See how rural India has been overrun by the pandemic's second wave

Sparse healthcare. Social stigma. Undercounted deaths. The consequences for the country's rural populations will likely play out for years to come.

Family members of a critically ill 32-year-old man suspected of suffering from a fungal infection that affects COVID-19 patients, listen as a MAHAN Trust’s hospital doctor in Amaravati, Maharashtra, India, advises them to take him immediately to a hospital four hours away for better treatment. Locals believe that taking patients to a far-away hospital is a point of no return, and many would rather take their loved ones back home to die.

There were no funeral pyres on June 10 at the Tavarekere mass crematorium, roughly 19 miles outside the South Indian city of Bengaluru; for the first time since April, the site had received no bodies. In large cities throughout India, daily COVID-19 cases are decreasing, the supply of medical oxygen is becoming consistent, and a system of triage at hospitals has been established. There is a sense that the COVID-19 pandemic’s deadly second wave has passed.

But outside India’s dense urban centers, COVID-19 is still battering the rural regions where two-thirds of the country’s population lives. Despite sparse or nonexistent COVID-19 testing outside cities, the data team at The Hindu newspaper has estimated that 65 percent of new cases through the beginning of June 2021 are in rural and semi-rural areas.

Lack of access to essential healthcare, misdiagnosis, pandemic denial, and social stigma are all fueling the spread of the virus in the countryside. In India’s poorer northern states, some villagers have dumped the bodies of relatives who have died of COVID-19 in the sacred river Ganges; others have fled to cattle sheds and farms, the only spaces where they can socially distance.

A core part of the crisis is the fact that migrant workers and religious pilgrims had to leave larger cities as lockdowns were imposed during the surge. According to a report released by the city government on May 21, more than 800,000 migrant workers left Delhi. Other Indian cities saw a similar exodus. Estimates suggest anywhere from 22 million to 50 million migrant workers returned to their home states and villages during the 2020 COVID-19 lockdowns, but it’s not yet clear how many traveled home this year.

“The story of rural India is actually a double whammy,” says Rama V. Baru, a healthcare policy expert at the Center for Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi, and a member of the Indian Council of Medical Research that is spearheading India’s pandemic response.

“There is the visible crisis of not getting care, and the invisible story of the migrant crisis, where migrant workers who were forced to return to their villages have acted as carriers of the infection,” Baru says. “The migrant crisis and the rural spread are not separate, they are very much connected.”

What’s more, undercounting the deaths of India’s rural citizens is making their loss invisible. As of June 18, India officially has 794,493 active COVID-19 cases and 16,546 deaths in the last seven days—most in rural regions. But these figures are likely a gross underestimate, which some experts calculate might be six times higher. (Here’s why it is so difficult to gauge the pandemic’s death toll.)

A losing battle

Upendra Avula, 24, was relieved in early May when his 45-year-old diabetic father was finally on the path to recovery after a particularly severe bout of COVID-19. A first-generation graduate and civil engineer, Avula and his family live in Nagarkurnool, which is among the most underdeveloped regions in the southern Indian state of Telangana. He had been able to provide timely care for his father based on telemedicine consultations, via smartphone, with Vishnu Mummadi, a 32-year-old physician at Asram Medical College in Eluru, about 250 miles away from Avula’s village.

But on May 6 his father’s condition began to deteriorate rapidly, so Avula reconnected with Mummadi. While on-call in his own hospital, Mummadi is also teleconsulting and offering advice to families of COVID-19 patients across rural Andhra Pradesh and Telangana. He told Avula to move his father to a government hospital. But apart from a bed, the hospital had little to offer. There was no medical infrastructure or staff who could help. So Mummadi told Avula which medicines and simple diagnostic tools to purchase and how to monitor his father and act as his nurse.

When his father stopped responding to the medicine and his blood oxygen level dropped below 90 at around 10 p.m., Mummadi advised him to seek out a hospital with respiratory support in the nearby Mahbubnagar district. By the time they managed to get a bed, his father’s oxygen levels had dropped to 50. He improved a little after receiving oxygen, but then continued to get sicker. At 7.30 a.m. on May 7, his father passed away. Avula then began taking care of his mother, who had also caught the virus. She has since recovered.

Avula’s story is emblematic of how the rural spread of the virus has been amplified by sparse access to healthcare in much of the country. According to a 2015 report from by insurance group Swiss Re and the Harvard T.H. Chan School of Public Health, only 25 percent of Indians have access to healthcare services. In addition, 60 percent of the country’s estimated two million health workers cater to urban India, according to a 2016 report from the World Health Organization.

