As coronavirus reaches rural India, three cases reflect the steep challenge ahead

A 25-year-old village resident reported sick at the Basti district hospital on March 28. For more than two days, he was shunted from ward to ward and hospital to hospital before he finally died in Gorakhpur, the largest city in eastern Uttar Pradesh, 70 km from Basti. He would be the first confirmed coronavirus casualty in the state.

The 48 hours leading up to his death paint a grim picture of provincial India’s health infrastructure and bare the lack of preparedness or even training to handle the pandemic.

More than 3,000 people have tested positive for the coronavirus in the country till April 4. From 75 districts on March 22, the outbreak has now spread to 211 of India’s 720 districts. Though no clear data is available, media reports show many of the cases have emerged in rural areas.

Rural healthcare facilities in India are under-staffed and under-equipped even in the best of times with some districts lacking even a basic secondary-care hospital. How are rural health systems coping with the coronavirus outbreak?

Scroll.in traced the graph of three Covid-19 patients in rural Uttar Pradesh, Gujarat and Assam and found alarming gaps in detection, isolation and treatment in two states. To make matters worse, the health authorities in Uttar Pradesh and Assam appear to be covering up the lapses even though experts say initial failures must be used to strengthen systems for the future.

Neglect in Uttar Pradesh

The 25-year-old man came from a colony in the district headquarters of Basti, one of the poorer districts of Uttar Pradesh, which is among the least developed states in India.

He was admitted to the 300-bedded district hospital on the morning of March 28, said the hospital’s medical officer Ramji Soni. He spent around 16 hours there – first in the emergency ward, then in the general ward. Both wards had scores of other patients, said Soni.

Doctors said they did not treat him as a suspected Covid-19 patient because neither he nor his family disclosed any recent travel history. “He said he had a history of asthma,” said Ram Prakash, a doctor at the hospital. “He initially had no fever, though he told us he had been running a temperature in the last few days.”

The official protocol laid down by the Indian Council of Medical Research initially restricted Covid-19 testing to those with international travel history or those who had come in contact with confirmed cases. On March 20, however, it was expanded to include hospitalised patients with severe acute respiratory infection: fever and cough, or fever and shortness of breath. The same day, the Ministry of Health and Family Welfare issued guidelines to hospitals stating that “all pneumonia patients must also be notified to NCDC [National Centre for Disease Control] or IDSP [Integrated Disease Surveillance Programme] so that they can be tested for Covid-19”.

This means the case of the 25-year-old man should have been notified to the disease surveillance authorities and tested for Covid-19 in Basti itself. But that did not happen.

Uttar Pradesh health officials said he exhibited “no critical symptoms” during his time in the Basti district hospital “He just had fever and cough, that’s it,” said Vikasendu Agarwal, who is joint director at the state’s Integrated Disease Surveillance Programme.

However, Basti’s chief medical officer, JP Tripathi, contradicted Agarwal. The patient, he said, had come in a “serious, emergency” state.

On March 29 afternoon, the patient was shifted to Gorakhpur hospital by his family “without informing anyone”, Agarwal claimed. But Ram Prakash, the doctor at Basti district hospital, said he was ferried in an ambulance arranged by the hospital itself.

At Gorakhpur’s BRD Hospital, he was lodged in the general ward for several hours. It was only after his symptoms deteriorated that he was shifted to the intensive care unit, said Gorakhpur’s chief medical officer SK Tiwari.

According to Agarwal, there was only one other patient in the general ward during that time. “It is unlikely there was large-scale spread,” said Agarwal. Again, local media reports contradict him. The ward reportedly had at least 48 other people in addition to their attendants, according to an April 2 report in the Hindi daily Hindustan.

The Basti youth died in the early hours of March 30.

Asked when his swab sample was collected, Agarwal said it was done in accordance with the Indian Council of Medical Research’s stipulations. “The instructions say that samples of people with SARI [severe acute respiratory infection] should be taken, so when he landed in SARI, we took the sample,” said Agarwal.

