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COVID-19 has been spreading fast in rural areas while issues related to its management and the government’s response to the pandemic remain. In continuation with the ongoing discussions on the rural realities amid the pandemic around the country, Impact and Policy Research Institute, New Delhi organized a panel discussion “Rural Realities | Telangana & Andhra Pradesh | Practitioners’ Experiences in Tackling the Second Wave in Indian Villages” on May 14, 2021, as the second wave of coronavirus pandemic raged through the rural heartland.
Epidemiology and transmission dynamics of COVID-19
“COVID-19 pandemic has reached a stage of community spread in both rural and urban areas breaking all barriers of gender and age affecting a large population. As per a report, there are more than 39.6 lakh people in rural areas infected with COVID-19 in the second wave. This is much more than the peak infection of the first wave in September 2020 resulting in rural places being affected further in the second wave,” said Prof. Prakash Babu, Dean, School of Medical Sciences, University of Hyderabad while chairing the session.
The issues which have amplified the second wave crisis in rural areas are ignorance, malnutrition, and infrastructure deficiencies.
“The symptoms of the first wave and second wave have been very different; initially the second wave symptoms were hard to be attributed to COVID-19. So, diagnosing it has become problematic in rural areas. Also in rural areas, people lack awareness of the disease and of symptoms associated with it,” he said.
The younger population in rural areas is much more affected. The majority of people below 45 years are asymptomatic resulting in the high spread of the infection.
The lack of vaccination facilities in rural areas is also a major concern. The availability of vaccination at the last mile is bleak. Prof. Prakash Babu said that due to the existing inconsistency in production, supply, and demand it will not be available to the entire population even in the coming 2-3 years. The only hope is the hard immunity attained by the people following the community spread.
Prof. G Sridevi, Associate Professor, School of Economics, Central University of Hyderabad moderating the session stated that a major issue was of lack of testing or of hiding positive cases in Telangana. Andhra Pradesh on the other hand had conducted large-scale testing accompanied with more reliable data in terms of positive cases. Both the states failed in improving the health infrastructure and health care facilities in terms of primary health care centers and availability of manpower and medicines. Despite the pandemic, the expenditure of the government in health care was merely 3.3% in Telangana and 5% in Andhra Pradesh.
The major issues leading to the upsurge of cases in the second wave were lenient lockdown rules, the government’s failure to create a proper health care system in rural areas and implement vaccination policy at both central and state level. It also failed to create awareness among rural people towards the vaccination drive.
Preferential treatment was noted at various levels i.e. village, mandal or the state and the state support policies were discriminatory. Vulnerable groups in rural areas faced exclusion due to online registration for vaccination. The non-availability of oxygen, medicines and vaccines led to a financial burden in rural and urban households. “In rural areas, there is a need for rural direct drive rather than online vaccination drives,” said Prof. Sridevi.
Malnutrition as a threat multiplier
Prof. Sridevi also highlighted the high level of malnutrition in India. “As per the NFHS report, 14 states in India suffer from high levels of malnutrition in children under 5 years of age and 60% of women in the reproductive age suffer from moderate or acute anaemia. These malnutrition indices have a great impact on immunity levels and cognitive skills leading to a high death rate. Without addressing the already existing issue of high levels of malnutrition and poverty, it is difficult to tackle the current pandemic as well as the upcoming third wave,” says Prof. Sridevi.
Negligence and continuing challenges of infectious diseases
“People are dealing with perceptions more than actual statistics and there is a need for much more granular understanding to get a grip of the reality,” said Dr. Donthi Narasimha Reddy, Independent Consultant, Policy Expert, and SDG Campaigner. Dr. Reddy highlighted that rural health infrastructure has been neglected in the last two decades Andhra Pradesh and Telangana.
“There is more emphasis on privatization within public hospitals with diagnostic centres, sanitation services, etc., being privatized within these. Because of widespread privatization in the health sector and poor public investments, the response to COVID by individuals, families, society, and government has been poor. We have failed in bringing together institutional change in terms of identifying, diagnosing, treatment and also post-treatment of diseases,” said Dr. Reddy.
Talking about the history of diseases in Andhra Pradesh, he stated that it has a history of past infectious diseases like viral fevers, Japanese encephalitis, Chandipura virus, anthrax, HIV, chikungunya, and malaria.
