young farmer told Article 14 how he cremated his father on their farm, days after oxygen ran out in the hospital. In Rajasthan, a labourer said he carried his sick father around a Covid ward looking for a bed. In Maharashtra, some tribals refused to go to a city hospital though entire hamlets were down with severe flu symptoms. In an Odisha district town, a migrant worker back from Bengaluru was among the few who could use social media to get a hospital bed for his Covid-positive parents. In Bihar, relatives donned protective gear to themselves pack the corpse of a loved one.
Mehdi and Salui, and other residents and practitioners in small towns and villages, spoke of patients who died before they could reach a hospital; black-marketeers of even ordinary fever medication; and acute shortages of hospital beds and oxygen in nearby towns. Salui is the only practitioner in his village of 1,500 people. By May, Mehdi and his son Kamal were the only doctors still practising in Sarai Rasulpur, donning protective gear to meet the crowds of patients outside their home-clinic by 6 am everyday.
Strikingly similar stories emerge from across India’s rural districts and villages. Even as the pandemic’s second wave appears to plateau in the big cities of Mumbai, Delhi, Bengaluru and Pune, a surge of untested, undocumented and unmonitored infections and deaths continues in the villages, where 800 million Indians, or 65% of the population, lives.
Facing The Covid-19 Surge With Sparse Means
In the new battleground of independent India’s worst-ever health crisis, chronic neglect has blighted public healthcare; and staff and infrastructure shortages impede the working of primary health centres (PHCs) and rural hospitals, according to the union ministry of health and family welfare’s (MoHFW) latest report on rural health statistics.
A 2020 study by the Centre for Policy Research found that 86% of care providers in Indian villages are in the private sector, and 68% of these are ‘informal’ doctors, without a degree in medicine, now finding themselves out of their depth. By early May, every second new Covid-19 patient belonged to a rural district, but testing in rural centres continues to be a fraction of the total, indicating that the countrywide problem of under-reporting of cases and deaths is compounded in India’s villages.
As reports emerged of up to 2,000 dead bodies of possible Covid patients in shallow graves along a 1,000-km stretch of rural Uttar Pradesh, the union government scrambled to address the rural surge.
On 16 May, Prime Minister Narendra Modi instructed officials to ensure oxygen supply to rural hospitals and to train health workers to operate modern equipment. On 16 May, the MoHFW released an elaborate new protocol for containing the pandemic in rural, peri-urban and tribal areas.
This protocol foresees preparatory work ranging from training of village-level health workers to perform rapid antigen tests, equipping all public health facilities with antigen test kits, mobilising AYUSH doctors (trained in traditional medicine, such as ayurveda and homeopathy), final year AYUSH students and final year students of BSc courses in nursing to operate village Covid-care centres and more.
But in the absence of adequate testing and data, an accurate assessment of the situation on the ground remains missing, hampering alleviation strategies for the future, said experts.
Jishnu Das, an economist and professor at Georgetown University, told Article 14: "A long-term impact of what is playing out in the villages now is that the poor have taken the brunt, and this will exacerbate the inequality that is inherent in our systems (in coming years)."
The Rural Pandemic Is Spreading
According to research by the State Bank of India, the share of rural districts in new cases rose from 36.8% in March to 45.5% in April and 48.5% in May. This comes alongside a dip in the 15 top districts’ share of new cases, from 55% in March to 26.3% in May, indicating a much wider dispersal of new infection, with test positivity rates, active infections and daily new cases not following similar trajectories as in the big metropolises.
The north-eastern state of Assam recorded its highest ever daily new cases at 6,573 on 20 May, days after chief minister Himanta Biswa Sarma, having declared in the first week of April during an election-time interview that “there is no Covid” in the state, launched a two-week ban on inter-district movement.
In Assam, over 10 days between 13 May and 22 May, Kamrup metropolitan district accounted for about a quarter of the state’s 45,432 new cases, but 16 other mostly rural districts added more than 1,000 new cases each in this period, including more than 3,300 cases each in Kamrup rural, Dibrugarh, Nagaon and Cachar.
