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Vaccinating all Indians 'not possible', herd immunity via community spread only hope

By IMPRI Team

In continuation with the ongoing discussions on the Rural Realities around the country, the Centre for Habitat, Urban and Regional Studies (CHURS), Impact and Policy Research Institute ( IMPRI), New Delhi, organized a Panel Discussion on “Rural Realities: Telangana & Andhra Pradesh -- Practitioners’ Experiences in Tackling the Second Wave in Indian Villages”, as the second wave of coronavirus pandemic is engulfing the length and breadth of our country, India, and hitting the heartland of our country which is the rural areas.
The chair of the session, Prof Prakash Babu, Professor, Dean, School of Medical Sciences, University of Hyderabad, Hyderabad, Andhra Pradesh set the tone of the discussion by sharing his views that the Covid-19 pandemic has reached a stage of community spread in both rural and urban areas breaking all barriers of gender, age affecting a large population.
As per the report, there are more than 39.6 lakh people in rural areas infected with the Covid-19 pandemic in the second wave which is much more than the peak infection of the first wave in September 2020 resulting in rural places being affected equally in the second wave.
The issues which have widened the second wave crisis in rural areas are ignorance, malnutrition, and deficiencies. Since the symptoms of the first wave and second wave have been very different and difficult to be attributed to Covid and hence diagnosing it has become a complicated issue in rural areas. Also in rural areas, people lack awareness of the disease and monitoring symptoms associated with it.
The younger population in rural areas is much more affected. The lack of vaccination facilities in rural areas is also a major concern. The majority of people below 45 years are asymptomatic resulting in the high spread of the pandemic. People in rural areas are losing their lives due to a lack of minimum basic facilities.
Dr G Sridevi moderating the session indicated a major issue of lack of testing or hiding positive cases in Telangana as compared to Andhra Pradesh which conducted large-scale testing accompanied with more reliable data in terms of positive cases. Both the states failed in improving health infrastructure and health care facilities in terms of primary health care centres and availability of manpower and medicines.
Despite the pandemic, the expenditure of the government in health care was merely 3.3% in Telangana and 5% in Andhra Pradesh.
Major issues in related with the second wave catastrophic rise:
  • Lenient lockdown rules.
  • Failure of implementation of vaccination policy at both center and state level.
  • Failure of government in creating awareness among rural people towards vaccination drive.
  • Existence of preferential treatments at various levels i.e. village, Mandal or state.
  • Exclusion of vulnerable groups and rural areas due to online registration for vaccination.
  • Non-availability of oxygen, medicines, vaccines leading to a financial burden in rural and urban households.
  • Failure in creating a proper health care system in rural areas.
  • Discriminatory state support policies.
"There is a need for rural direct drive than online vaccination drives”, said Dr Sridevi, highlighting, the level of malnutrition in India is very high as per the National Family Health Survey (NFHS) report 14 states in India suffer from High levels of malnutrition where levels have gone alarming up for below 5 years of age children and 60% of women in their reproductive age suffer from moderate or acute anemia. These malnutrition indices have a great impact on immunity levels and cognitive skills leading to the death rate.
“Without addressing already existing issue of high levels of malnutrition and poverty, it’s difficult to tackle the current pandemic situation of the expected third wave”, she said.

Negligence and continuing challenges of infectious diseases

Dr Donthi Narasimha Reddy, Independent Consultant, Policy Expert, and SDG Campaigner talking about pandemic says that people are dealing with perceptions more than actual statistics and there is a need for much more fragmentation to understand the reality.
Presenting ground realities of Andhra Pradesh and Telangana Dr Donthi highlighted that rural health infrastructure has been neglected in the last two decades and there is more emphasis on privatization within public hospitals with diagnostic centers, sanitation services, etc. being privatized within public hospitals.
Talking about the history of diseases in Andhra Pradesh he stated that it has past infectious diseases like viral fevers, Japanese encephalitis, Chandipura Virus, Anthrax, HIV, Chikungunya, and Malaria. He further pointed following factors of poor vector management, mainstream neglect, and Andhra Pradesh incapability of responding to viral fevers as a complete chain and the vulnerability factor of malnutrition in rural areas as a major cause of the spread of infectious diseases in states since past.
Throwing light on the impact of Covid-19 on the livelihood of people he said that pandemic has impacted badly the livelihood of people doing small jobs due to lockdowns. Various handloom weavers in both states were affected severely.
Various risk factors driving deaths and disability in Andhra Pradesh are malnutrition, dietary risks, High blood pressure, and air pollution, water, sanitation and hygiene (WASH), occupational risks, etc. with malnutrition topping the chart.
“Lack of nutrition is a major issue in rural areas contributing too low immunity and high spread of the pandemic”, said Dr Donthi. Highlighting the number of Covid cases in Telangana, he added, the number of cases in urban areas is much more than in rural areas wherein Andhra Pradesh there is an equal amount of surge in cases both in rural and urban areas.
Dr Donthi highlighted various observations: 
  • The conception that infectious diseases are for the poor, rural, and tribals.
  • The annual feature of viral fevers in rural areas, especially tribal lands
  • Privatization-public investments being low.
  • Access to nutritious food.
  • Covid response – individuals, families, society, and government.
  • Fragmented Institutional chain.
“We have failed in bringing together institutional change in terms of identifying, diagnosing, treatment and also post-treatment of diseases and pandemic”, said Dr Donthi.

