The initial misplaced optimism that India is somehow protected from the COVID-19 pandemic has proved to be illusory, with rapidly escalating numbers of cases and deaths in urban India. The urban blight is so intense as to occupy the entire attention of the health-care workforce, planners and policy makers. The medical services in these urban areas — Mumbai, Delhi and Chennai to cite the three major epicentres of the epidemic — have been overwhelmed, judging from the reports available every day in the public domain.
We are now facing only the fury of the urban wave of this epidemic in India. Remember, 65% of the country’s population is rural. They have been relatively underexposed, with very few cases and deaths. Thus, the large, vulnerable majority in rural India is yet to feel the heat of this epidemic.
There is a pervasive and false confidence among the general public that, somehow, rural India will escape with minimal casualty. The recent (limited) restoration of public transport and a relaxation of restrictions on the movement of people are developments that have set the stage for the inevitable and even more dangerous wave of this epidemic. Just as importations from other countries through air traffic set the stage for the urban blight, importations from urban to rural India will set the stage for the rural wave. We need to remind ourselves that rural India is clearly unprepared to face this epidemic.
Contrasts in health care
There has always been an urban-rural divide in India in health care and education, two vital indices of human development. This deficiency has been very costly not only in terms of rural lives and livelihoods but also overall national wealth creation. If the first urban wave of the COVID-19 tsunami is overwhelming our relatively better urban health-care resources, one can imagine the predicament of rural India with its already deficient health-care resources when it faces the rural epidemic tidal wave.
The lockdown of the entire country led to a paralysis of urban and rural life synchronously while the urban and rural waves of this epidemic are clearly asynchronous. The rural wave is just beginning while the urban wave is about to peak. When rural areas were hardly affected we had the lockdown but now that the rural wave is just beginning, paradoxically, we find that rural people are going about without masks or physical distancing, congregating in marketplaces and places of worship. This portends an imminent catastrophe, yet unrecognised and therefore inadequately anticipated for risk-mitigation.
Administer the social vaccine
Now is the right time to implement the social vaccine, a prophylaxis before the rural spread of the epidemic. A decentralised approach with participation of all stakeholders in each village, taluk and district is the need and potential of the day. The most important step would be to educate rural people with all the tools at our disposal — print, radio, the electronic media, and messages through mobile phones. We need to give them accurate information in simple language to make them clearly understand that their self-protection and the protection of their families are entirely in their hands.
Two behaviourial changes are critical — every man, woman and child must wear a cotton cloth mask when out of the home, and observe strict hand hygiene. All elders and any person with a co-morbidity should be cocooned (by reverse quarantine) — all wearing masks when interacting with others even inside homes. It is mortality that we must prevent in this unfair disease for the vulnerable.
Proceeding step by step
At the State and district levels, we need a systematic approach; it must entail blocking urban-rural importations, quarantining those who move from red zone to green, diagnosing and managing clinical COVID-19 syndrome with or without positive PCR test results, and providing field hospitals exclusively for isolating and managing COVID-19 cases (manned by younger, and therefore less vulnerable, medical and nursing teams). Simple clinical diagnostic criteria are available with the writers of this article.
At the same time, we need to protect and sustain existing hospitals and primary health centres not to be frequented by COVID-19 patients, but for providing care for all other medical, surgical and obstetric emergencies.
Mildly and moderately symptomatic COVID-19 patients should be managed by home isolation, delivering essential and medical supplies at home, and home monitoring of oxygen saturation by readily available portable finger pulse oximeters. Each such patient should be followed up daily by a designated medical professional, who should call over the phone and identify those who need hospitalisation for life-threatening pneumonia.
Non-communicable diseases and other common diseases should be handled on a tele-medicine platform manned by experienced and older (age more than 55 years) medical personnel; there should be a follow-up over the mobile phone. This approach will minimise the loss of medical manpower due to COVID-19 at the time when we need them the most.
If we are caught napping at this crucial hour, it will be a monumental error for which we can never forgive ourselves. State health administrators and the medical fraternity have the knowledge and skills to tackle the rural wave with courage and wisdom.
M.S. Seshadri is retired Professor of Medical Endocriniology, Christian Medical College (CMC), Vellore and now Medical Director, Thirumalai Mission Hospital, Ranipet, Tamil Nadu. T. Jacob John is retired Professor of Clinical Virology, CMC, Vellore and past President of the Indian Academy of Pediatrics