The vast majority of coughs and fevers are treated by informal sector providers. (Ilustration by C R Sasikumar)
In just a few weeks, the novel coronavirus disease (COVID-19) went from being an unknown entity to the largest problem we’ve faced in India in recent history. But the real worry is when the virus enters the community transmission stage in rural areas.
Community transmission of the coronavirus is already happening in India; to assume that no one infected by a traveler has yet passed it on to others is just naïve. Debating about whether the epidemic is still in stage two or three misses the point. The virus is here and the epidemic is growing exponentially, and this means, expect a staggering increase in the number of cases in the coming days and weeks. The reported data so far shows the beginning of an exponential growth of this epidemic.
To understand the seriousness of what exponential growth could mean, consider a large pond with waterlilies that double in number everyday. Now imagine the pond is covered with lilies, millions of them. How long does it take for the pond to go from being half empty to fully covered? One day. Even more stark, just five days before the pond is fully covered, just over 6 per cent of the pond is covered with lilies. This is the problem with exponential growth — it is too slow and then too fast. By the time we see it, it is too late.
My objective today is to bring attention to a major chink in our armour and to offer suggestions on how policymakers might respond proactively to stem the tide. The three main things to bear in mind are: First, two-thirds of India lives in rural areas. Second, the quality of healthcare available to them is staggeringly poor, and third, the most common symptoms of COVID-19 are cough, fever and shortness of breath. We need to plan ahead to mitigate a potential epidemic in these areas because it is merely a matter of time (weeks, not months) before this becomes our biggest collective challenge.
Because the coronavirus arrived in India with international travellers, most cases so far have been in cities. But not much longer. Family members, extended contacts, and household workers have been infected. A major event that has happened is the dramatic contraction of economic activity in cities which has pushed migrant labourers back in droves to their villages in rural Bihar, Uttar Pradesh, and other states, potentially carrying the virus back home.
Over 70 per cent of primary care visits in India happen in the private sector. Furthermore, in rural areas in states like Bihar, Madhya Pradesh, and Uttar Pradesh, unqualified healthcare providers — what we call “informal sector providers” — provide care for over 75 per cent of primary care visits. Studies, including several that my co-authors and I have conducted, show that the quality of care available to people in rural parts of India is staggeringly poor. Providers in these areas have very low levels of knowledge and they often do even less than they know — what we refer to as “know-do” gaps. As a result, we find providers frequently under-prescribing the right treatment and over-prescribing harmful ones even when they know better. We see similar patterns for a number of conditions including diarrhoea, pneumonia, maternal health, tuberculosis and other conditions in a wide range of settings. Providers with advanced medical training working in large tertiary centres do better. Sadly, these are not representative of the typical doctors or healthcare settings that most people in India can access, because two-thirds of India lives in rural areas.
If — or perhaps when — rural areas start seeing transmission, we would expect an uptick in the number of people suffering from cough, fever, and shortness of breath. None of these, however, are exceptional symptoms. In fact, tuberculosis, which also presents with cough (although not dry as with COVID) and fever, is quite common: India, after all, accounts for over 27 per cent of new TB cases globally.
The vast majority of coughs and fevers are treated by informal sector providers. Their clinics, very quickly, can become sites of transmission unless providers know what to expect, how to protect themselves, and how to prevent transmission. These providers will not have access to protective equipment. They have no idea about how to recognise or manage COVID cases if they show up in their clinics. Prescribing the common treatments they offer (typically a cocktail of antibiotics, cough syrups, fever medication, and pain killers) might offer some relief, but it is just a matter of time before many of these cases will need hospitalisation and ICU care. If that happens the health system will be totally overwhelmed because India just does not have enough ICU beds to meet that demand.
Now, consider an alternate scenario where the provider decides that it is safer (for themselves) to just refer all cases that have fever, cough, and shortness of breath, to larger urban centres for testing and consultation. The massive demand will again overwhelm the limited capacity of the system. Furthermore, if suspected positive patients from rural areas try to travel to urban centres to get tested, this can undermine efforts to limit transmission.
If all this sounds like trouble brewing, that’s mostly correct. But there is still time to get ahead of this challenge. The three pronged approach that I would recommend is as follows: First, prepare healthcare providers for what is coming; second, educate patients about what coronavirus is and how to deal with it; and third, make strategic investments in creative surveillance systems that can help get ahead of the epidemic.
Informal sector providers are untrained, and hence will need clinical guidelines that are in local language, and more accessible ones than are currently available from the Ministry of Health and the WHO. I expect resistance from the formal medical establishment and some doctors, but this is not a time for a turf war. We could leverage the presence of a vast network of medical representatives of the pharmaceutical industry to reach informal providers. It is possible to develop videos in local languages to inform providers about safety and prevention.
Educating patients about the illness to avoid panicking and overwhelming the health system with every fever or flu will be critical. In the absence of clear information aimed at ordinary citizens from reliable sources, social media is currently rife with fake remedies and misinformation. The collaborative effort between the health ministry and WhatsApp is an excellent step in this direction, and needs to be publicised widely.
Finally, trying to chase this epidemic is futile — it will move faster than any system can respond. We need to put in place a system of surveillance to help policymakers learn where the epidemic could be peaking in the next week. Creative solutions such as digital surveillance systems based on self-reporting of symptoms using the wide cell phone coverage in India have the potential to be a second-best solution that can be mobilised immediately. Learning about a significant uptick in symptoms can help policymakers identify potential hotspots of transmission in order to plan and coordinate delivery of more testing kits and drugs for palliative treatment. It will not put an end to the epidemic, but it is the best chance we have to prevent an early system failure.
The writer is associate professor of public policy, economics, and global health at Duke University