Interview: ‘Shortage of doctors in rural India will hamper effective response to Covid-19 pandemic’

Rural districts in India have accounted for over 50% of new coronavirus cases in July and August, according to a research report by State Bank of India.

Based on a district wise analysis of Covid-19 cases, the report states that of the top 50 districts where the maximum number of new cases have occurred in August, Andhra Pradesh comes on top with 13 districts, of which 11 are rural. Next is Maharashtra with a total of 12 districts, of which six are rural. The World Health Organisation last fortnight expressed concern that Covid-19 is moving “efficiently” between urban and rural India.

In this interview with Scroll.in, Dr Yogesh Kalkonde, neuroimmunologist and public health practitioner, working in Maharashtra’s Gadchiroli district talks about the state of rural health systems and what to expect as the virus penetrates deeper into rural and peri-urban areas.

What is your understanding of the scale and speed of spread of Covid-19 in rural Maharashtra?
Cases are now being reported from rural areas of various districts in Maharashtra including those in eastern Maharashtra. However, information on these cases is based on stories reported in the news media. The number of Covid-19 cases is not reported separately for rural areas so the exact extent cannot be commented upon. I think data on rural cases need to be reported separately in order to design and evaluate strategies to counter the Covid-19 epidemic.

As far as the spread is concerned, initial cases are emerging in villages which had migrants returning from affected urban areas. Next, we might see cases in villages which are peri-urban or those that are closer to highways as the epidemic spreads.

Given that Covid-19 infection spreads from person to person, in theory, one would expect that low population density should help reduce the spread of infection. But in rural areas, the advantage due to lower population density could be offset by factors such as lower acceptance of preventive practices, lesser or no access to diagnostic facilities and poor healthcare infrastructure. Mortality could be high given the lack of access to good healthcare facilities.

What is the capacity for testing in rural areas. Is access to RT-PCR tests, considered the gold standard of testing for Covid-19, difficult? How robust is the process of testing, tracing and isolating?

Laboratory testing is the Achilles’ heel of rural healthcare and even simple laboratory tests are not easily available. Access to RT-PCR is very difficult in rural areas. In many districts such a facility is only available at the district headquarters. In some districts of India, these facilities are not available even at the district headquarters. Some states like Jharkhand have only few centres in the entire state. In such cases the samples need to be transported more than 100 km to get tested. It takes two-ten days to get the reports. This is a serious challenge and local capacity to test samples with RT-PCR needs to be built urgently as the epidemic spreads to rural areas.

Testing is usually done on those who are in quarantine facilities which are set up at the district and taluka levels and for close contacts of those who have tested positive. In hospitals those with severe acute respiratory infection are tested. However, testing, tracing and isolation is variable across rural areas based on the available capacity within the public health system.

Administrations face several challenges to testing, tracing and isolating in rural areas. Farming activities in monsoons create unique challenges to containment. As this activity is important to feed the family, it takes precedence over other health issues. Despite sealing villages due to Covid-19 cases, people often go to their farms. Also, in rural areas, a more spread out population means less work is done per unit time and arrangements are needed to transport healthcare professionals. Lack of local testing facilities complicates this process further.

The stunning over-reliance on private healthcare in rural (and urban) Maharashtra is borne out in the latest National Sample Survey on household consumption related to health.

Private hospitals in rural Maharashtra had 71.1 % of rural hospitalisation cases.

The average medical expenditure incurred for treatment during stay at private hospital is more than four times the spending in government hospitals.

People in rural India and not only Maharashtra are forced to access private care. It is well known that close to 70% of care in India is provided by the private sector. Due to chronic underfunding of public health systems, understaffing, lack of infrastructure and often lack of caring attitude in the public healthcare facilities, people avoid going to these facilities. Lower budget allocated to health for the last several years in Maharashtra (4.3% as against 5.3% which is the average allocation in other states) means services reduced in the public sector. This has led many people to abandon seeking care from the public sector. Only those who are really poor will seek care from government facilities as they have no other option’ is often the opinion expressed by rural people.

The alternative is not easy either. Private health care is quite expensive. The gamut of private care is quite wide in rural areas. The mention of a private health facility often brings forth a picture of swanky expensive hospitals. However, in rural areas the private sector starts with the informal providers (or village doctors). These are unskilled or semi-skilled providers who are often the primary respondents after an illness. They make home visits on a phone call and give IV fluids on demand so are preferred by villagers. These providers often outnumber qualified doctors in rural areas.

Since doctors do not want to work in rural areas, the void created is filled by these providers. In Gadchiroli, we see these providers giving antibiotics to patients with malaria who need antimalarials and not antibiotics. They often charge upward of Rs 500-Rs 600 for each malaria treatment while the treatment is free through the government health services. If the care provided by these providers does not work, care is then sought from private providers at taluka and district levels. Unnecessary investigations and treatments at these facilities are quite common, sometimes at the request of the anxious patients, which adds significantly to the costs. In our rural hospital in Gadchiroli we often see patients who have spent tens of thousands of rupees on ailment which can be easily diagnosed and treated in less than a thousand rupees.

