Tracking the pandemic’s rural march

States, especially in the north, are facing the brunt of the second wave, made worse by their poor health infrastructure

When the first wave of the novel coronavirus pandemic hit the country, the central government imposed the strictest lockdown for almost two months. For most of the migrants stuck in urban areas without incomes, jobs and food to survive, the only escape was to walk back to the rural areas where they came from. Migrants walked back thousands of kilometres to return to rural areas not because the villages were best equipped to deal with the pandemic but primarily because it provided them protection from hunger and starvation. During the second wave now, it is the rural areas which are bearing the brunt of the pandemic with most cases being reported from rural areas. And, unlike last time, there is nowhere to go.

Estimates versus the reality

The second wave was expected at least based on past experience of other countries and of earlier pandemics but also because most scientists predicted it given the changing nature of the virus and the pandemic. However, unlike the last time when it was largely in urban areas, this time it has spread to villages. Also, in contrast to the previous episode, it has spread this time to the rural areas in Bihar, Uttar Pradesh, West Bengal, Jharkhand and Odisha — States which remained largely unaffected by the spread of the pandemic during the first wave. Most of these States are those with a low availability of health professionals and a lower level of health infrastructure. The result has been a much higher level of infections and deaths. Stories of bodies floating in rivers or left buried on the banks are being reported from both Uttar Pradesh and Bihar. While these are stark visuals of the nature of impact that the pandemic has caused on infections and deaths resulting from the infections, these are all estimates; gross underestimates of the actual reality in the rural areas in many of these States.

Neglect of primary care

The scale of the misery inflicted by the pandemic was expected in most of these States, where the existing health infrastructure has been found lacking. But what made it worse was also complete apathy and a lack of governance in improving the health infrastructure despite knowledge of the second wave of the epidemic.

As in the latest report of the Rural Health Statistics 2019-20 released by the Ministry of Health and Family Welfare (MOHFW), not only are these States which figure among the States with the worst health infrastructure but are also ones where the situation has worsened over the years. Compared to 10,337 functioning subcentres in rural Bihar in 2005, only 9,112 subcentres were functioning in 2020. The number of community health centres declined during the same period from 101 in 2005 to only 57 in 2020. Despite population growth, during the same period, the number of primary health care centres increased marginally to 1,702 in 2020 compared to 1,648 in 2005.

The situation in Uttar Pradesh, another large State, is no different with the number of primary health centres declining from 3,660 in 2005 to 2,880 in 2020. While the number of community health centres increased from 386 to 711 during the same period, sub-centres increased only marginally, from 20,521 in 2005 to 20,778 in 2020. The situation with regard to the availability of health professionals is not very different, with most States witnessing a worsening situation. For example, only 29% of specialists were in place in the community health centres in Uttar Pradesh as against the requirement based on official norms. Compared to the norm, Bihar reported the highest shortfall in availability of subcentres, at 58%, followed by Jharkhand, at 44%, and Uttar Pradesh, at 41%, as on July 1, 2020. Similar numbers in the case of primary health care centres were 73% for Jharkhand, 58% for West Bengal, 53% for Bihar and 51% for Uttar Pradesh.

Avoidable events

Given the state of the rural health infrastructure, it was obvious that the pandemic would lead to catastrophic outcomes once the rural population was exposed to the virus. The lack of governance in this case is not the state of health infrastructure that the State governments inherited but the failure to contain the spread of the pandemic despite the knowledge of the state of rural health infrastructure. This failure to estimate the scale of the havoc created by the pandemic was obvious in the case of the central government — steps were not taken to contain the spread along with augmenting the rural health infrastructure and there were decisions such as prolonged electioneering in some of the States. West Bengal, which has seen the fastest rise in cases, was witness to the longest period of electioneering this time, with no precautions such as social distancing in place. Similar adventurism in the case of Uttar Pradesh saw hundreds of polling officials getting infected and passing away due to the pandemic during the conduct of local body elections in the State. The Maha Kumbh organised in the middle of the pandemic, with millions of devotees participating, further added to the spread of the infection with devotees returning to rural areas in different States. All of these were eminently avoidable, with the resources used to augment and strengthen the rural health infrastructure.

Judiciary and the state

While all these created the perfect breeding ground for the pandemic to spread to rural areas, the severity of the infections was also a result of the misgovernance of State governments. This bordered on ignorance of the level of severity to outright denial and complete apathy of the health and humanitarian crisis unfolding in the respective States. In most cases, the judiciary at the level of High Courts has stepped in to fill the vacuum created by an absent state. The judicial intervention of the Allahabad High Court last month directing the State government to impose lockdowns in Uttar Pradesh was in turn challenged by the State government in the Supreme Court. Attempts to voice concern over the state of health infrastructure and the spread of the pandemic by helpless citizens was countered with threats of legal action by the Uttar Pradesh government until the Supreme Court stepped in.

Instead of expanding testing and contact tracing, attempts were made to restrict testing and report a lower number of infections, leading to a sense of complacency within the State administration. The reality in rural areas of most of these States is worse than what is being released to the public through official estimates. This is true for the number of deaths which by all measures appears to be much higher than official statistics. The absence of testing and treatment infrastructure has left the rural population at the mercy of private health providers; a large majority of the population has been left unable to avail the services of private health-care providers. The slow pace of vaccinations in rural areas despite the vulnerabilities has only contributed to the rise in infections and thousands of deaths which could have been easily prevented.

Aggravating rural distress

Rural areas provided refuge to the majority of the migrant population which had lost jobs and incomes during the first phase. It also helped the economy revive given that rural areas were largely unaffected. However, this time round it is the rural areas which are facing the worst of the pandemic as well as economic distress. Rural wage data as well as data on rural non-farm income available from official and private surveys point to a dismal economic scenario. While many have lost their primary income earner, even for those who managed to recover, it has come at the cost of huge private health expenditure. Many are likely to fall into a debt trap with the usurious rate of interest from the private money lenders pushing them into chronic poverty. For the rest, the loss of jobs and income has come at the cost of depleted savings. Rural areas are not just staring at the worst of the pandemic but also at prolonged economic distress.

While the pandemic with its uncertain nature is certainly responsible for it, the blame must equally lie with the government, both at the State as well as central levels, for its failure to anticipate and prevent the thousands of deaths.

Himanshu teaches Economics at Jawaharlal Nehru University