On Covid-19, Bharat looks and thinks differently than India

Covid-19 is seen in rural areas even today mostly as a disease of the urban areas. The picture was well summarised by this view aired by a woman volunteer, responding to news of the launch of a vaccination drive to halt the pandemic: “Is Covid-19 still around in the city? From here it has gone away!”

Many in rural India, where we work as doctors in the area of primary healthcare, have heard about the vaccine from government representatives, healthcare workers or from social media. And many of them think that the vaccine would probably be useful for those who go to work in cities. “It may be helpful for them but may not be for us. We will wait and see,” is a common reaction.

It is not the Covid-19 vaccines but jobs, money and food that are foremost on their minds, followed by care for illnesses they are suffering from. We saw how men started migrating back to cities soon after the lockdown was lifted -- they chose to go to cities in Gujarat where cases of Covid-19 were rising sharply, leaving the safe environment of their village, as staying back was a luxury many of them could not afford. They had to risk the pandemic to earn a livelihood.

The media shows in different ways the frenzy associated with the “largest vaccination programme”. We need to remember that under the “Universal Immunisation Programme”, India vaccinates about 20 million infants every year. So, while a vaccine against the Sars-Cov-2 virus grabs the headlines and the national mood, we may pause to think that childhood immunisation was halted and would add to the largest pool of unimmunised children in the world. The recent announcement of deferment of the polio vaccination round scheduled on January 17, on account of Covid-19 vaccination, is a sign that health systems are getting so drawn into Covid-19 vaccination that other “routine” services will be affected. In rural areas with high burden of diseases and poor access to services even in normal times, this could be disastrous.

In rural areas, there is an imperative to view Covid-19 as not a standalone epidemic but as a “syndemic”, coexisting with many other conditions that continue to cause many other deaths. Managing a “syndemic” would require strengthening systems that are able to prevent and manage all existing and emerging diseases. At the least, Covid-19 vaccination should not be allowed to disrupt other health services.

It was Richard Horton, Editor of The Lancet, a premier medical journal, who referred to this coexistence of Covid-19 with other illnesses as a “syndemic”. What we are seeing in resource-poor rural areas of India is precisely this: the threat of Covid-19 on one hand, and the persistence or exaggeration of other epidemics (such as malaria) or endemic conditions (hunger and tuberculosis, for example). Among rural, tribal communities in India, infant death rate is among the highest for indigenous and tribal populations anywhere in the world. Under-5 mortality in these communities is one-and-a-half times and prevalence of tuberculosis is more than twice the country’s average. They also carry 80% of the country’s burden of malaria. About 20% of children remain unimmunised for diseases that are easily preventable by available and effective vaccines.

Wind back to March 2020. Soon after the lockdown was announced, we witnessed large numbers of migrant workers returning to their villages on foot, facing harsh weather, hostility by police and the apathy of local communities. While surveying one such community in rural Rajasthan, we found no evidence of Covid-19 infection among the returning migrants at that time. However, those who were forced by circumstances to stay back in cities contracted the infection from the city locals. When they subsequently returned in May, this contact seeded the infection in villages.

While the incidence of Covid-19 did rise between May and September (only to fall again later on), case fatality rates in rural areas remained low. Low population density, limited areas of congregation, fewer closed areas and more time spent in the open, lower proportion of older people and lesser proportion of co-morbidities are possible explanations for lower spread as well as lower case fatality rates in rural areas.

Following the abrupt lockdown, health services were also interrupted as all focus was diverted to “managing” Covid-19. The fear of contracting the disease and of being “taken away”, severe restrictions on movement, and loss of livelihoods led to a decline in people seeking even essential healthcare. Within the first month, on the ground, we saw a halting of key inputs and services like childhood immunisation and antenatal care, as also the stoppage of contraceptive services and increased numbers of unwanted pregnancies. The number of home deliveries rose, even for those with complications, which is estimated to result in large numbers of additional maternal deaths.

Tuberculosis was one of the conditions worst affected -- the cough and stigma delayed seeking care, testing declined sharply, many patients faced treatment interruptions due to the lockdown, all of which accelerated the spread of the disease. Patients with diabetes and hypertension also saw treatment breaks and a worsening of the condition. We also found declining availability of food and increasing childhood malnutrition during these times.

The worry is that some of these may turn out to be bigger challenges in the coming months and years than Covid-19.

(The writers are doctors working in rural Rajasthan and are founders of Basic Health Care Services, a non-profit that provides primary healthcare services in remote rural areas) (Syndicate: The Billion Press)