Is Covid-19 less fatal in India’s villages?
The Covid-19 pandemic started as an urban phenomenon in India. But it is now spreading at a faster rate in rural areas. An HT analysis on August 26 had shown that 55% of new Covid-19 cases reported in August were in districts where the rural population had a share of more than 60%. These districts had reported only about 23% of new cases in April.
With the pandemic spreading to rural areas, fatality should have gone up. India’s rural population is poorer compared to their counterparts. According to the 2011-12 consumption expenditure survey (latest available estimates) average monthly per capita expenditure was ₹1,430 in rural areas compared to ₹2,630 in urban areas. This has a direct bearing on ability to access health services. India has among the higher share of out of pocket expenditure (62.4%) in total health spending in the world (average 18.2%). Health infrastructure in rural areas is also significantly worse compared to urban areas. According to the National Health Profile 2019, there were 1.2 government hospital beds per 1000 people in urban areas compared to just 0.3 in rural areas.
An HT analysis based on data compiled by How India Lives throws a counter-intuitive result. Rural areas seem to be doing better in terms of case fatality rate (CFR). CFR is defined as the cumulative number of deaths as a share of the cumulative number of cases.
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). The proportion of rural population in 94 districts created after 2011 has been assumed to be the same as the districts they were carved out of. The analysis shows that CFR drops sharply from urban to rural districts. It is 2.66% in the 16 ‘entirely urban’ districts to as low as 0.98% in the 357 ‘entirely rural’ districts.
As a result of this variance, urban areas account for a disproportionate share of Covid-19 deaths. Forty-nine ‘entirely urban’ and ‘mostly urban’ districts have reported 39% of India’s Covid-19 cases but a majority 54% of the country’s Covid-19 deaths. Similarly, districts with higher rural population have a higher share of confirmed cases and a lower share of deaths.
What explains the fall in CFR from urban to rural areas? Experts are divided on the issue. Some believe this to be a result of poor data collection on cause of death in rural areas, while others think lower co-morbidities and a relatively younger population in rural areas could be the reason. The truth, as is often the case, could be somewhere in the middle.
Dr T Jacob John, professor emeritus and former head of virology at Christian Medical College, Vellore, said poor data reporting could be one possible reason. “In the best of times as well, India’s health management system does not monitor deaths. Also, the quality of data will be much better in urban areas than in rural areas,” he said.
Data from the ministry of home affairs support this line of argument. While 86% of deaths are registered in India, the cause of death is medically certified in only 21% of registered deaths. A state-wise analysis shows that the share of medically certified deaths to total registered deaths was lower in states which have a higher share of ‘mostly rural’ and ‘entirely rural’ districts. Of the 584 ‘mostly rural’ and ‘entirely rural’ districts in India, 211 are in five states – Uttar Pradesh, Bihar, Assam, Madhya Pradesh and Odisha. These states are among the laggards in terms of the share of deaths that have a medically certified cause.
“A large number of non-Covid deaths in rural India go unreported, do we know that it is not true for Covid-19 as well?” asked Satyajit Rath of the Indian Institute of Science Education and Research, Pune. “We may be undercounting deaths... It is quite possible that confirmed Covid-19 patients staying at home might die there and not be reported,” he said.
Experts also cited lower share of population with co-morbidities in rural India as a possible reason for lower fatality rate there. “People in villages are relatively healthier and prevalence of diseases such as diabetes and high blood pressure is lower in rural areas,” said Dr Suresh Kumar, medical director at Delhi’s Maulana Azad Medical College. “People in rural areas generally have a healthier lifestyle, they breathe cleaner air, have good food and also do a lot of physical activities,” he said. People with diseases such as diabetes are at a higher risk of developing serious consequences and dying due to Covid-19.
According to the fourth National Family Health Survey, conducted in 2015-16, diabetes and hypertension was more prevalent among both men and women in urban areas. For example, in urban areas, 2.6% women and 2.1% men reported diabetes compared to 1.2% women and 1.5% men in rural areas.
To be sure, even as the prevalence of diseases such as diabetes is lower in rural areas, life expectancy at birth – the number of years a new-born can expect to live – is higher in urban areas (72.4 years) than in rural areas (67.7 years).
The government does not release data on the age-structure of patients at the district-level. However, the Census 2011 data shows that rural areas in India have a slightly higher proportion of younger population than urban areas. For example, nearly 52% of people in rural areas were under 24 years of age while this figure was 46% in urban areas. But the proportion of persons above 50 years old was similar in both urban and rural areas, about 16%.
Another piece of evidence suggests that data coming from rural districts might not be as good as its urban counterpart. The ‘entirely rural’ districts have not caught up with the trend of dropping fatality rates in India.
In three months between June 1 and September 1, the fatality rates dropped in all groups of districts except in the 357 ‘entirely rural’ districts where it hovered around 1%. It dropped by nearly one percentage point elsewhere. Here, only the period after June 1 has been compared as all groups of districts had at least 15,000 confirmed Covid-19 cases by then.
Even if rural India is less vulnerable to Covid-19, at least in terms of deaths, there is merit in pushing for better data collection and monitoring to fight the pandemic better.