Impact of COVID-19 on those on fringes of healthcare: Urban & Rural Perspectives I Part 1
19 May 2020
For many living on the fringes of society, public health care services are often inaccessible. The impact of the COVID-19 pandemic on the most vulnerable populations of our society -- migrant workers, the urban poor and daily wage earners, tribal communities, and agricultural men and women -- are deep and far-reaching. In the ‘Webinar on COVID19: Ask The Experts – Part 6’, we explored the impact of the COVID-19 pandemic on the health of vulnerable populations. Our guest experts – Yogesh Kalkonde, Divya Varma and Gautam Bhan – discussed unique health challenges posed by the pandemic for urban and rural populations; communication and community engagement strategies to mobilize/reach help to the vulnerable communities; lessons for urban-planning from COVID-19; and, impact on the health of migrant workers and their entrenched relationship with urban India.
This is the first part of the edited excerpts from the webinar, wherein Yogesh Kalkonde brings forth the challenges posed by COVID-19 and lockdown in rural healthcare.
On risk and protective factors: Rural versus Urban
The risk factors for COVID-19 can be divided as environmental and individual risk factors. From the data that we have for COVID-19, the cases seem to be a function of travel or mobility of urban residents or in areas with high population density. And then at the individual level we have risk factors such as age; people over 60 years have underlying diseases like hypertension diabetes and cardiovascular diseases. So, if we take these four risk factors, how does rural India fair in comparison with Urban India?
Rural India has a population density about six times lower than of urban India. And then as far as Mobility, we could take a look at certain proxy indicators. So here I'm taking position of two-wheeler vehicle as a proxy indicator for mobility and you can see that vehicles are about 2.5 times lesser than that in Urban India. Both these factors seem to be potentially protective factors against COVID-19.
But there are also certain vulnerabilities. The elderly population is particularly vulnerable to the effect of this disease and the predominant COVID-19 mortality world over has been in this population. The number for adults 60 years and above, are not very different between rural (8.3%) and urban India (8.4%). There is again no major difference in the number of people with hypertension in rural and urban areas. Although diabetes is less common in rural areas (5.2 %) compared to urban India (11.2%).
Healthcare services: 66% of the population in India lives in rural areas which has only 40% of total healthcare workforce which includes doctors' nurses and other paramedical workers. The challenge in rural India is that all these resources are very dispersed so it is very hard to mobilise them, specially during a pandemic.
Public perceptions of the pandemic: People's perceptions are guiding their response at this time. In rural Gadchiroli where I am based, so far, people are worried about COVID-19 and this is largely driven by media messages. Good thing is that we are seeing technology, especially mobile technology has reached rural areas and even deep-seated tribal areas and people now have access to information, even though it is to a lesser extent. Right now, the fear is overweighing the lived experience of new cases around.
In rural areas behavior is usually dictated by lived experience rather than theoretical knowledge, and certainly there is no recent lived experience of pandemics. But this might change if they don't see cases around. A tribal elder that I met a few days ago told me “my father told me when he was very young, must be more than 100 years ago, so many people died in the village because of mari [pandemic] that there was nobody to bury them...they gave a pint of alcohol to a bullock cart driver who placed all the dead bodies in a cart and dumped them in jungle”. So they don't know what to expect if the pandemic comes to villages. There are also certain perceptions like these “I do hard physical work in farms so I'm unlikely to get COVID-19.”
On the impact on rural populations – COVID-19 & the Lockdown
As far as the impact on the rural populations is concerned, you could divide it in two different phases. What we are seeing right now is impact of lockdown then as we will go to a staggered lifting of the lock-down we will see exodus of migrants from urban to rural areas. Then there could be a possible spread of infection in rural communities and then there could be a next phase, about which we don't know yet.
Food security – The lockdown is affecting families strapped in urban slums or other rural areas and elderly people in villages who do not have children and live by themselves. It has made them food insecure.
Impact on livelihood – In agricultural sector, only 45% are cultivators and rest 55% are agricultural laborers who are dependent on daily wages. Their daily wages are suffering right now as we are going through this lockdown. There are about 40 million internal migrants who could be affected by this lockdown at this time.
On dehumanization/loss of dignity and distress
People are resorting to very demeaning practices to get food. People are trying to migrate back to their native villages as they are very distressed in urban areas. Back in their villages, they will have some more dignity and more resources. A few days ago, there was a story of a 12-year-old girl who died of exhaustion by walking. We are seeing almost every day that each village gets three to four people who are literally walking hundreds of kilometers to reach the village.
On healthcare seeking/delivery during lockdown
What we see in our rural hospitals is that the consultations have been reduced by almost five folds. There are challenges for patients to travel as well as to seek care. This has led to disruption of both healthcare seeking and delivery. In urban areas, you see the doctors are not getting paramedical workers to come and work in their clinics. So even there the consultations have gone down significantly. This is going to result in both short and long-term effects on the health of rural people.
Can rural communities face this challenge?
We don't know how this is going to play out because there is hardly any data. So going forward, the question is can rural communities face this challenge as there are many other challenges in rural areas. The social issues would be, lower level up information resources and behavior change may take long compared to what we see in urban areas. The real challenge in terms of medically managing COVID-19 in rural areas is that there is no testing facility. For us in Gadchiroli, the nearest testing facility is 200 kms away and even then the healthcare facilities are inadequate. Another issue is lack of real time data; there are hardly any reported rural cases as of now, there could very well be rural cases and there could be rural deaths.
The good thing about this epidemic is that most of the cases are mild - 85% of cases are mild and only 15% need hospitalization. So one could argue that 85% of these cases could be actually managed at the community level through community action and containment and only 15% need to go to medical systems to seek care.
Many Gram Panchayats have sprung into action and they have got information from television and social media. This particular Gram Panchayat (photos below) made and distributed masks to people. This village also made arrangements for quarantine of migrants who were coming from districts where there are COVID-19 cases. Even in tribal areas, we have seen distribution of hand sanitizers and masks. In general, the community is very curious and ready to take action at this time.
On community mobilization in rural and tribal areas
SEARCH has developed a program which focuses on awareness generation specific actions guiding community to take certain actions to prevent COVID-19, quarantining of cases, referral only where needed so as not to inundate the healthcare system and surveillance of data so as to gather some data to get a sense as to where things are going in the area we work in Gadchiroli.
On short- and long-term impact on rural population
We are going to see a short and long-term impact on rural population and socio-economic impact could be actually more than the health impact, we will have to see how this unfolds. Farming people who are dependent on forest produce collection to earn some money, poultry and so on will be affected. How this might play out in rural area would be similar to what we are seeing in the USA where now gradually cases are spreading from urban areas to small towns which are adjacent to the big cities and villages which are along the highway. So these are the two potential areas where it would start in rural areas.
COVID-19 is a stress test for Health and Human Social systems. In rural areas, particularly tribal areas, the governmental machinery is very weak. So we will have to design rural or tribal context specific strategies with emphasis on community action and local governance. Technology will continue to play an important role in this response. And the question will be - will COVID-19 be a bigger disease of economy than body. We will have to see as it unfolds in rural India.
Watch the webinar HERE.
Visit India Alliance COVID-19 Resource Hub HERE.