Odisha’s real Covid-19 challenge lies in rural areas, say experts
On Saturday, the in-laws of a 25-year-old newly-wed woman went from one hospital in Bhubaneswar to another, frantically searching for a bed with oxygen facility. Swarnalata Pal, who got married last month, developed fever last week followed by a dip in her oxygen saturation levels leaving her breathless. Her family members first took her to a community health centre near the village, which referred her to Capital Hospital in Bhubaneswar, triggering a chain of refusals by private and government hospitals including AIIMS and SUM to admit her in absence of a Covid-19 positive test report. After eight hours of a fruitless hunt for treatment, she died the same afternoon.
While the administration ordered a probe into the circumstances leading to her death, it has served a rude reminder about the state’s healthcare system’s capacity to deal with the challenges posed by the second wave, especially in the rural areas. However, the authorities are keen to suggest that the situation is under control now.
“The situation is stable now. The daily count is hovering between 10,000 and 12,000,” said director of public health, Dr Niranjan Mishra.
While the state’s Covid test positivity rate may have come down slightly from over 20%, witnessed over the last 10 days, the fact that around 56% of the 2.9 lakh Covid cases registered in the second wave are from rural areas offer little comfort to epidemiologists and health experts.
Dr Binod Patro, professor of community medicine at AIIMS Bhubaneswar and a leading epidemiologist, said to fight the pandemic successfully, Odisha needs to move beyond its current focus on building big corporate type hospitals in cities and instead build 30-50 bed hospitals at block level with oxygen facilities and support staff.
“There is no point celebrating the fall in TPR as it would fluctuate and any fall in TPR has to be seen over a week. Currently, the testing is inadequate and so Rapid Antigen Tests need to be ramped up in villages as they will give results in 15 minutes. Once tested positive, they should be admitted to the block-level Covid hospitals. Only if the patient’s condition is serious then they should be shifted to Covid hospitals in nearby big cities,” he said.
Gouranga Mohapatra, the state convenor of Jana Swasthya Abhiyan, an NGO working in health sector, said compared to last year, the spread of Covid in districts like Khurda, Kalahandi, Nuapada, Sundargarh and western Odisha districts like Bargarh and Sambalpur has been very fast this year.
“When the second wave of the pandemic broke out in early April, the government did not get serious. While districts like Nuapara, Kalahandi and Sundargarh reported over 50% TPR, no institutional quarantine facility was available there. In villages, where large families have fewer rooms in houses, official quarantine centres are the best way to isolate infected patients to break the chain of transmission. But micro-containment was not done adequately, and a certain amount of complacency was visible in the health administration. With surveillance lacking, many people in villages may have succumbed to the pandemic,” said Mohapatra.
Traditionally, Odisha’s response to health crises has been far from ideal. In 2016, at least 93 children in tribal-dominated Malkangiri district died of encephalitis between September and November. A year later, 53 people died of Swine Flu.
Then there is the problem of severe understaffing. Of the 1,326 sanctioned posts of doctors in primary health centres, only 917 have been filled up, while in community health centres, there are only 253 doctors for the 1,529 posts sanctioned. In district headquarter hospitals, there are 1,094 doctors for the 1,427 posts. Similarly, there is severe understaffing of paramedical staff.
Dr Sarit Kumar Rout, additional professor of Public Health Foundation of India, said the pandemic may have exposed the underbelly of an already decrepit health infrastructure in rural Odisha. “Considering that we have more than one lakh active Covid cases right now, the current bed availability is just inadequate. As it is, the distribution of medical manpower is skewed in favour of urban areas. How would critical Covid patients get treatment in rural areas, where pulmonary doctors and medicine specialists are almost absent,” asked Rout.
Like several government hospitals in blocks, the Balipatna community health centre where the newly-wed woman was first taken to, does not have any Covid treatment facility though it is just 25 kms away from the state capital. The woman’s brother-in-law Niranjan Bhol said several people in the panchayat have Covid symptoms, but not all of them are getting tested. “Occasionally we hear of people dying of fever. Others who manage to travel for 25 km to hospitals in Bhubaneswar get tested there and if lucky get a bed in Covid hospitals there,” he said.