More than 2,500 km to the south, an almost parallel rural surge was underway in Andhra Pradesh, in its coastal and Rayalaseema regions that recorded a deluge of cases. For the week ending 16 May, more than one third of the 147,000-odd new cases in all of Andhra Pradesh came from just three rural districts—Anantapur, Chittoor and East Godavari, all districts with several busy towns and peri-urban clusters adjoining villages.
Anantapur district saw active cases go from 9,865 on 1 May to 15,852 on 15 May before dipping to 9,256 on 23 May; the coastal district of Prakasam recorded a rise in active cases from 7,257 on 1 May to 18,540 on 15 May and further rose to 24,877 active cases on 23 May. Anantapur had the state’s highest test positivity rate for the week ending 23 May at 37.8%.
Eight districts in Andhra Pradesh recorded a weekly test positivity rate of over 20% for the week ending 23 May. Seven of them are predominantly rural districts. District-wise testing data is not released by the Centre, but low testing is usually the underlying cause for high test positivity rates, indicating that this rural district’s surge may be higher than its recorded cases.
While new cases in Chennai appeared to slow down after hitting a high of 7,466 on 11 May, Tamil Nadu recorded a highest-ever daily addition of 36,184 new cases on 21 May, with the urbanising Chengalpattu and Tiruvallur districts recording between 1,000 and 1,800 new cases daily for a week. Twenty districts in Tamil Nadu recorded a weekly test positivity of over 20% for the week ending 23 May, five of them rural.
Eleven of 16 West Bengal districts with a test positivity of over 20% for the week ending 23 May are predominantly rural.
In Telangana, the Greater Hyderabad Municipal Corporation district accounts for the most daily new cases, but districts such as Nalgonda, Khammam and Karimnagar—with over 60% rural population—added 200-250 new cases everyday for the week ending 13 May, and 100-200 new cases everyday for the week ending 24 May. Industrial and peri-urban areas in Medchal Malkajigiri and Rangareddy districts were adding between 250 to 400 new cases each day, dipping a little to 200-250 cases daily last week.
Remote, hilly areas with large tribal populations have not been spared the second wave’s rural surge. On 31 December 2020, tribal-dominated Gadchiroli district on the eastern edge of Maharashtra had a total of 8,507 cases and 87 deaths until then. Following a surge that began in March, Gadchiroli as of 24 May recorded 27,655 cases and 403 deaths in all, a more than three-fold jump.
Maharashtra’s Amravati district, home to a couple of hundred tribal villages located in the Melghat forest, had 7,277 cases and 169 deaths by 31 December. Now witnessing what appears to be a renewed second wave after cases plateaued earlier this month, Amravati recorded 44,922 cases until 24 May, a six-fold rise; and 808 deaths, a five-fold increase.
In Odisha, activists wrote to the chief minister on 21 May expressing concern over the surge in Covid cases among the Dongria Kondhs of Niyamgiri and the Bonda tribes of Malkangiri, both classified as particularly vulnerable tribal groups.
‘I Begged, I Cried’
On 5 May, when his 55-year-old father developed a fever, Dinesh Chaudhary (32) of Sagwar village in eastern Uttar Pradesh’s Unnao district requested a local medical practitioner to visit the house for a check-up.
On 7 May, when his father complained of a terrible body-ache, the local doctor checked his blood oxygen saturation. The oximeter reading was 84.
A neighbour agreed to ferry Dinesh and his highly febrile father to Unnao town, 60 km away, in his car. Two private clinics refused to admit the patient, and at Unnao District Hospital, no bed was available. “Main bahut gidgidaaya, bahut roya. (I begged and cried.)”
After several pleas, he was directed to a bed in a ward with Covid and non-Covid patients. Past midnight, he realised there was no oxygen flowing out of the cylinder. “It had been empty all along,” said Dinesh.
Dinesh argued with hospital staff and waited until morning for a new cylinder. It never came. He finally decided to take his very breathless father back home, “Ram bharose” or left to the will of god.
