The Rural Challenge

We need different protocols to deal with the pandemic in rural India. Instead of supplying oxygen we need to provide them with a supply of medicines and basic equipment they need. Since it is not feasible to get RTPCR tests done in a reasonable time frame we need to replace that with syndromic testing using oximeters and thermometers. And we need to leverage our decentralised healthcare networks.

This article was first published in The Mint. You can read the original at this link.

It’s got to that point in the pandemic when we all know someone who has died or suffered greatly. Our messaging apps have, at one time or the other, been filled with pleas for help and with heart-wrenching stories of grief and frustration. We’ve all, individually and collectively, done our best to get beds, oxygen cylinders and medicines for friends and family, raise funds or even just maintain lists of verified sources of medicines, oxygen and hospital beds so that we can be helpful when the inevitable call comes.

And yet, as bad as things are in the city, they are far, far worse in [[rural India]]. Last week, possibly for the first time since the beginning of the pandemic, 13 states reported that the total number of new cases in rural areas exceeded those in urban areas. Till now, covid-19 has largely been an urban disease. Unfortunately, this time around, it seems that it will not spare our rural hinterland.

Early Warning

The earliest sign I got that things were not ok in rural India was when a doctor friend of mine told me that the district hospitals were getting a larger than normal number of patients from the surrounding villages - all of whom had travelled the long distances to the nearest city because the health centres in the villages where they lived were unable to treat them. This exodus has only increased since then and, unless something is done about it soon, the extent to which the disease will ravage our villages is going far exceed the damage it has done to the cities.

When you discuss the situation with doctors on the ground, it quickly becomes clear that we need to adopt a very different approach to combat covid-19 in rural India. Urban relief efforts have, for the most part, centred around creating oxygen beds and covid care facilities to supplement the medical facilities that our government and private hospitals already provide. However, in the rural hinterland, access to oxygen is just one among a number of complicating factors that need to be addressed on a war footing.

Change the Protocols

Healthcare in our villages is almost entirely provided for by the government. As a result, rural health centres are subject to all the procedural impediments that dog government procurement. This bureaucratic bottleneck is causing severe shortages of even the most basic medicines required to treat the disease as the velocity at which drugs are being consumed far outpaces the rate at which government procurement can replenish them.

To cope, the health officers at most Taluk Hospitals (and the public health centres under them) have been forced to ration whatever medicines they have, to ensure that the meagre supplies at their disposal can be stretched to cover as many patients as possible — even if that means that everyone they treat gets less medicines than they need. This hidden consequence of this is that under-medication is shaping up to be a real challenge in rural India, having already resulted in multiple instances of post-Covid complications and secondary infections.

That said, as important as it is to treat symptomatic patients, we also need to make sure that we detect the disease early enough to prevent mild cases from becoming more serious. This is particularly important in rural areas as it is only by successfully treating patients in our villages that we can ensure that hospitals in larger towns don’t get overwhelmed. If we fail, the repercussions simply do not bear mentioning. Our fragile, distributed health system will simply collapse under the weight of uncontrollable outbreaks.

Delayed Detection

All this is easier said than done. In its early stages, the disease is indistinguishable from the common flu and as a result, people in the villages treat themselves with herbal remedies for a few days before even thinking of going to public health centres for a checkup. When they finally do get tested (and the test results wends its way back to them), as much as 5 days could have elapsed between the detection of the first symptoms and the commencement of the treatment.

In most cases it is precisely this delay that has resulted in the serious illnesses that forced patients from rural India to flock to the District and City Hospitals. By the time they knew, for sure, that they had covid-19, the disease had already taken such a powerful hold over their bodies that the Taluk Hospitals simply could not give them the treatment they needed. If we want to improve our ability to manage the disease before it completely overwhelms our rural health system, we need to shorten the time taken to detect so that we can start isolation and treatment much sooner than is currently being done.

A Practical Approach

The health officers in the HD Kote taluk of Southern Karnataka, with the encouragement of their local MLA, have, over the past few weeks, been trying out an alternate approach. Volunteers and ASHA health workers equipped with thermometers and oximeters have been going door-to-door testing every single resident in the village for two key early warning symptoms of the disease - oxygen saturation and temperature. By monitoring this information over time they are identifying infected people early - sometimes days before the RTPCR test results are available. This is giving health workers in the area the time they need to appropriately isolate the infected and, where appropriate, providing them basic treatment. By activating the health system early, they are hoping to have a realistic chance of keeping mild infections from progressing to moderate — or at the very least being able to escalate before it is too late.

It is still early days with this approach - and probably too soon to make any definitive conclusions — but last week three of the persons identified through this method actually tested positive. By the time the test results reached the taluk health office they had already been isolated and were being treated.

Now that we know the disease is rampant in our rural population we need to be innovative in our approach. It makes no sense to flood the villages with oxygen concentrators where the real need of the hour is medicines. It makes no sense to wait till patients show up at their local PHCs before isolating and treating them when syndromic testing can give us early information. If we can be more proactive and innovative with our approach to covid-19 we may still be able to blunt its impact on the rural hinterland.