But according to several local news reports, the youth’s swab sample was collected only on Monday, after his death in Gorakhpur. The test result came out positive on April 1, Wednesday.

Scroll.in contacted Gorakhpur’s chief medical officer but he claimed ignorance about the matter, directing this reporter to the hospital authorities. BRD Hospital’s chief medical superintendent, RS Shukla, declined comment.

‘No testing without travel history’

Agarwal insisted that there was no lapse in procedure while dealing with the patient. It was the patient’s responsibility, he maintained, to inform the authorities about his travel history. “He did not reveal that he may have recently travelled to Mumbai,” said Agarwal, conceding that it was still “not confirmed” if he had indeed travelled out of the state. “We have some input, but the family is not confirming it,” he said. Scroll.in was unable to speak to the family.

But if the health ministry’s March 20 guidelines make it clear that even patients without travel history must be notified for testing, why did that not happen? After the young man’s death, have the state authorities asked all districts to be more vigilant and refer all pneumonia patients to government facilities that are equipped to test and treat suspected Covid-19 patients?

Not quite, said Agarwal. “ARTI [Acute Respiratory Tract Infection] symptoms that are typical of corona (virus) are typical of all viral infections,” he said. “Unless people come forward and tell their travel histories, domestic as well as otherwise, we cannot do anything.”

“You have seen the condition of our OPDs,” he continued, referring to the outpatient departments of public hospitals. “They are handling so many people. They are so crowded that it is simply not possible to treat every fever and cough patient as a suspect.”

Agarwal said the situation was particularly dire in rural areas.

ASHA workers deployed

Like other states, Uttar Pradesh has been tracing people with international travel history since mid-March to check for symptoms of Covid-19. More than one lakh people in the state have been identified as having recent foreign travel history. But until April 1, only 3,142 samples have been tested in the state.

This exercise has been mostly limited to urban areas, said Agarwal.

But after the prime minister addressed the nation on March 18, announcing a one-day curfew, rural migrants who had moved to other parts of the country for work have been returning to Uttar Pradesh. This influx intensified after a 21-day lockdown began in India on March 24.

With lakhs of migrants back in Uttar Pradesh, Agarwal said the state health department has asked the panchayati development department in every district to provide them a list of internal migrants. An official of the state’s panchayati development department said gram pradhans or village heads were being asked to provide details of residents who work outside the state usually, but had recently come home.

“We are disseminating these lists of each district’s chief medical officers who will then pass it on to ASHA workers, who in turn, will track these people down,” Agarwal explained. ASHA or accredited social health activists are health volunteers in rural areas who work as part of each state’s National Rural Health Mission.

In Basti, specifically, Agarwal said there was an elaborate contact-tracing exercise underway to identify people who may have come in contact with the dead man. At least one person has tested positive for the virus. All health workers who were involved with the young man’s treatment have been quarantined.

Better systems in Gujarat

While the Indian government announced the 21-day lockdown to contain the spread of the coronavirus, the lack of work and food security has sparked large-scale reverse migration from cities to rural areas. This has made rural areas more vulnerable.

In Gujarat, a 36-year-old daily-wage labourer with respiratory complaints came to a small private hospital in Chorasi town in Surat district on March 31. A resident of Sachin village, he had travelled to Uttar Pradesh for work. Just before railway services were suspended on the midnight of March 21, he had taken a train back home. “He had boarded the train from Jhansi,” said Piyush Shah, epidemic medical officer of Surat district.

Unlike Uttar Pradesh, where the 25-year-old’s case was not notified immediately, the small private hospital in Chorasi immediately alerted district health officials. From there, a government ambulance took him to the designated Covid-19 hospital in Surat where his sample was collected. He tested positive on April 1.

Gujarat has instructed all hospitals of all sizes and affiliations to immediately report any patients with Covid-19 symptoms to district health authorities, irrespective of travel history. “It is the physician’s call, and as soon as he informs us, we send a vehicle to ferry the patient to the nearest designated facility,” said Shah.

