Mumbai: The number of Covid-19 cases and deaths are dipping across India. There's been a 70% decline in active cases since the peak of the second wave on May 10, according to the Ministry of Health and Family Welfare. Though directionally, India's Covid-19 situation seems to be improving, the true Covid-19 numbers are not known.

What is the actual Covid-19 situation in rural India? How can India respond to the rural healthcare gaps seen in the second wave, and apply those learnings as we gear up for a potential third wave? To discuss this, we spoke with S.P. Kalantri, director and professor of medicine at the Mahatma Gandhi Institute of Medical Sciences and medical superintendent of Kasturba College, Sevagram, Maharashtra. Kalantri is an MD from the Government Medical College, Nagpur, and has a master's in public health from the School of Public Health at the University of California, Berkeley.

Edited excerpts:

Tell us what you've seen in the behaviour of the virus in the last few months, during the highest points of the second Covid-19 wave, and people's behaviour in response.

I work in a rural teaching hospital in a small village called Sevagram, where Mahatma Gandhi once lived. We have a medical school and an attached 1,000-bed hospital. The first Covid-19 patient was admitted to our hospital last year on May 10. The first six months [saw us] learning on the job, screening patients to detect Covid-19, admitting and caring for them, making sure that we reduced morbidity and mortality as much as we could. Around mid-January 2021, we heaved a huge sigh of relief because the number of patients admitted to our hospital came down from an all-time high of 325 to just 28. For almost 15 days, we wondered if Covid-19 had really gone for good. We started clapping and celebrating. But in mid-February, we realised that our celebrations were premature. The virus came in the second wave and hit rural India very hard, very mercilessly, almost below the belt.

I'll tell you what exactly happened in the second wave. At one time, we had as many as 550 Covid-19 positive patients in our hospital, almost all hypoxic [short of oxygen]. We had no ICU beds vacant, we ran out of oxygen cylinders. On one day, our oxygen was barely sufficient to last for about 30 minutes or so. The main difference between the first wave and the second wave was that the virus in the second wave was more virulent, more aggressive. And this time it achieved great transmissibility. So unlike the first wave, in the second wave, we found that entire families would get affected--grandparents, parents, even younger adolescents. And the virus was so virulent that within just a couple of days, patients would walk in with very severe hypoxia and oxygen saturation levels of barely 50 and 60. Try as hard as we might with all our resources of oxygen support systems or ventilators, our ICUs, we found that mortality was extremely high. In fact, on April 21, we found that a patient was dying every 90 minutes in a rural hospital. And many of these patients, unlike during the first wave, were young. They were hardly in their thirties and forties. They were principal breadwinners. And they deteriorated very, very fast, barely within say three or four days after their Covid-19 was detected.

The entire healthcare system in rural India at that time was completely overwhelmed. Doctors were tired, exhausted, fatigued; nurses didn't know what to do. Despite putting in our best efforts, we were not able to save almost a fourth of the patients that were admitted to our teaching hospital.

Was there any difference in the way the virus spread in rural areas, which are more open and where people work in more ventilated areas compared to densely populated cities?

The virologists tell us that the Covid-19 virus doesn't respect the boundaries between cities and rural areas. It doesn't know this artificial dichotomy of rural versus urban. This time, compared to the first wave when our villages were relatively spared, the virus had definitely achieved more power of transmission and affected our villages. As I said, the virus was very, very virulent this time.

Unlike the first wave, where we would see people in their late fifties or sixties getting admitted, and only those who had comorbidities and those who were elder dying, this time, we found perfectly fit younger individuals came in with very severe hypoxia, and they died very quickly.

When you look at people's behaviour, what would you say was the biggest shortcoming? Was it just a plain lack of knowledge? Or was it something else like the confidence that nothing would go wrong?

I won't say that we were in a dangerous sense of complacency. But the problem is that if suddenly your hospital services get completely overwhelmed, and you run out of hospital beds, there are no ICU beds, there are no ventilators to put your patients on, the oxygen supply is going down, then despite your best efforts, it's very difficult to run the system.

My question is about the patients. Were they more aware of Covid-19 or not? Were people in rural India behaving any differently from those in urban India when it came to acknowledging the fact that they had Covid-19?

The main problem in rural India is that when people test positive, they are a bit reluctant to get admitted to the hospital--particular the elderly population--for the simple reason that they know from their past experience and whatever they have heard in their communities that once they get into the hospital, they are completely isolated, marginalised. They are very lonely. And if they die there, then they die a very lonely death away from their family, relatives and loved ones. The younger generation at home also feels a big sense of guilt that in the final phase of their parent's life, they are not able to stand by them.