Then, Dinesh borrowed Rs 100,000 from friends and acquaintances and travelled to Kanpur, 70 km away, to purchase an oxygen concentrator.
“There is no oxygen anywhere for a 100 km, no beds available, no facility in the village for early testing, no ASHAs visiting us, nothing,” Dinesh told Article 14. The RT-PCR report from the district hospital arrived the following day, 9 May: positive. The family was not advised to get tested or isolate themselves, nor was any contact-tracing initiated.
On 10 May, hours after his father died despite the expensive new machine at home, Dinesh and his brother conducted the last rites on their four bighas of farmland. No special Covid protocol was followed.
Baksar ghat, the sandy shore of the Ganga, one of several riverfront locations in Uttar Pradesh where hundreds of dead bodies were discovered in shallow graves since early May, is 13 km from Sagwar.
“Four or five bodies would be cremated there on a normal day; now about a 100 are coming every day,” Dinesh said, adding that the situation is “worse than anyone has reported and worse than you can imagine”. He estimated that 60-70% of people in nearby villages were suffering bouts of fever and cough, almost none getting tested unless they make the 60-km journey to Unnao.
Fighting Fatigue And Frustration
As per government of India norms, rural regions must have one primary health centre (PHC) per 30,000 people. In Uttar Pradesh, Jharkhand, Bihar and West Bengal, a single primary health centre caters to a population of more than 50,000, and these are saddled with staff shortages, according to the government’s report on rural health statistics.
The rural hospitals or community health centres (CHCs), which are meant to have X-Ray machines, other diagnostic equipment, an operation theatre for deliveries and for some basic surgeries, are facing a critical shortage of doctors.
The norm for CHCs is one facility for every 1,20,000 people, but in the villages of Telangana, Andhra Pradesh, Karnataka, Maharashtra and Uttar Pradesh, these CHCs cater to between 2,00,000 and 5,00,000 people. In Bihar, the rural population covered by a single CHC is more than 5,00,000.
Across India’s CHCs, 68.4% of sanctioned posts for surgeons, 56.1% posts for obstetricians and gynaecologists, 66.8% posts for physicians and 63.1% posts for pediatricians are lying vacant. Sanctioned posts are fewer than the requirement, so actual shortfall is even wider. Overall, there is a 76.1% shortfall of specialists at rural CHCs. There are also vacant posts for laboratory technicians, pharmacists and nursing staff.
In UP, of the sanctioned 2,171 specialist-posts at CHCs (the most posts among all states), only 816 are in position—not counting any further shortages on account of Covid.
As many as 75.1% of sub-centers of PHCs in Uttar Pradesh function without regular electric supply, 54.9% in Bihar. More than half the sub-centres in Bihar do not have regular water supply.
Districts that managed to overcome the shortfall had to think outside the box. Pune, which has remained India’s worst-hit district from the first peak onward, decided to recruit 100 MBBS doctors and 30 MD specialists for a three-month tenure at a much higher salary than National Health Mission norms. Zilla Parishad chief executive officer Ayush Prasad said the excess would be paid from funds raised separately, including donor contributions.
In the absence of such initiatives, hospital staff across rural India are quietly fighting fatigue and frustration.
A Frontline In Tatters
In Punjab, about 50 male nurses from the All India Institute of Medical Sciences-Bathinda went on a hunger strike on 18 May at the Government Medical College, Patiala to draw attention to their living quarters in a college hostel.
Mukesh Saini, a protesting nurse, sent photographs of dingy rooms, soiled commodes, broken plumbing and crumbling walls. “Bitten by mosquitoes all night, unable to eat the food served, living in filth, we preferred to go on strike,” Saini told Article 14.
A government release denied the nurses’ allegations, but said the nurses were to be sent back to their parent positions.
At the Aul CHC in Odisha’s coastal district of Kendrapara, Dr Debasmita Kanishka said she is working “24X7” to ensure things don’t spiral out of control. On average, Aul records 15 positive cases everyday, but one significant departure from the first wave is that most positive patients now require hospital admission, Dr Kanishka told Article 14.