The state also seems to have better tracking systems in place. By April 2, Shah said the family members and other people that the 36-year-old patient had come in contact with had been traced and put in a quarantine facility.

The Gujarat government has also embarked on a door-to-door survey to seek out patients with influenza and acute respiratory symptoms. Symptomatic patients have been put under surveillance, according to the government.

However, local news reports suggest that the survey may not be as wide-spread and exhaustive as the government has claimed.

Series of misses in Assam

Gujarat is among the better performing states when it comes to health systems, according to an index prepared by the Niti Aayog in 2019. For states with fewer resources, keeping track of people with domestic travel history may be even tougher.

Consider the case of the Islamic preacher from Assam’s Karimganj district, the first person in the state to test positive. The 52-year cleric, a resident Srigauri village in the South Assam district, is afflicted with blood cancer.

The man, who runs a madrassa in the village, had gone to Delhi on March 5 and attended the now-infamous religious congregation at Nizamuddin organised by the Tablighi Jamaat, according to Assam health minister Himanta Biswa Sarma. The preacher returned home on March 13.

On March 18, he went to the Cachar Cancer Hospital and Research Centre, where he was undergoing treatment for cancer. He was running a temperature that day, said Kalyan Chakarabarty, administrative officer at the hospital. “He went straight to the usual palliative [care] doctor who conducted a routine blood test,” said Chakarabarty.

But as he was running a fever, the doctor advised him to go to the government medical college in Silchar before heading back home, said Chakarabarty.

The preacher did not and returned home instead. The next few days, he suffered from intermittent bouts of fever for which he consulted a local private doctor. This doctor, too, did not make much of it and advised him to rest at home.

As Assam’s health minister Himanta Biswa Sarma recounted the patient’s case history during a press briefing on April 2, he said: “The cancer hospital for some reason did not alert us about the person so we could not collect his sample then.”

On March 29, as his symptoms worsened, the preacher’s family informed the local government-run community health centre, said Utpal Maity, a senior doctor at the facility. “When our doctor went there, his condition was not good, so he said it would be better to take him to Silchar medical college,” said Maity.

However, when the doctor and the family dialled the emergency ambulance service on 108, they were told there was no vehicle available, said Maity. Finally, a private ambulance was arranged, which ferried the patient to the Silchar medical college and hospital where he subsequently tested positive for the virus. He is currently undergoing treatment at the hospital.

Surveillance fail

This account, however, does not completely square up with the Assam administration’s version. According to health minister Sarma, the patient came under the radar when the health department’s “field staff” visited the patient’s home after “hearing news that he was suffering from intermittent bouts of fever”.

Karimganj deputy commissioner Anbamuthan MP also claimed the person was detected in a “routine surveillance” as he was a “renowned person in that locality”.

However, ground officials said that the preacher had slipped through the health department’s surveillance network. “We have 24/7 surveillance, but we missed this person,” said Maity.

Public health experts say that slip-ups in surveillance were natural, given India’s health infrastructure. “Right now, we can just hope that people stay home, maintain physical distance and don’t spread the virus,” said Poonam Muttreja, executive director at the Public Health Foundation of India. “That is our only hope.”

Others, however, were more critical. T Sundararaman, former director of the National Health Systems Resource Centre, an advisory body of the Union Ministry of Health and Family Welfare, was particularly scathing of Uttar Pradesh’s handling of the Basti resident. “The only way at this point of time is to test everyone with fever-like symptoms beyond three days without waiting for signs of breathlessness,” he said.

Like Gujarat, he said, it was imperative that other states too tested everyone with symptoms at the “first point of care contact”. “That is the only way to protect the thousands of hospitals where people will go for treatment,” he said.

Late diagnosis, he said, came with a whole range of problems, the most obvious being the challenge of tracking down people patients had come in contact with. “You are completely underestimating the total number of movements people make. They are all over the place,” he said. “They would infect hundreds of people.”