Having said this, it also needs to be mentioned that care provided for maternal and child health, immunisation, care for tuberculosis, malaria, sickle cell disease and some chronic diseases does benefit the needy population. There is a lot of scope to improve these services further.

I think Covid-19 epidemic provides us an opportunity to review rural healthcare services and make improvements by improving care in public facilities and by providing insurance cover to seek care from private providers without suffering catastrophic expenditures and better regulation of private healthcare.

Will the limited availability of specialist doctors, required for critical care, impact the response to Covid-19?

The availability of doctors in general and specialist doctors in particular is very limited in rural Maharashtra and rural India. So is the availability of nurses and other paramedical workers. We have this 60:40 paradox in rural areas.More than 60% of India’s population lives in rural India while only 40% of healthcare providers work here.According to one report there is 83% shortfall of physicians, 76% for obstetricians and gynaecologists, 82% for paediatricians and 83% for surgeons in community health centres in rural areas. This will impact the response to Covid-19 especially for patients who will need medical care. While we know that about 85% of Covid-19 patients have mild symptoms the remaining 15% get sicker and need hospital care – mainly secondary and tertiary level care. Lack of secondary and tertiary level care is likely to increase mortality among these patients in rural areas.

How is the impact of the healthcare system’s focused response to fighting Covid-19 being felt in other areas?

There has been a significant impact of Covid-19 related lockdown on almost all other areas of health care. Institutional deliveries, care for chronic diseases including sickle cell disease, mental health disorders as well as surgical care all have suffered due to either closure or lower level of operations in private facilities, reduced frequency of state transport buses, restrictions on travel between districts and fear of contracting Covid-19 in a health facility among patients. This has led to families scrambling to find a healthcare facility where they can take their patient. Some patients with heart conditions and other chronic diseases have gone without medicines leading to complications. There is a concern that this will increase non-Covid mortality in rural areas.

Immunisations and nutrition care through the Integrated Child Development Scheme was also disrupted in the early phase of the lockdown. There were concerns of healthcare workers themselves becoming the source of spreading Covid-19, especially Auxiliary Nurses and Midwives who have to move from place to place for immunisation. Immunisation camps could not be held.

There is very little reporting on rural health systems. Could you tell us some of the biggest myths about rural healthcare?

It is a big irony that we have poor reporting on rural health systems and I will explain why. About seven out of every 10 Indian and every eighth person in the world lives in rural India. Therefore, one cannot ignore rural health. India’s healthcare indices and one can argue that global health will not improve unless we improve rural healthcare and reporting on rural health systems.

A common myth is that rural people do not suffer from chronic diseases such as high blood pressure, diabetes, strokes, heart attacks and mental health problems. Lifestyles in rural areas are rapidly urbanising, with a rising number of patients with chronic diseases. High blood pressure, which is a risk factor for strokes, heart attacks and kidney diseases is seen in one in four adults in urban areas as against one in five adults in rural areas.

So the difference between urban and rural areas is not big. People with chronic conditions such as high blood pressure, diabetes and heart attacks are at a higher risk of dying due to Covid-19 and these conditions have become common in rural India too. That should get us very worried.

You are a neurologist and a public health researcher trained in India and then in the US. Why did you choose to return and work with rural and tribal communities? Could you tell us about your work at SEARCH?

After my training in medicine I was looking for a mission that I can pursue for my life. Initially I worked in basic science research- in the field of neuroimmunology. I worked at the forefront of basic science research and wanted to apply the knowledge obtained from research to improve care of patients with neurological problems. A visit to see work of SEARCH changed that trajectory. I suddenly came face to face with challenges in providing very basic health care to rural and tribal people.

Work done by SEARCH to improve child mortality also showed me the potential of systematic research in improving health care of people who need it the most. Therefore, I decided to take up this as my mission. I quit my job as a faculty member in neurology at the Baylor College of Medicine in Houston and moved back with my family to live and work in rural and tribal Gadchiroli 10 years ago. Currently, I look after the chronic diseases and tribal health programmes of SEARCH.

Our research showed that in an underdeveloped district like Gadchiroli stroke (paralysis due to blocked or ruptured blood vessels in the brain) has become the leading cause of death. Deaths caused by stroke in rural Gadchiroli equaled deaths due to tuberculosis, malaria and diarrhoea put together. As very little advanced care for stroke available in Gadchiroli, we developed a community-based preventive programme for stroke, a first-of-its-kind in rural areas of the developing world, and conducted a field trial to assess if this would reduce stroke deaths.

We have completed the field trial and are keenly awaiting the final results. If successful, such a care can be scaled up to prevent deaths due to strokes. As the risk factors are shared, such a programme can also reduce deaths due to heart attacks, heart and kidney failure as well in rural areas of India and other developing countries.