To discuss the ways to tackle the spread of the second wave in rural areas, the Centre for Habitat, Urban and Regional Studies (CHURS) and Impact and Policy Research Institute (IMPRI), New Delhi, organised a panel discussion on Rural Realities | Himachal Pradesh and Uttarakhand | Practitioner’s Experience in Tackling the Second Wave in Indian Villages on May 17, 2021.
The esteemed panellists were Dr PC Negi, Professor and Head, Department of Cardiology, Indira Gandhi Medical College and Hospital, Shimla, Himachal Pradesh (HP); Renu Thakur, Secretary, Association of Rural Planning and Action, Askote, Pithoragarh, Uttarakhand; Shankar Datt, Founder Member and Treasurer, Shramyog, Dehradun, Uttarakhand; Dr Anil Jaggi, Founder, Venture, Dehradun, Uttarakhand, Dr OP Bhuraita, Chairman, State Resource Centre, HP; Prof Sas Biswas, Professor and Head, Department of Forestry, Dolphin Post Graduate Institute of Biomedical and Natural Sciences, Dehradun; Dr Jitender Kumar Mokta, Professor of Medicine, Indira Gandhi Medical College and Hospital, Shimla, HP.
The moderator of the discussion, Tikender Singh Panwar, Former Deputy Mayor, Shimla, and visiting senior fellow at IMPRI started the session by asserting strongly that it is important to learn from best practices in combating this virus effectively.
Science Vs Old Customs
He contextualised the session by giving a brief socio-historic background of HP and Uttarakhand by stating that both these states are predominantly rural. Historically, both the states have focussed on their health sector. The states were the largest investors in ’90s, as a result of which there are not many private hospitals, especially in HP. Also, there is a deep culturally connect among the people in both these states.
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According to Mr Tikender, there is software of people who are good-hearted and connected to each other in hilly sates. Old customs and cultures bind people together. There is an ongoing debate between science and old customs, and doctors are seen as avatars of God in India. According to Mr Tikender, negotiation skills are crucial at this point of time.
A brief presentation was presented by the IMPRI team to understand the data analytics of both these states. Uttarakhand and HP lead the country in the standard of living index. Case fatality rate, doubling rate and positivity rate have been low in both the states. The Kumbh mela organised in Haridwar amidst the second wave has proved to be deadly. Oxygen and vaccine shortages and subsequent global tenders has put health infrastructure under a lot of stress.
Active Surveillance
There has been a manifold increase in the number of patients, with cases rising to 5,000 per day. Primary Health Centres (PHCs) and Community Health Centres (CHCs) in rural areas are less in number and inadequately equipped with resources. A point of concern is that people in rural areas are ignorant about the symptoms of Covid and perceive it as any other illness.
Educating people is very important as the burden of the disease is increasing exponentially. No monitoring system and surveillance mechanism can add to the problems arising out of the pandemic. According to Dr PC Negi, many patients are admitting themselves late to hospitals and there is no monitoring of oxygen at homes in rural areas due to lack of oxy meters and thermometers.
Support groups and self-help groups (SHGs) at the ground level can be helpful in providing support to people during this hard time. The role of ASHAs and Anganwadi workers is of great importance as they are the agents of awareness in rural areas. Active surveillance is the need of the hour. Strengthening institutions is of utmost significance and role of panchayats is pivotal.
Policy Advocacy And Research
Renu Thakur focused started her speech by highlighting that people were scared during the first wave — there was considerable focus on migrant workers, quarantine centres, problems of livelihood, and government packages and schemes, and the lockdown was strictly followed. Ration has been a huge problem, but the support of community kitchens has been tremendous.
According to Renu Thakur, there are many gaps in India’s policymaking. The focal point of the second wave has been on announcing curfews, sampling and vaccination. We also need to keep in mind that information dissemination and reaching out to people effectively is important to build trust in people as in rural areas, they are scared of testing. There are also very less Covid centres.
There needs to be proper information about data on vaccines as people from far-off areas come to the villages in large numbers for vaccination. There is huge mismanagement in these drives and the rate of infection is alarmingly high in hilly areas.