“There is also a sense of fear among people. Anyone who shows symptoms usually prefers hospital admission and not home isolation,” she said. The CHC caters to 34 gram panchayats and a population of over 1 lakh, but can admit at any time no more than 12 Covid patients with mild symptoms. Anyone requiring ventilation or even oxygen has to be referred to the district’s two Covid hospitals.
These two Covid hospitals are straining under the burden—the district has more than 1,400 active cases; while the maximum daily new cases in Kendrapara was 155 during the first peak in September 2020, the district added 309 new cases on 24 May.
The MoHFW has now recommended that CHCs be “redesigned” to function as Covid hospitals for all cases that are clinically assigned as ‘moderate’ (respiratory rate more than 24 per minute, saturation between 90% and 94% on room air).
But in district after district, CHCs have been able to do little more than refer Covid patients to district hospitals—a triaging system to keep in these facilities all patients not requiring ICU care could have reduced the burden on the full-fledged hospitals. The ground reality is that CHCs have not admitted patients because they don’t have oxygenated beds; they have too few ambulances to ferry the sick from villages; and many are racing to buttress infrastructure now, nearly a month since the rural surge became apparent.
Covid care centres functioning at the block-level struggle without adequate manpower. In Bihar’s Gopalganj district, when a 40-year-old man who appeared to be recovering from cancer suddenly fell ill, tested positive and died a few days later at the Thawe block Covid care centre, there was no staff at the hospital to pack the dead body as per Covid protocol.
“The dead man’s relatives donned PPE and packed the body, carried it to and out of the hearse themselves,” said Ayaz Ahmed, a resident of Inderwa Bairan village, where eight died in the first two weeks of May, but testing levels were negligible.
Abhay Mohan Jha, a journalist from Bettiah in north Bihar’s West Champaran, said poor awareness of safety protocols extend to Covid hospitals, where family members continue to attend to patients in what are meant to be isolation wards. He cited instances in which packed dead bodies of Covid patients were then ripped open before the final rites.
Entire Families, Villages In Sick Bay
A common thread emerges in conversations with dozens of villagers across states and districts—that entire villages are down with “bukhaar” or fever, and only a small fraction was administered the RT-PCR test. So, a sizeable number of deaths, and a very large majority of patients, remains unreported or unregistered as a Covid-19 case.
In Sherpur village of north-western state Rajasthan’s Sawai Madhopur district located along the border with Madhya Pradesh, Raman Saini, 30, lost his father on 21 April, two days after the asthmatic complained of severe difficulty in breathing. Before the 55-year-old man died, Raman rushed around asking for an oxygen cylinder, and eventually took his father to the district hospital. No bed was available.
“I carried papa on my back and walked around the beds to see if any patient had died and a bed was free,” Raman told Article 14 over the phone. He returned home with a prescription. A couple of hours later, his father was dead, said Raman who works as a daily wage labourer in Ramsinghpura, a village on Ranthambore Road. His father was never tested for Covid-19.
Sherpur’s sarpanch Om Prakash said the village has never recorded so many cases of fever and cough. “Entire families are sick, every second household, and multiple deaths occurred in some families,” he said. “Dehshat hai. (It’s a horror.)”
In a village of 6,000 residents, only about 150 had undergone an RT-PCR test at the district hospital, located 12 km away. “There was 50% positivity,” according to the sarpanch.
Prakash himself was sick, tested positive and after a couple of days in hospital and a week of home isolation, returned to the district town to get re-tested and obtain a negative RT-PCR report. “I didn’t eventually get tested— the line was so long I felt I’d contract the disease again by standing in the crowd,” he said.
During the first wave, barely four cases were recorded in villages across a 15-20 km radius of Sawai Madhopur town. In April, the situation was starkly different. Wildlife photographer Aditya Singh, who lives on a farm in Sawai Madhopur, said cases and deaths began to be reported from almost all villages, including from the remote ‘Dang’ or plateau region beyond Sawai Madhopur, in Karauli, Dausa, Dholpur districts, even from Gujjar cattle-grazers’ communities.
