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 organized a Panel Discussion onRural 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; Renu Thakur, Secretary, Association of Rural planning and action, Askote, Pithoragarh, UK; Shankar Datt, Founder member and Treasurer, Shramyog, Dehradun, UK; Dr Anil Jaggi, Founder, Venture, Dehradun, UK.
Dr OP Bhuraita, Chairman, State resource centre, Himachal; 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, Himachal.
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 contextualized the session by giving a brief socio-historic background of Himachal Pradesh and Uttarakhand by stating that both these states are predominantly rural. Historically, there has been focus on health sector in both of these states. State was the largest investor in 90s as a result there are not many private hospitals in Himachal. Also there is a deep connect among the people in both of these states culturally.
The joy of learning is as indispensable in study as breathing is in running
According to Mr Tikender, there is software of people who are more hearted and connected to each other in hilly sates. Old customs and cultures bind people together. There is an ongoing debate b/w “Science vs old customs” and doctors are seen as an avatar of god in India. According to Mr Tikender, Negotiation skills are crucial at this point of time.
A brief PPT was presented by the team of IMPRI to understand the data analytics of both these states. Himachal Pradesh and Uttarakhand leads in standard of living index. Case fatality rate, doubling rate and positivity rate is low in both states. Kumbh mela organized in Haridwar during the midst of a pandemic has proved to be deadly. Oxygen and Vaccine shortages and subsequent global tenders has putted health infrastructure under a lot of stress.
There is a manifold increase in patients, cases rising to 5,000 per day. Primary health care centres (PHCs) and Community health centres (CHCs) are less and inadequately equipped with resources in rural areas. A point of concern is that people in rural areas are ignorant about symptoms of COVID and perceive it as a normal illness.
Educating people is very important as burden of disease is increasing exponentially. No monitoring system and surveillance mechanism can add to the problems arising of COVID as according to Dr PC Negi, many patients are admitted late to hospitals and there is no monitoring of oxygen at the home level 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. ASHAs and Anganwadi workers role is also of great importance as they are agents of awareness in rural areas. Active surveillance is the need of the hour. Strengthening institutions is of utmost significance and role of panchayat is pivotal. .
Policy Advocacy and Research
Renu Thakur focused started her speech by highlighting that people were scared in the first wave. There was considerable focus on migrants, quarantine centers, livelihood problems, packages and schemes in the first wave and lock down was really strict. Ration is a huge problem but community kitchens support has been tremendous.
According to Renu Thakur, there are many gaps in the policy making of India. Second wave’s focal point has been on curfew, 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 the people as people are scared of testing in rural areas. There are very less COVID centers.
There needs to be proper information about vaccine numbers as people come from far away areas, there is huge mismanagement. Infection rate is alarming in hilly areas.
According to Renu Thakur, COVID-19 is a medical disaster as there is no infrastructure and medicines available. Policy advocacy and research is the need of the hour. We need to motivate people to get vaccinated as people believe in rumours quite easily in rural areas. Accessibility in hilly areas is a major issue.
Digital illiteracy is a huge hurdle as registrations of vaccine are held online, leaving people without smart phones in despair. No remuneration to panchayat heads has been given. Quarantine centers aren’t equipped. Linking people to major areas is important.
People coming with patients are also at the risk of catching the virus, association of rural planning and action has been providing packed food to the family members who accompany patients. ASHA workers have to be equipped. Logistics is the major issue which needs to be catered.
Dr Anil Jaggi underlined that there are 1500 per day cases in Dehradun. Migration is a huge issue in Uttarakhand. 2000 villages have been declared as ghost village because people are moving out for jobs and opportunities. Also infrastructure is very old in rural areas.
Dr. Anil expressed his disappointment over the fact that doctors perceive posting in rural areas as punishment posting and don’t want to work in remote areas. There is a problem of transportation in rural areas as there is a pertinent question of how people will come for treatment from rural to urban areas. 40 lakh people attended Kumb but only two lakh were tested, as a result many sadhus too died.
Dr. Anil further talked about “Uttarakhand Dialogue program” wherein administration is utilizing corporate social responsibility funds of the companies. All stakeholders need to be involved. The core of the problem is that there are no clear guidelines and consortium by the government.
Governance part is totally missing. Initially, COVID was perceived as a city disease by the rural people, hence they were not prepared for second wave. Coordination and synchronization is needed by the government. Resident welfare association are too 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 mind-set.