Overall, the country has just 80 doctors practicing of all types of medicine—allopathic, Ayurvedic, and homeopathic—and 61 nurses per 100,000 people. Of the physicians in rural India, only 19 percent had a medical degree, compared with 58 percent of those in urban zones.

Mummadi says that while most doctors are trying everything they can to save every life they can, “we are witnessing and hearing about really bizarre situations.”

For instance, many doctors in rural India are misdiagnosing COVID 19 as typhoid. India is among the worst afflicted countries when it comes to this disease; according to the latest Global Burden of Disease report, published by the medical journal the Lancet, the country had 5.8 million cases, and 58,552 people died due to typhoid in 2017. Doctors use the Widal test to detect typhoid, but this test is old and unreliable and can also produce a false positive result when a patient has COVID-19. When a sick patient tests positive, instead of following up with a COVID-19 test or even assessing the patients’ blood oxygen level, rural medical practitioners give the patients antibiotics.

“A patient who might be suffering from COVID-19 is not only misdiagnosed but is also given the wrong medication,” says Mummadi. Because antibiotics kill bacteria and not viruses, the patients’ condition only worsens. “By the time they come to the regional hospital, there is a long delay from the first onset of symptoms. This makes it harder to treat them and ensure they recover.”

In impoverished states such as Uttar Pradesh and Bihar, proper diagnostics and technological interventions were not set up, so rural people there are also turning to harmful medications that fail to treat the virus, says Amir Ullah Khan, a health economist at the Centre for Development Policy and Practice based in Hyderabad. These treatments range from using an iron rod to brand the patient in the parts of their body where they complain of pain, to diet plans that claim to cure COVID-19. (This is how the Indian government has been pushing unproven Ayurvedic treatments to treat COVID-19.)

And with only 35 percent of Indians having any kind of health insurance, the majority spend money out of pocket to pay healthcare service providers directly at the time of service. This means that many citizens are left to fend for themselves during a health crisis.

“During the last wave and the lockdowns of last year, even those who were reasonably better off completely ran out of cash,” says Khan. “When the second wave hit, there was no cash to fall back upon.”

Indigenous communities suffer the most

The second surge in India has even reached into more remote communities that fared better during the first wave. The village of Bamhani sits deep within the central Indian forests of the Achanakmar wildlife sanctuary and tiger reserve, in the Indian state of Chhattisgarh. It’s home to the Adivasi—indigenous communities of Gond, Baiga, and Oraon—who are among the most disempowered in India.

According to fourth National Family Health Survey, conducted in 2015-16 on behalf of the Indian government, the Adivasis of India already fare the worst according to various health indicators such as child mortality, child malnutrition, and chronic malnutrition.

“As our analysis of the NFHS-4 data shows, the Adivasis really are at the bottom of not only health but all development indicators,” says Venkat Ramanujam, a scholar at the Ashoka Trust for Research in Ecology and the Environment, Bengaluru, who studies changing Adivasi livelihoods in central India.

This region in central India escaped much of the pandemic in 2020, but during the second wave it wasn’t as lucky. When the first wave peaked in October 2020, the district of Mungeli, where Bamhani is located, had a total of 2,755 cases. Last month, even as the second wave was just beginning to spread to India’s rural regions, Mungeli had a total of 21,332 cases, of which 5,217 were active.

To seek medical attention, villagers must visit one of three affiliate centers set up by Jan Swasthya Sahyog (People’s Health Support Group), or ask for help from health workers who make daily visits and provide basic medicines as well as advice. When they need more advanced care, the patient’s family is advised to take them to the Jan Swasthya Sahyog hospital, more than 40 miles away.

Apart from resources, social stigma associated with testing positive for COVID-19, mistrust of the government, and disease denial are also major issues here, says Pranav Dhamdhere, a 29-year-old physician at Jan Swsathya Sahyog. Even though villagers know that COVID-19 can be lethal, most are still reluctant to come to the hospital.

“Many times, by the time they come in, the patient is at quite an advanced stage of hypoxia. What we are trying to do here is to use the resources we have in the most optimal way, to do the best we can.”

Related issues like lockdowns are also having an adverse impact here. “Over this year and the last, I have lost patients who were suffering from various types of cancer and even tuberculosis who could have been operated on or medicated back to health pre-pandemic,” Dhamdhere says.

T. Jacob John, a retired professor of clinical virology at Christian Medical College in Vellore and former head of the Indian Council for Medical Research’s Center for Advanced Research in Virology, fears the situation is much worse than what we know so far.

“The rural wave will be outside the radar of the media,” John says. “The way dead bodies are floating in rivers tells you that rural people are not able to cope. It is a horrible nightmare that is going on for most of India’s rural citizens.”

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