According to Renu Thakur, Covid-19 is a medical disaster as there is no infrastructure and medicine available. Policy advocacy and research is the need of the hour. We need to motivate people to get vaccinated as there are many rumours about the vaccine in rural areas. Accessibility in hilly areas is also another major issue.
Digital illiteracy is a huge hurdle as vaccine registrations are held online, leaving people without smart phones in despair. No remuneration to panchayat heads has been given. Quarantine centres aren’t equipped. Linking people to major areas is important.
People coming along with patients are also at the risk of catching the virus. Associations of rural planning and action have been providing packed food to the family members accompanying patients, for which ASHA workers have been equipped. However, logistics is the major issue that needs to be catered to in rural areas.
Stakeholders Involvement
Dr Anil Jaggi underlined that there are around 1,500 per day cases in Dehradun. He added that migration is a huge issue in Uttarakhand, where around 2,000 villages have been declared ghost villages because people are moving out looking for jobs and livelihood opportunities. The infrastructure of these villages is also very old.
He expressed his disappointment over the fact that doctors perceive posting in rural areas as a punishment posting and don’t want to work in remote areas. There is a problem of transportation in rural areas, and here arises a pertinent question of how people can go for treatment from rural to urban areas. This especially became a problem when over 40 lakh people attended the Kumbh, but only two lakh were tested. As a result, many sadhus too died without getting proper treatment.
Dr Anil further talked about the ‘Uttarakhand Dialogue programme, under which the administration is utilising corporate social responsibility funds of companies. All stakeholders need to be involved, but the core of the problem is that there are no clear guidelines or consortium released by the government.
The governance part in managing the pandemic has been missing. Initially, Covid was perceived by rural citizens as a city-disease, and hence, they were not prepared for a second wave. Coordination and synchronisation is needed by state governments to handle the rising cases. Resident welfare association, too, are working in combating Covid. Public private partnership can go a long way.
Decentralisation should be democratised. Dr Anil Jaggi concluded by asserting that we need to break the inertia and work towards developing an innovative mindset.
Prevention Is Cost Effective
Dr Jitender Kumar Mokta expressed his concern over the fact that it took 191 days for Covid cases to peak in India in the first wave, on September 16, 2020. But the second wave witnessed a rapid upsurge in April 2021 that India was not able to control. In HP, Hamirpur, Mandi, Kangra and Solan were severely impacted by the rising cases.
Festivals and local marriages are also the cause of concern because people find it difficult to not meet their loved ones during such auspicious events. Many people perceive Covid as similar to cold, which is really worrying as we cannot take this virus lightly. Around 10, 000-18,000 Covid positive cases were detected in a week in February, an alarming number.
According to Dr Mokta, we need to pay more attention to public behaviour as it is a people’s virus. We need to understand that prevention is better than cure. Avoid gatherings and be pro-active. Wearing masks reduces the infection by 20-25%, according to Centre for Disease Control (CDC).
Information and communication technology can play a vital role in public awareness. Nobody knows the nature of this virus. Hard times require hard measures and everybody has to work together. Dr Mokta suggested the following measures to contain the spread of this virus.
1. Masking
2. Social-distancing
3. Good hygiene
4. Vaccination (more than 60% to be vaccinated in HP)
Ground Reality Of Rural Areas
Mr Shankar Datt advised that there had been a sudden upsurge in rural areas. Isolating people who come from outside is the main problem as not enough space is available in villages to quarantine them. Mr Shankar’s organisation, Shramyog, has made 4-5 houses in 50-53 villages for isolating people who come from outside.
ASHA workers have helped in building deep connect among the people in rural areas as their role in distributing oxy-meters, thermometers and creating awareness. Local help is also important during these hard times.
A taxi drivers’ database has been used for transportation purposes. It is important to note that there is a single source of water in rural areas and due to Covid’s stigma, access to water has become a major issue in these villages. According to Mr Shankar, people are closely knitted to each other in villages, as a result of which when somebody dies, people can’t stop themselves to visit the deceased’s family to grieve their loss.
He also highlighted that there are small things in villages that needs due consideration. People are facing money crunch, then there are pregnant women who might be facing health issues. In such a situation, the supply of medicines is crucial as there are not enough medical stores in rural areas.