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 16 September 2020 and in second wave there has been a rapid upsurge in April 2021 which India was not able to control. Hamirpur, Mandi, Kangra, Solan were severely impacted in Himachal Pradesh.
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 similar to cold which is really worrying as we cannot take this virus lightly. 10, 000 to 18,000 COVID positive cases were detected in a week in February which is alarming.
According to Dr Mokta, we need to pay more attention to the 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 the mask 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. Everybody has to work together. Dr Mokta suggested following measures to contain the spread of this virus.
2. Social -distancing
3. Good hygiene
4. Vaccination: More than 60% vaccinated in Himachal Pradesh.
Rural Areas Ground Reality
Mr. Shankar Datt advised that there had been a sudden upsurge in rural areas. Isolating people who come from outside is a main problem as not enough space is available. Mr Shankar’s organization Shramyog has made 4-5 houses in 50-53 villages for isolating people who come from outside which is praiseworthy.
ASHA workers help has helped to build deep connect among the people in rural areas as their role in distributing oxy-meters, thermometers and creating awareness is very significant. Locals help is also very important during these hard times.
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 is also a major issue in the villages.
According to Mr Shankar, people are very closely knitted to each other in villages as a result when somebody dies; people can’t stop themselves to visit the deceased’s family to grieve the loss.
He also highlighted that there are very small things in villages which needs due consideration. People are also facing money crunch. There are many issues in rural areas, for instance, problems faced by pregnant women. Supply of medicines too is very crucial as there are not enough medical stores in rural areas.
Micro Level Policies
Prof Sas Biswas enlightened the conversation by pointing to how crucial Policy research is. According to Prof Sas, Socio-economic survey in villages should be conducted because data collection is important. More attention needs to be on micro-level policies. Migrants, weddings and funerals are the major causes of the spread of this deadly virus. We have to develop a road map.
According to Prof Sas, ghost villages are now deserted; they 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 and from our traditional systems. What should be the post-COVID world and what are the sustainable mechanisms is a question that needs deeper attention and more discussions.
Psychological First Aid
Dr Om Prakash Bhuraita warned that In Himachal, there is low population density but high habitation density which translates into higher cost of delivering goods and services. According to Dr Om, it is small things that are important. In rural areas, people are in fear and denial mode. The problem lies in hospital mismanagement. Info deficit and trust deficit in rural areas is a huge problem that needs to be addressed. According to Dr Om, following are the major problems:
- Vaccination is less. Only 4 lakh people have been given second doses. Further there are no slot announcements of vaccines and Internet connectivity problem is a big hurdle in the registration process of vaccines in the online mode.
- Testing problems, reports come after six days which is problematic.
- Lack of Physiotherapists in COVID wards
- Attendants are less
- Mental health care, psychological first aid is needed. Physical distancing has to be practiced not social distancing.
- Lack of oxygen despite so many 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.
- Increase attendants and vacancies.
- Decentralise services.
- Monitoring oxygen at home level increased.
According to Dr Om, government has failed to provide basic amenities to the people, thus it needs to look deeply into its mechanisms. Social Vaccine is the need of the hour.
Misconceptions in our understanding need to be addressed. According to Manshi Asher: Himachal Pradesh’s health infrastructure is a kind of image building. There are severe regional imbalances. Roads aren’t also there in some villages till now. PHCs are ill equipped. Focus has to be on counseling as there is wide prevalent social stigma. There has been 60% rise in suicides and increase in anxiety during the pandemic as there in uncertainty regarding the future in youth population. We have to address the fear and train health-line workers.
Economy is dependent on migrant labour in Himachal, thus government needs to be more alert in its approach. People are going out for better opportunities from Himachal. Invisible group like- Tribal and LGBTQ+ needs attention. Isolation in public hospitals is also a cause of concern. Manshi concluded by asserting that learnings need to be remembered. Data needs to be collected, even labour commission doesn’t have it. Coordination with civil society groups is of substantive value!
Dr Mokta answered the question regarding masking; he said that people should do double masking to safeguard themselves in an effective manner. Psycho-social issues also needs to be addressed, 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 today needed 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 and within community is very important at this juncture. Government has to be an enabler in creating social awareness. Rural and urban areas lie at a continuum.
Dr PC Negi provided way forward by underlining that health has been neglected. 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 we need public support as highlighted by Shankar Datt. This is a learning experience for all of us! Health and education are very important pillars of a society to become resilient and responsive. Holistic approach needs to be adopted.