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Migrant worker may increase the spread as they have travelled on crowded buses and trains, says health experts (Photo: PTI)
Migrant worker may increase the spread as they have travelled on crowded buses and trains, says health experts (Photo: PTI)

Bharat’s health infrastructure inadequate for a spike in virus cases

Rural areas have poorly staffed healthcare facilities, lack testing labs and have no critical-care equipment

NEW DELHI : The exodus of millions of labourers from cities, some of them potentially infected, is set to stretch the capacity of India’s underfunded and inadequate rural health facilities to the limit.

While coronavirus infections have been largely restricted to urban hotspots in India with few rural cases so far, the situation has been exacerbated as migrant workers fled the cities after Prime Minister Narendra Modi announced an unprecedented 21-day lockdown.

Public health experts fear the mass migration, the biggest since partition, may trigger an explosion of cases in rural areas where healthcare facilities are poorly staffed, lack testing labs and almost no critical care equipment, leading to avoidable deaths.

“They may be carrying coronavirus infection inside their nose and throat and they may increase the spread as they have travelled in heavily-crowded buses, trains or vehicles," said Dr Jugal Kishore, professor and head in the department of community medicine at Vardhman Mahavir Medical College and Safdarjung hospital.

Detecting infections is also a challenge because symptoms of covid-19 can appear days after a person is infected. According to the World Health Organization (WHO), an infected person may not show any symptoms for as many as 14 days.

“Migrant workers are a link between the rural and the urban India. We have dealt with migrant workers in HIV and polio control programmes. But covid-19 is different. One option is to screen them when they deboard, and isolate them if they have fever and/or cough," said Lalit Kant, a former head of epidemiology and communicable diseases at the Indian Council of Medical Research (ICMR).

The severity of the challenge facing India can be gauged by the fact that migrants comprise 48% of residents in India’s six largest cities of Delhi, Mumbai, Kolkata, Chennai, Hyderabad and Bengaluru in 2011, according to the national census.

To mitigate the situation, state governments are carrying out door-to-door surveillance and tracing the contact history of all confirmed patients in rural areas. But the scale of the challenge is daunting.

“During an outbreak of a communicable disease or during social distancing measures, as is being undertaken for the covid-19 pandemic, such populations tend to return back to their homes. In such a scenario, the resultant congregations of migrant workers in bus stations/state borders may make them susceptible to infections. Further, such exposed individuals may carry this infection to far flung rural localities. Also, it would be difficult to track them and their contacts," the Union health ministry said in an advisory on Thursday.

The infected migrants will also put the elderly to risk, which may prove difficult to handle.

“So far there does not seem to be a spike in pneumonia or respiratory illness-related cases/deaths in rural areas. However, with the mass exodus of migrant labourers, the likelihood of increased number of cases emerging in rural India has also increased. If this happens, this would hit the weakest link in India’s healthcare systems and lead to higher mortality rates. The doctor per patient ratio, and availability of ventilators is rural areas is really low and would put additional pressure on the government’s limited resources," said Himanshu Sikka, chief strategy and diversification officer, health, nutrition and wash, IPE Global, an international health consultancy.

There is a 22%-30% shortage of primary health centres (PHCs) and community health centres in rural India, with West Bengal, Uttar Pradesh, Bihar, Jharkhand, Rajasthan and Madhya Pradesh having the most inadequate infrastructure.

“The major areas where enhanced deployment of human resources is required are surveillance activities at grass root level, supervisory management of containment operations, laboratory testing, collection, collation and dissemination of data, risk communication and clinical management," said Arun Singhal, special secretary in the health ministry.

At least 60% of PHCs in India have only one doctor while about 5% have none, according to the Economic Survey 2018-19. More than 10% PHCs in Jharkhand and 20% in Chhattisgarh don’t have any doctors. More than 90% PHCs in Gujarat have only one doctor.

The situation is the same in 80% of PHCs in Kerala and Karnataka, and 70% of those in Rajasthan, Uttar Pradesh and Bihar.

Health experts have said that the containment plan for rural areas should be robust.

“Normally there is a group of persons from the same village which go to same urban area for employment. So, when these group of people return to their village, people get to know. The peripheral worker at the village level should inform their health counterparts about their arrival. Screening for fever and cough can be arranged. And those having symptoms be isolated in Panchayat Ghar. Alternatively, some kind of mark can be made on the house where migrant workers live with their families so that they could be monitored for fever and cough. It is important that we take care of these migrant workers as they are critical in putting our economy to tick again," said Kant at ICMR.

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