Cuttack district, which is among the top-5 districts with high Covid caseload, too has seen cases rising quickly in rural areas, Cuttack chief district medical officer (CDMO) Satyabrata Chhotray said around 4,000 of the district’s 7,800-odd active Covid-19 cases are in villages. “This time cases are quite high in blocks like Narsinghpur, but there are fewer doctors to treat them. While a small portion of the Covid patients need hospitalisation, still there is paucity of ICU beds,” said the CDMO.
Almost a month and half into the second wave of the pandemic, with 26 of the state’s 30 districts in red zone-- a district is classified as a red zone in the state if it has more than a thousand active Covid cases-- more than 80% of the 3,049 ICU beds in the state are occupied. Similarly, 608 of the 975 ventilators are occupied. People flocking to cities like Bhubaneswar, Rourkela, Bargarh and Sambalpur have little chance of getting an ICU bed or a bed with oxygen facility.
Microbiologists say the current TPR of 18.2% and 10,321 new infections may be the tip of the iceberg. There are likely to be many more unreported cases due to lack of tests.
The number of tests was below 50,000 for most of April and crossed that mark only a week ago. Bhadrak district, which reported TPR of 33.4% between May 10 and 16, tested about 12,426 samples while Balasore with TPR of 30% tested 18,664 samples. In several other districts, the testing is abysmally low with RT-PCR tests barely making up 20% of the total tests. Many districts like Nuapara and Nabarangpur don’t have RT-PCR machines and thus have to wait for 5-6 days for test results. By the time the results arrive, the Covid positive person’s condition is likely to have deteriorated significantly.
“Rapid Antigen Tests are being conducted in the rural areas, where the positivity rate is 40% to 50%, indicating high rate of infection. The main problem is lack of testing facilities in villages,” said Niroj Mishra, a senior doctor in Bhubaneswar.
Leading microbiologist Dr TM Mohapatra, who was earlier associated with the Indian Council of Medical Research (ICMR), said the state should have been testing at least 1 lakh samples every day. “As the current strain is very infectious compared to last year’s, tests should have been ramped up. If tests are delayed and the number of infections are not kept in check, the virus may mutate more making it difficult to contain in the next wave,” he said.
The state government could have utilised the time between January and March this year to get more labs. The decision to set up RT-PCR laboratories for Covid-19 testing in 16 district headquarters, with each lab costing ₹1.20 crore, was taken only last week and they may not be ready in time.
Very few experts believe the government’s claim that only 414 Covid patients have died in the second wave since April 1. RTI activist Pradip Pradhan said more than 3,200 Covid casualties were cremated at Bhubaneswar’s Satya Nagar crematorium between April and December 2020, while Odisha’s official Covid death toll was 1,873 last year. “If so many people were cremated last year at Bhubaneswar when the infection rate was not high, imagine what would be happening in the entire state this year,” said Pradhan.
Prodded by Prime Minister Narendra Modi to ramp up tests, Odisha on Monday said ASHA and Anganwadi workers will conduct house-to-house surveys from May 24 to detect persons with Covid symptoms and co-morbid conditions.
During an all-party meeting on Monday, chief minister Naveen Patnaik said 786 doctors and 5,137 paramedics will be appointed. Gaon Kalyan Samitis will be given ₹10,000 each to carry out Covid containment activities at the village level. It also promised an additional incentive of ₹1,000 per month and one-time assistance of ₹10,000 to ASHAs and Anganwadi workers to buy a bicycle, cupboard, slippers, an umbrella and a torch so that they could monitor home isolation cases.
Patnaik also declared that sarpanchs will continue to have the powers of district collectors in enforcing lockdown etc.
The decision to engage with the sarpanch may have come late. Amita Pattanayak, sarpanch of Bari gram panchayat in Simulia block of Balasore, does not think much of the decision. “Last time we were entrusted with running temporary quarantine centres in the early days of the pandemic. But several sarpanchs including me did not get reimbursed the money spent for those centres. Why should I start a quarantine centre now when there is no assurance of reimbursement,” she asked.