“Poor vector management, mainstream neglect, and Andhra Pradesh’s incapability of responding to viral fevers and the vulnerability emerging from malnutrition in rural areas is a major cause of the spread of infectious diseases in the state,” he said.
“The number of cases in urban areas is much more than in rural areas in Telangana. In Andhra Pradesh there is an equal surge in cases both in rural and urban areas,” said Dr. Reddy.
Various risk factors driving deaths and disability in Andhra Pradesh are malnutrition, dietary risks, high blood pressure, air pollution, poor WASH, occupational risks, etc., with malnutrition topping the chart. Tribal lands in particular are faced with viral fevers every year.
“Mere technical fixes of vaccination cannot solve the problem. We need to look at the spectrum of solutions, especially for local solutions at the rural level,” said Dr. Reddy.
The importance of prioritizing mental health during COVID-19
“Fear-driven mental health related to COVID precipitates from the community to the family and finally to the individual. A consistent feeling of helplessness arises. This results in anxiety leading to depression, obsessive-compulsive disorder, or a sense of hopelessness. Prolonged anxiety leads to other forms of severe mental and physical health like loss of sleep and appetite,” said Dr. Varudhini Kankipati, Co-founder, InnerConnect.
“The pandemic will lead to long-term mental issues in individuals and its repercussions will last for next 7-8 years,” she said.
Time to understand inequality of distribution
“Before the bifurcation of the Telugu states in 2014, the socio-political, educational and medical infrastructure of the region was centred in Hyderabad for almost half a century. The pandemic struck at a time when medical facilities were highly divergent in both the public and private sectors in the two Telugu states,” said Dr. P B N Gopal, Chief of Critical Care and Senior Consultant Intensivist, Continental Hospitals.
The results in the second wave are different from the first one considering that the response in the former was national whereas that in the second wave is regional. COVID-19 is everyone’s disease but treatment facilities are not for everyone. There is no transparency on whether medical facilities have reached the last mile or not. Testing, vaccination, and treatment are severely lacking in the rural areas of both states.
There exists a lack of central command in both states taking into account the availability of beds, healthcare workers, supply of oxygen etc. Government lacks data on the number of patients in corporate, private, and public hospitals and statistics on the supply of oxygen from various non-government organizations.
The inability to start the vaccination drive in the inter pandemic period and the lack of preventive measure to tackle the spread of the second wave were major holdups, he added. “Also, the second priority given in vaccination to elderly people was skewed and should have been given to migrant labourers instead. The majority of the population affected in the second wave are younger. The second wave is an iceberg phenomenon and we are seeing only its tip,” said Dr. Gopal.
"Where the disease is universal, the treatment is urban, corporate, and metropolitan," he said.
Need of reviving civil society organizations
“COVID-19 has had an adverse impact on the livelihood of people doing small jobs due to lockdown. Various handloom weavers in both states were affected severely,” said Dr. Reddy.
Throwing light on the effects of the pandemic on rural livelihoods, Dr. G V Ramanjaneyulu, Executive Director, Center for Sustainable Agriculture, Secunderabad, Telangana said that the situation is dismal with people facing difficulties in finding work. Public health facilities are collapsing significantly in both states. The pandemic brought in new challenges to rural areas where people are divided on caste and party lines creating serious problems.
The suggestions from the civil society are taken as political statements and there is a collapse of civil society initiative at the grassroots level with government initiatives taking over that of the civil society. There is a need to strengthen data-driven transparency in response to COVID-19.
“There is a need for isolation and quarantine centres as the disease is infectious and cannot be curbed by home isolation,” said Dr. A Suneetha, Coordinator, Anveshi Research Centre for Women’s Studies.
“The side-lining of the voluntary health networks by the Telangana government and the suppression of data and information by the state has cost it badly. The primary health level reporting shows a high positivity as well as mortality rate. This has not been disclosed and the major allocation by centre to state that is based on this data has fallen short in meeting the needs. The media too has been suppressed by the government and there is a kind of policy paralysis because of the image trap. The state government is more interested in managing its image rather than showing the ground realities of the state transparently,” said Dr. Suneetha.