Battle shifting as Covid threat stalks rural India

Over half the new cases in August come from 584 non-urban districts

NEW DELHI: More than half of all Covid-19 cases recorded in August came from 584 districts that are classified as “mostly rural” or “entirely rural”, reflecting the spread of the coronavirus disease from the large urban centres into the Indian hinterland where health care challenges, from testing to treatment, are much more significant.

The trend is very different from that seen in the initial months of the pandemic, when the cases were largely in the urban areas, especially the three metropolitan cities of Delhi, Mumbai and Chennai.

This Hindustan Times analysis is based on district-level data by How India Lives, which is available till August 24, although even a cursory look at the HT dashboard suggests that, if anything, this trend has been strengthening for weeks. The front lines of India’s fight against the viral disease have clearly moved.

Experts said the lack of adequate health infrastructure in villages will be a major challenge. “The first challenge that villages will likely face is of testing. Most of the RT-PCR labs are currently located in big cities or district headquarters, and are very rare if one looks for them at the subdistrict level. There is also the issue of the lack of medical equipment and physicians. Machines like pulse oximeters and radiology facilities such as good quality chest X-rays, which are crucial tools to monitor the health of Covid patients, are not as easily found in rural areas,” said Dr Suresh Kumar, medical director, Delhi’s Maulana Azad Medical College.

To be sure, there is a counter view as well: “There are reports of cases coming from rural areas, but the advantage that we have there is that population density is low because of which

cases can be identified, isolated, and treated early. In these areas, surveillance can be far better and also compliance, and that is instrumental in controlling spread of the disease effectively,” says Dr VK Paul, member, Niti Aayog, who also chairs one of the National Task Forces on Covid-19 management.

“Having said that, we have to be careful and concentrate on rural areas as some of the villages may suffer from lack of adequate health infrastructure to manage positive cases,” he added.

The analysis also shows that few of India’s 734 districts are untouched by Covid-19: More than 700 districts and the national capital have reported cases so far. When a nationwide lockdown was imposed on March 25, just over a hundred districts had reported cases (many of them just had one case). The number of affected districts was more than 600 by the end of May.

Experts said that the spread of the disease in rural pockets may lead to a long-drawn battle. “We’ve seen the disease spread like wildfire in cities such as Delhi, Mumbai and Chennai. But equally fast, the governments were able to bring the outbreak into relative control. What we are likely to see in villages will not be like this – it will be a slow- and long-burning fire, which will be much harder to contain.

But in general, villages are already disadvantaged because of their inadequate health care system, so this may end up becoming a much longer battle,” said Dr T Jacob John, professor emeritus and former head of virology at Christian Medical College, Vellore.

The analysis classifies districts into five categories based on the proportion of the rural population – entirely urban (under 20% of the rural population), mostly urban (20%-40% rural), mixed (40%-60% rural), mostly rural (60% to 80% rural) and entirely rural (over 80% rural population). The proportion of the rural population is based on the 2011 census (the latest data available).

According to the analysis, 55% of the about 1.4 million new Covid-19 cases reported in August (those cases where the district is known) have come from 584 districts in the last two categories. This was not the case earlier. Only 23% of new cases reported in April came from these districts. This share, though, has been steadily increasing every month – it was 28% in May, 24% in June and 41% in July.

As Covid-19 shifts away from the urban centres, 16 urban districts (15 districts plus Delhi) where the share of rural population is less than 20% reported only 13% of the country’s Covid-19 cases in August. More than 44% new cases reported in April, May and June came from these urban districts. In July, 23% of the cases came from these districts (See Chart 1).

The bulk of the rural challenge is likely to be centred around two states that have sizeable rural populations – Uttar Pradesh and Bihar – which have seen a rapid and steady growth of cases in the past few weeks. The two states, which together account for more than a quarter of the country’s population, are also among the states with the lowest testing rates in the country despite a recent jump in numbers in the past few weeks. Both have conducted a little over 20,000 tests per million of their population against the national average of around 28,000.

Nearly all major metropolitan cities in the country are districts among themselves, with the exception of Delhi, which consists of 11 revenue districts. However, the Delhi government does not release a district-wise breakup of cases, deaths and recoveries.

The move into the hinterland has also decreased the share of metros in new Covid-19 cases. For instance, about 40% of the country’s Covid-19 cases in June were being reported from only three metro cities – Delhi, Mumbai and Chennai. They accounted for only 6% of the new cases in August.

The number of Covid-19 cases reported in urban areas is still disproportionately higher than their population. The 16 districts which reported 13% of new Covid-19 cases in August are home to only 5.6% of India’s population. Similarly, the 584 districts where the share of rural population is more than 60% are home to 74% population, but reported only 55% of new Covid-19 cases this month.

The disproportionate role of urban areas is also reflected in the number of cases currently active in the country. Regions with the recent outbreaks generally tend to have a higher share of active cases. Of the 10 districts with the most active cases in the country, seven are city districts or districts that constitute a single city, and thus entirely urban. This can also be explained by two other factors: the number of cases in rural India are spread over a large number of districts; and at least some of the active cases are those from June and July.

The number of active cases — those still under treatment — directly reflects the pressure on the health care system in any region. It is calculated by subtracting the number of recovered patients and deaths from the total tally. As of Tuesday night, of the 3,229,351 total Covid-19 cases in the country, 704,672 (21.8%) were active, according to HT’s Covid-19 dashboard.

With over 44,717 cases out of the 150,207 cases in Pune active, the city tops this list. It is followed by Bengaluru with 34,877 cases active out of the 107,875 cases, and Thane, where 20,372 cases out of the 122,626 infections are active.

Delhi, which is the city with the most cases in the country, had 11,778 active cases as of Monday.

East Godavari (17,228 active cases as of August 23) and Chittoor (9,999 active cases), both in Andhra Pradesh; and Maharashtra’s Nashik (10,667 active cases) are the only three districts in the top 10 that are not entirely urban.

The only major city-district excluded from this tally is Hyderabad as Telangana does not release recovery and death data for the city.