“A large number of people are coming from outside every day to my district. There is no testing facility. In my neighbourhood, two people came from Mumbai the day before. There was no inquiry even after I reported it through social media to the district authorities. People are also not being made aware. We have been made aware by news channels that the matter is very serious. However, no awareness is made through the community and primary health centres,” said Harish Singh, a social worker in Bhadohi.

He is concerned because a large population of Bhadohi district, adjoining Varanasi, about 250 km away from Uttar Pradesh capital Lucknow, lives in Mumbai for a livelihood and most are now returning home, increasing the risk of Coronavirus. Chief minister Yogi Adityanath has advised against this mass movement, but people continue to ignore the advice.

As the country is forced into a lockdown in its fight against the virus, rural areas, especially in Uttar Pradesh and Bihar, are reporting an increasing number of Covid-19 cases as a result of the huge influx of workers returning home from cities like Mumbai and Pune in Maharashtra —

one of the states worst affected by the pandemic — due to lack of work. This is putting a severe strain on the health infrastructure in rural India not equipped to deal with an outbreak of such scale.

“Our health infrastructure is weak, that is why the entire country has been locked down,” said Dr Vandana Prasad, director, Public Health Resource Network.“When even countries with strong health facilities are struggling to cope with the epidemic, it is going to be very difficult for us to deal with the outbreak,” she said. “Our rural health infrastructure is even worse,” she said. “The government has always ignored it.”

“There are neither sufficient doctors nor beds in hospitals. So, if Coronavirus reaches villages, we will just be counting the casualties. We have no means to fight this epidemic. All that we can do is keep ourselves safe and protect ourselves,” said Dr Sunil Kumar, secretary, Indian Medical Association (IMA).

Availability of doctors

The availability of doctors is a major challenge for rural India. There is only one allopathic doctor for a population of 26,000 in the rural areas of India, while the World Health Organisation (WHO) stipulates one doctor for every 1,000 people.

The situation in West Bengal is the worst in India in terms of availability of doctors. According to the National Health Profile 2019 report of the government of India, 881 doctors serve about 6.2 crore people in the rural areas of West Bengal, which translates into one doctor for about 70,000 people. The condition in Jharkhand and Bihar is also bad, with only one doctor 50,000 people.

According to the Medical Council of India (MCI), there are about 1.1 crore allopathic doctors registered with it. So, for the nation as a whole, there are about seven doctors per 10,000 people. China has more than 17 doctors per 10,000 people, while the US, with a total population of 32 crore, has more than 25 doctors. There are about 37 doctors per 10,000 people in Italy, which has a population of 6 crore.

Primary and community health centres

The bedrock of health services in rural areas are the primary and community health centres, but they are not in good condition.

The Ministry of Health and Family Welfare told the Lok Sabha on November 22, 2019, that the primary health centres in the country required 34,417 doctors to run them properly. But only 25,567 doctors were actually posted as on May 31, 2018 — a shortage of 8,572 doctors.

Also, in 72,045 primary health centres, sub-centres and community health centres, there is no provision of toilets for the staff, while in 1,15,484 centres, there are no separate toilets for women and men. There are 823 health centres with no electricity and 1,313 centres do not have regular electricity. There are many health centres with no provision for even water.

Among states, Uttar Pradesh fares the worst in primary health services. As per a government of India report, the state requires 3,621 doctors, but has only 1,344 to run the primary health services. The 942 primary health centres in the state do not have regular electricity or water. Roads are in such a poor state that the patients cannot reach the centres in inclement weather. The other states with poor rural health facilities are Chhattisgarh, Odisha, Karnataka and Bihar, the report said.

Beds in hospitals

As per the Census of 2011, about 69 percent of the country’s population lives in rural areas. But, according to the government of India’s National Health Profile 2019, the 21,403 government hospitals (primary, community and sub-districts/districts) in these areas have only 2,65,275 beds against the 4,48,711 beds in 4,375 hospitals in cities. So, while there is one bed for 1,700 patients in cities, there is just one bed for 3,100 patients in rural areas.

Bihar fares the worst in hospital beds. It has 1,032 hospitals with only 5,510 beds for a population of 10 crore (2011 Census). In effect, there is one bed for 18,000 villagers.

In Uttar Pradesh, where 77 percent of the population, or over 15 crore people, lives in villages, there are 4,442 hospitals with 39,104 beds — or about 3,900 patients per bed. Tamil Nadu is the best in India, with 690 government hospitals and 40,179 beds in the rural area, or about 800 patients per bed.

Delay in medical services

The situation is exacerbated by the delay in providing medical attention to the infected as illustrated by the case of a youth from village Murwa under the Vindhamganj police station, 90 km away from Sonbhadra district headquarter in Uttar Pradesh.

When he fell sick after returning from Mumbai on March 14, a village doctor prescribed him medicines. When his condition did not improve and he started having difficulty breathing on March 24, the doctor advised that the youth be taken to the Vindhamganj Primary Health Centre (PHC), 10 km away from his home. But the doctor at the PHC directed him to the Community Health Centre (CHC) at Duddhi, about 45 km away. By then, it was 1 pm.

There was commotion at the CHC, when it was discovered that his symptoms were similar to those caused by Coronavirus. The other patients fled and, worse, the doctor refused to see him out of fear. The young man was put under a peepal tree outside the hospital, where he remained for about three hours. At about 5 pm, a health department team came from the district headquarter, Robertsganj, about 75 km away, and took him to an isolation ward. His blood sample was then sent to Sir Sundarlal Hospital, about 80 km away in Varanasi, for testing.

Testing labs

The government is opening new labs all over the country to test for Coronavirus. A total of 119 government and 25 private labs have already been set up. A private lab is indicated by blue color.

According to the Indian Council of Medical Research, eight labs have been set up for COVID-19 testing in Uttar Pradesh, which has a population of about 20 crore. These labs have been set up at Lucknow, Varanasi, Aligarh, Meerut, Saifai and Gorakhpur.

Maharashtra now has eight government and four private labs — four labs have been set up in Mumbai, three in Pune and one in Nagpur. The four private labs are all in Mumbai.

Similarly, five test labs have been set up in Bihar — three in Patna and two in Darbhanga.

But the numbers are still low to cater to the huge population. Besides, the labs are also situated very far off. So, if a suspected patient is found in Pratapgarh in Uttar Pradesh, he will be screened either in Lucknow, a distance of 165 km, or at Varanasi, about 143 km away.

This can pose a huge challenge in the fight against the virus in rural India. Besides most labs have not even started functioning.

“We had to start testing in two labs, but, so far, the work has been started only for one,” said IMA’s Dr Sunil Kumar, talking about the situation in Bihar. “There is a machine reserved for the other, but no one knows when it will start operating. Thousands of people are returning to the villages every day, but no testing is happening,” he said. Dr Sunil. “There are only 600 ventilators in the entire state.

According to Dr Vandana Prasad, it is high time we started investing in rural health infrastructure. “We need to be very much invested on this side. At the moment, it is crucial that we make the villagers more and more aware and tell them to do what the government says. But we must learn a lesson from this. Our system should always be up to date, not merely at the time of a disaster,” she said.