The second fear that invaded the rural areas was that should death occur, then according to the government guidelines, rites and rituals cannot be performed. So, many villagers said that they would rather die at home than face an ordeal in the hospital and die a very lonely death away from family members. This was one of the main reasons that led to a problem in the rural areas.

Looking ahead at a potential third Covid-19 wave, what are the issues that India must address? Where do we train our efforts and focus our energies?

I think we need to follow the same simple principles as were used for eradicating smallpox way back in the 18th century: identify every case, isolate every positive person and make sure that all contacts are isolated and immunised. These principles look very simple in theory, but they are extremely difficult and particularly challenging in rural areas because rural hospitals are understaffed, under-equipped. Doctors and paramedics are not well trained to take care of Covid-19 patients. Quacks abound. There, polypharmacy is the rule. There is also a lack of connectivity between the primary health centres, sub-centres, community health centres, district hospitals and medical care hospitals. The result is that the medical care and tertiary care hospitals are getting overburdened. People who should have been treated in the vicinity of their home or in the community are being transported for about 50-100 miles.

This is also one of the reasons why people do not want to be tested, because who wants to travel 100 miles from his or her village to be treated in a remote hospital, where the doctors are not familiar, where the milieu is very foreign, and where they do not know enough about the healthcare workers? So, we must decentralise everything. Make sure that people are able to seek proper scientific healthcare near their homes. You will have to empower sub-centres and primary health centres; train the doctors; make sure that drugs are available, make sure that evidence-based therapies really travel into the heart of these centres, and that unnecessary drugs and unnecessary investigations are weeded out. Ensure a proper relationship between these three tiers of primary, secondary and tertiary care.

Given that a potential third Covid-19 wave may arrive in months, what of this could we achieve? What are the areas that we could move faster on, say by using information toolkits?

Because 70% of India lives in villages, ensure that those doctors at the primary health centres, sub-centres and community health centres are quickly trained right now, See, Covid-19 is a simple disease. All you need to do is screen people, [see] who is positive and who's negative. Those who are not hypoxic, all they need is just a couple of tablets of paracetamol and monitoring of their oxygen saturation by pulse oximetry. So even if we are able to achieve these two simple things, avoiding polypharmacy and making sure that oxygen saturation is properly monitored, we would have achieved much more than what we are doing right now.

You mentioned immunisation. How is vaccination being administered and received in your area?

There's a lot of confusion about who would get a vaccine. Would it be persons aged 60 years and above, would it be persons aged between 18 and 45 years, and so on. The problem in rural areas is that people are not very technology-savvy. They do not know which vaccine centres are located near their areas. And again, the problem is that for those who live in a village and have to travel about 50 or 100 miles to get a vaccine, the travel expenses, the very thought of going to a foreign hospital, getting an unknown vaccine, deters them from vaccination. So again, as I said earlier, we will have to decentralise and make sure that Covid-19 vaccines are available in their villages, in their communities, near their homes. There is no point in having just one big mega vaccine centre in the district and then people having to spend a lot of time, effort, energy and money to get that vaccine. It won't work in rural India.

Assuming India has enough vaccine supply, could that problem be solved with mobile clinics administering vaccines in different places?

Maybe. But my point is, why not aim for the sub-centres and primary health centres, which are already located in the village, which the people are aware of? They know these doctors, they know these centres. The idea is to make sure that these primary health centres, sub-centres and community health centres have adequate trained manpower and enough vaccines to take care of this within their community.

We've seen the virus rage through the country and the number of cases come down. What learnings can you take away from the behaviour of the virus and of those who've been affected by it, particularly in rural India?

The virulence of the organism, its increased transmissibility, affecting the younger generation are the three important things that we observed [compared to] the first wave.

As for behaviour, this time, for the first time, we found that in rural India people were a bit more apprehensive and fearful compared to the first wave. They were fearful for the simple reason that they knew that once they tested positive and were taken to hospital, they would be completely lonely there. And should they go there, they would die a very lonely, neglected, marginalised death.

Also, death is a very special [situation] so far as rural India is concerned, in terms of the rites and rituals associated. Many people in the villages who we spoke to said that they didn't want to spend the evening of their lives in a hospital dying a very lonely death. They would rather remain at home in the midst of their family, friends, relatives and loved ones, and they would do whatever they could to treat this virus. So probably this fear deterred villagers from seeking healthcare services and many of them went to non-qualified healthcare professionals. They went to quacks, resorted to polypharmacy, whatever they could to stay away from the hospital.

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