Further north, in Uttarakhand, Swaraj India member-activist Tushar Rawat told Article 14 that in districts such as Chamoli and Pithoragarh, which share a border with Nepal, large numbers of villagers have been sick, but testing facilities are unavailable in the hilly villages. “There have been cremations on the terraced farmland, not something we have seen before,” he said.
In West Bengal, activist Kunal Deb, founder of non-profit Uthnau that works with the Santhals in Birbhum district, said a single ambulance with a single driver-attendant pair functions in the 200 sq km area of Rampurhat sub-division, home to about 250 villages. They operate for 12 hours everyday. “They are very prompt, but you can imagine how inadequate this is right now,” he said.
In a region that suffers outbreaks of seasonal fevers, malaria and dengue each year, and with very poor villagers suffering from unique co-morbidities such as respiratory disorders, tuberculosis and silicosis from the pollution of the stone-crushing units they work at, Deb said, “People accept premature death as part of life.” He said there was no panic in Birbhum’s villages, only resignation, and fear of lockdowns that jeopardise daily wages.
Healthcare For All: Making It Work
According to S P Kalantri, MD, MPH, professor of medicine at the Mahatma Gandhi Institute of Medical Sciences (MGIMS) and medical superintendent of Kasturba Hospital in Sewagram, in Maharashtra’s Wardha district, the virus in the second wave appears more virulent and more transmissible, so multiple family members are suffering from the disease simultaneously.
“People are coming to the hospital with life-threatening hypoxia as early as day 4 of the symptom onset. Villagers don’t have oximeters at home, so they don’t realise how dangerous their condition is until it is too late,” he said.
At MGIMS, patients in the emergency unit have shown oxygen saturation levels of 60% and 70%. “Some died at the hospital doorstep.”
This new spectrum of very ill patients also means mortality rates are higher this month in hospitals treating rural patients. At MGIMS, this has been 25%. MGIMS also saw 21 cases of mucormycosis or black fungus in the last 15 days. “The black fungus hits the nose, sinuses and orbit savagely, and these patients need early surgery and treatment with intravenous antifungal drugs—another challenge in a rural setting,” he said.
The report from nearby Melghat is almost identical. Ashish Satav, MBBS, MD, founder of the MAHAN Trust and Mahatma Gandhi Tribal Hospital (MGT) located in Melghat, said poor diagnostic facilities combined with malnutrition, alcohol and tobacco abuse, non Covid-appropriate lifestyle practices have led to at least 100 confirmed cases in the forest villages.
The MGT hospital is the only one in Melghat that has ventilators and oxygenated beds. At about 50% vacancy right now, there are seven critical patients, said Dr Satav, who has been offering medical services to the region’s tribals since 1997. Some critical patients have to be referred to Amravati, 150 km away.
While Covid healthcare facilities have focussed heavily on large, well-equipped hospitals in cities and bigger towns, rural patients have specific challenges in accessing this care, said Kalantri and Satav.
“They need a hospital that they can access, afford, and relate to. Hospitals that blend with their local culture,” said Kalantri. When MGIMS staff asked villagers from around Sevagram why they would not get tested, they spoke of the fear of isolation, quarantine, the anxieties of being away from their family.
“This pandemic is as much a community problem as a medical problem,” said Kalantri, recommending community engagement and mobilisation of ASHA/anganwadi workers, self-help groups, volunteers and local non-profits in tackling the rural surge.
Sensitive to tribal patients’ unwillingness to be admitted to a tertiary care hospital in Amravati town 150 km away, project officer Mitali Sethi of the Integrated Tribal Development Project (ITDP) in Dharni, about 40 km away from the forest, decided to set up a Covid hospital in Dharni.