Prioritizing mental health during Covid-19

Dr. Varudhini Kankipati, Co-founder, InnerConnect, concentrating her talk on mental health and said that there is the scenario of fear-driven mental health related to Covid in place and secondly the fear of the impact of the pandemic on family and individual.
She further says that once fear precipitates from community to neighborhood then family and finally to individual a consistent feeling of helplessness arises. This consistent feeling of helplessness results in anxiety leading to depression, OCD symptoms, or a sense of hopelessness. Prolonged anxiety leads to other forms of severe mental and physical health like loss of sleep, appetite.
She also underlines that media should also take responsibility in showing hope instead of only showing catastrophe and effects of a pandemic on everyone which has huge repercussions on individual and community level. She also underlines the pivotal role of women in understanding the mental health of the family.
“The pandemic will have long-term mental issues and its repercussions will manifold over 7-8 year”, said Dr Varudhini Kankipati.

Inequality of distribution

Dr PBN Gopal, Chief of Critical Care and Senior Consultant Intensivist, Continental Hospitals pointed that the Telugu states were set before division in 2014, the whole socio-political and medical region for almost half-century was centered in Hyderabad.
The medical infrastructural and educational systems were not evenly developed in Telugu states. The Covid pandemic struck in such a situation where the medical facilities are widely variable both in public and private sectors in both states.
The results seen in the first wave of Covid are very much different from the results seen in the second wave. Reason being facing the first wave of Covid the response was national whereas facing the second wave of it the response is regional. “Covid-19 is every man’s disease but treatment facilities are not for every man”, said Dr Gopal.
He stated that there is no transparency in what people are getting and whether medical facilities have reached the last mile or not. Starting vaccination drive in inter pandemic period and lack of preventive measure to tackle the spread of the second wave are major issues.
He underlined that the second priority given in vaccination to elderly people was skewed and should have been given to migrant labourers. He dwelled upon that majority of the population in the second wave are younger, fitter, and sicker resulting in increased mortality. “The second wave is an iceberg phenomenon and we are seeing only the tip of it and lot is lying behind it", said Dr Gopal.
Talking about medical facilities Dr Gopal stated that testing, vaccination, and treatment are severely lacking in rural areas of both states. There exists a lack of central command in both states taking into account the availability of beds, Proportion of health care workers indicating a lack of data.
We need to follow triaging policy so that we can treat able men first, who can go out and serve the society on the other hand we are thinking about the sickest first which has the highest mortality and expenditure and the least outcome. There also exists no regulation of oxygen supply proportionately to the highest number of attendees’ hospital. Government lacks data on the number of patients in corporate, private, and public hospitals and statistics supply of oxygen from various non-government organizations.
“Where the disease is universal the treatment is urban, corporate, and metropolitan”, said Dr Gopal, highlighting, there exist non-pulmonary infections of various organs lungs, brains, intestine, and kidneys along with secondary infection. He further stated that the highest risk factor is obesity with obese and elderly people having high mortality in the first wave of the pandemic while the second wave of the pandemic has hit younger and sicker patients resulting in stagnant bed occupancy rates.
“Asymptomatic carrier rate is going to be either stagnant or may increase with the spread of disease and vaccination in coming days”, he said.

Need to revive civil society organizations

Throwing light on pandemic effects on rural livelihood Dr GV Ramanjaneyulu, Executive Director, Centre for Sustainable Agriculture, Secunderabad, said that the situation is much worse with people facing difficulties in getting finding work. The health facilities in rural areas are poor with public health facilities collapsing significantly in both states. The pandemic brought new challenges to rural areas where people are divided by caste and parties creating serious problems.
He dwelled upon that often the suggestions coming from civil society are taken as a political statement and create a political issue rather than trying to resolve it. The collapse of civil society initiative is due to government initiatives taking over civil societies leading to the disappearance of civil society organizations working at the grass-roots level.
Talking about the impact of the pandemic on health he says that it has a lot to do with mental strength as holding on to the desire to live in such a situation is most important. The misinformation and rumors associated with the pandemic have also created panic among people and hence information filtering is important to be carried out.
Mentioning about major conditions constituted in Telangana, she stated that there exist three conditions these are:
  • Over centralized party system.
  • Neo-liberal government mentality in all senses.
  • Dissemination of civil society organizations.
Dr A Suneetha, Coordinator, Anveshi Research Centre for Women’s Studies, stated that the non-acknowledgment of voluntary networks by the Telangana government has led voluntary organizations to rely on local authorities. While the government was okay with the distribution of rations in the Covid-19 situation the voluntary health networks were side-lined completely.
She said that suppression of data and information by the state has costed the state badly as major allocation given by the central government based on data given by the state has fallen short in meeting the needs. PHC Level reporting shows a high positivity rate and mortality rate which has not been disclosed in data.
She highlighted that media too has been suppressed by the government. There exist a kind of policy paralysis because of the image trap. There also exists a need for open isolation and quarantine centers as the disease is infectious and cannot be curbed by home isolation.
“The state government is more interested in managing its image rather than showing the ground realities of the state transparently”, said Dr A Suneetha.

Pertinent questions

Responding to a question on the availability of vaccination at the last-mile Prof Prakash Babu said that considering the existing disproportionality in production, supply, and demand in vaccination it will not be available to all the population even in the coming two to three years and the only hope is the hard immunity attained by the people after community spread.
“Mere technical fixes of vaccination cannot only solve the problem we need to look at the spectrum of solutions and can look for local solutions at rural level”, said Dr Donthi Narasimha Reddy.

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