COVID-19 exposing urban-rural healthcare disparities in India

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The testing, treatment and tracing infrastructures in place in India may not at the moment have the bandwidth to serve the length and breadth of the country.

More important than migrant workers reaching their homes is for the Indian healthcare system to spread its reach. | K. Murali Kumar

On April 14, at the end of the first lockdown period, thousands of migrant workers were seen thronging the Bandra station in Mumbai, craning their necks and hoping for a bus or a train to take them home. Shielding themselves from the lathi charge by the police, their hopes of returning home were soon shattered, leaving them emotionally distressed. This is an enormously anxious time for everybody, especially migrant workers who live on day-to-day wages. With jobs in cities having been obliterated overnight and India now in the third lockdown period, what are the different factors that come into play when opening the State borders and allowing migrant workers to return? This article covers testing and treatment infrastructure, and contact-tracing capabilities in these rural areas (which constitute 70% of the population), and if it is adequate to handle the demands of a pandemic where timely testing and lockdown is key.

Testing infrastructure

In my earlier role, in which I worked in public health for TB, one of the biggest challenges in disease management was the transport of sputum samples (mucus coughed up from the respiratory tract). It is not uncommon to see sample parcels from remote locations being shoved somewhere below the driver’s seat in a rickety old bus as it makes its way to a larger town, often leaving the samples exposed to temperatures beyond 35℃ and thus leading to false-negative results. In remote areas of the country, people regularly travel up to 70km to get access to some of the advanced tests which require sophisticated equipment and cold storage.

In the case of the SARS-CoV-2 (COVID 19), while the antibody blood tests may serve as the primary test especially in remote areas, it only indicates exposure to the virus and the body’s reaction to it. What it cannot identify is if it is an active infection, the severity of infection, and hence, it cannot confirm if the person is infectious or immune. That can only be ascertained by the advanced RT-PCR test which cannot be done in the remote corners of the country as currently this test requires extremely skilled molecular biologists and is authorised to be done only in the 100-odd ICMR labs and few private diagnostic centres in the country. Also, a patient would need multiple tests and (occasionally) Lung CTs to monitor the disease over the course of a three-week period. Although the most common type of sample is the nasal swab, there are five other types of samples that could be taken depending on the condition of the patient. All of them need to be transported at 4℃ before 5 days to the testing centre with appropriate protective packaging. Some of the sample collections may even require highly-skilled physicians. Given these conditions, the best hope of timely and accurate diagnosis is when a suspected patient is in proximity to a city.

Treatment infrastructure

India has a tiered healthcare system with the Service centres (SC) at the bottom, followed by Primary Healthcare centers (PHC), Community Health Centers (CHC,) and finally the District Hospitals (DH) at a rural and peri-urban setting. The first connection of clinical personnel with the community is through the Auxiliary Nurse Midwives (ANMs) in SCs. For example, if we were to look at a State such as UP or Bihar, where the maximum number of migrant workers hail from, about 10% of the SCs do not even have ANMs and people need to travel up to 10km to find the nearest medical facility. At the PHC level, about 8% do not have clinical staff, 39% do not have lab technicians and 18% of them do not even have a pharmacist. To add to this, in some States, 50% of District Hospitals do not have adequate ICU beds, specialists or pollution control board clearances. The shortage of ambulances is another big challenge at this level.

Additionally, as per the MoHFW infrastructure guidelines for COVID-19 management, district hospitals need to have a dedicated 10-bed isolation ward of about 2,000 sq ft, with appropriate ventilation and negative pressure facility. The government has introduced trains furnished with hospital beds for healthcare access. But even with this and the district hospitals gearing up, the penetration to the lowest level of the healthcare system in remote corners is practically impossible, and certainly not at the rate at which the virus spreads.

Contact-tracing capabilities

Once a person tests positive, the system needs to conduct contact tracing to identify and quarantine all those who might be susceptible, identify geographic hotspots, and seal them to prevent mobility. The government launched the Aarogya Setu app on April 2, to be installed by all smartphone users, so that they can easily map out the people who might have unknowingly come in contact with COVID-19 patients. But here is the catch — India has only about 500 million smartphone users. Hence, contact tracing would largely fall upon the shoulders of the ASHA workers (Accredited Social Health Activist is a community health worker instituted by the Ministry of Health and Family Welfare as a part of the National Rural Health Mission) who are already overburdened with other responsibilities. In many States, there are about nine ASHA workers for every 10k people, so the enormity of the problem is apparent.

With other complexities such as comorbidities, low immunity, and ill-affordability of good treatment, the contrast gets only starker. Recent estimates from Azim Premji University indicate that 29% of the big cities’ population would constitute daily wagers looking to head back to their hometowns, mostly in States such as U.P. and Bihar. Therefore, the consequences of these millions, with many of them possibly being infected, returning back home could be terrible. In the last pandemic of this scale, the Spanish flu, entire villages were wiped out when soldiers travelled back home. Even though medical technologies and awareness have improved in manifold ways over the last 100 years, we are also facing a new virus that is far more infectious and spreads in stealth mode.

It is in the best interest of all to contain the virus in the existing hotspots. Therefore, we have a collective responsibility to ensure public safety, provide migrant workers with food, shelter and emotional support. As harsh an assessment as it may seem, in the Indian context we have to be mindful of protecting the rural from the urban.

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