In just three days mid-April, one floor of a newly reconstructed sub-district hospital building in the town was turned into a 60-bed Covid ward, roping in donors for some equipment, requisitioning oxygen cylinders from private hospitals and borrowing some equipment from MGT Hospital. “This assuaged tribals’ dread of the Amravati district hospital,” Sethi told Article 14.
There was also a “mortal fear of testing”, and in March, the administration made rapid antigen tests compulsory for anyone who visits the PHC, launched a video-series in the indigenous Korku language to spread awareness on Covid, safe practices, vaccines, testing and hospitals.
The Virus Also Divides
Kendujhar is one of 19 districts in Odisha that registered a test positivity rate of more than 20 in the first week of May, among several predominantly rural districts.
At the district’s two dedicated Covid hospitals that together have 92 beds including ICU beds, doctors said the challenge was tackling returnees from other states—Kendujhar alone has over 6,600 migrant workers who have returned, including 694 from West Bengal, where a new strain of the virus led to an explosion in cases.
Angaruss Khan, in his 40s and an employee at an IT firm in Bengaluru, returned to Kendujhar town in April, when his father took ill. At the municipal hospital, it took days of follow-ups, phone calls and visits to even get the RT-PCR report. For the next 10 days, Khan made dozens of phone calls and social media appeals seeking help to find a hospital bed as his father’s oxygen saturation levels dipped.
“My father was in desperate need of an ICU bed… I have never felt so helpless in my life,” said Khan. His father finally got a bed when his oxygen saturation was down to 78.
His mother, admitted to a government school-turned-Covid care centre 10 km away, would call him everyday to say she was not being administered medicines on time, nor were her vitals being checked.
When her health deteriorated, Khan again took to social media to get help finding a bed, and shifted her to the hospital in Ranki, on the fringes of the town.
With its 21 gram panchayats, Kendujhar municipal town has a population of 50,000. But Khan is among the handful here who knows how to use social media.
Frontline workers, children and small businesses are also affected much more than city counterparts. Various teachers’ unions in UP, for example, have sought government compensation for the families of 1,621 teachers who died of Covid after allegedly being infected while on mandatory poll duty in April when elections were held to 8 lakh posts in over 7 lakh gram panchayat wards of the state.
Dinesh Chandra Sharma, president of the primary teachers’ union, told Article 14 these teachers’ children were at risk of losing school years as families adjusted to the loss of a bread-winner. “We are seeking Rs 1 crore in compensation for the family of each of these 1,621 teachers,” Sharma said. The UP government has claimed that only three teachers died during poll duty.
On the border of Andhra Pradesh and Odisha, award-winning poet-activist Jacinta Kerketta of Jharkhand has been living in a village in the Chitrakonda block of Malkangiri district since the imposition of lockdown curbs. The first sense of fear in Chitrakonda came only in April, she said. A few cases have been detected since, as migrant workers continue to return home. All patients have to be sent to Malkangiri town, 60 km away.
Last weekend, villagers who brought vegetables to sell at the Sunday market in Chitrakonda because they had no idea about the lockdown ended up being thrashed by the police, she said.
“Policemen roam the villages in the evenings, levying fines on those without masks. One man hanging clothes out to dry outside his house was fined,” said Kerketta. “More than Covid, the fear is of the police.”
Das, the economist from Georgetown University, said it was puzzling that the work of tackling the long-term impact of the pandemic on rural India has not begun. He said expert consultations would be required about what happens to tribal children who could not get routine immunisation shots during the pandemic, those whose diabetes could not be diagnosed, tuberculosis patients whose treatment was stalled.
But the real long-term impact, said Das, would be on account of schools being closed for a year and remaining closed for the foreseeable future. According to Das, the biggest losses down the road from what is happening now in rural India will be experienced by households eight to 10 years later, when children missing school now begin to look for work and find their skills far lower than required levels.
“The rich will have been well-protected,” said Das. “But there is a huge potential hit to labour earnings, and therefore worse inequality."
(Tazeen Qureshy contributed reporting from Odisha. Kavitha Iyer is an independent journalist based in Mumbai.)