Micro-Level Policies
Prof Sas Biswas enlightened the conversation by pointing out how crucial policy research is. According to Prof Sas, socio-economic survey in villages should be conducted because data collection is important during a health crisis. More attention needs to be given to micro-level policies. Migrants, weddings and funerals are major causes of the spread of this deadly virus. We have to develop a road map to prevent the virus from spreading further.
According to Prof Sas, ghost villages are now deserted and can be converted into Covid centres. Public awareness and education is needed. Surveillance system has to be strong. We can learn from the best practices of our traditional systems. What our post-Covid world should look like and what are some sustainable mechanisms are questions that need deeper attention and more discussion.
Psychological First Aid
Dr Om Prakash Bhuraita warned that in HP, there is low population density but high habitation density. This translates to higher cost of delivering goods and services. According to Dr Om, these small things are important. In rural areas, people are living in fear and denial mode. But the problem lies in hospital mismanagement. Information and trust deficit in rural areas is a huge problem that needs to be addressed. According to Dr Om, following are the major problems:
- Vaccinations are less: Only four lakh people have been given second doses. Further, there are no slot announcements of vaccines and internet connectivity problem is a big hurdle while registering online for an appointment.
- Testing problems: Test reports come after six days , which is problematic in case of communicable diseases.
- Lack of physiotherapists in Covid wards
- Shortage of attendants
- Mental health care, psychological first aid is needed.
- Physical distancing has to be practiced, not social distancing.
- Lack of oxygen despite availability of funds. Uninterrupted oxygen supply should be ensured.
- Lack of ICU beds
We should focus on:
- Generating volunteers support, youth can play a significant role here.
- Awareness and education through counselling is needed.
- More oxygen plants are required.
- There is a need to increase attendants and vacancies.
- Services must be decentralised.
- Oxygen must be monitored at home.
According to Dr Om, the governments have failed to provide basic amenities to the people, thus, they need to look deeply into their ongoing mechanisms. Social vaccination is the need of the hour.
Coordinated Efforts
Misconceptions in our understanding of the pandemic need to be addressed. According to Manshi Asher, HP’s health infrastructure is a kind of image-building. There are severe regional imbalances, roads aren’t made in some villages till today, PHCs are ill-equipped. Our focus has to be on counselling as there is widening social stigma among people. There has been a 60% rise in suicide cases and increasing instances of anxiety during the pandemic as there is uncertainty regarding the future in the young population. We have to address the fear and train our health-line workers accordingly.
Economy is dependent on migrant labourers in HP, thus, the state government needs to be more alert in its approach. People are going out for better opportunities from HP. Invisible group such as tribal communities as well as the LGBTQ+ community needs more attention in the state. Isolation in public hospitals is also a cause of concern. Manshi concluded by asserting that these learnings need to be remembered and data needs to be collected. She said that even the labour commission doesn’t have sufficient data during an unprecedented mass exodus of migrant workers during the pandemic. Coordination with civil society groups is of substantive value.
Concluding Remarks
Dr Mokta answered the question regarding masking. He said that people should double-mask to safeguard themselves in an effective manner. Further, she said that psycho-social issues need to be addressed in the state and teachers can play a vital role here. Everybody should help each other during these turbulent times.
Dr Bhuraita’s concluding remarks were that decentralised awareness is needed today more than ever before. Prof Biswas concluded by highlighting that we need to understand weaknesses and opportunities at every stage. Manshi Asher asserted that talking to people within a community is very important at this juncture. Governments have to be enablers in creating social awareness. Rural and urban areas lie at a continuum.
The Way Forward
Dr PC Negi provided a way forward by underlining that health has been neglected in our country. We have to increase the GDP by investing in health infrastructure. Social determinants need to be looked upon deeply. Public health and curative medicines need to have different cadres as we need to have a preventive approach towards disease control. This situation is unprecedented and as highlighted by Shankar Datt, we need public support.
This is a learning experience for all of us. Health and education are important pillars for a society to become resilient and responsive. Holistic approach needs to be adopted.
YouTube Video for Practitioners’ Experiences in Tackling the Second Wave in Himachal Pradesh & Uttarakhand
