The Covid-19 pandemic started as an urban phenomenon in India. But now it is spreading at a faster rate in rural areas. An analysis by HT on August 26 had shown that 55% of the 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 spread of the pandemic to rural areas, mortality should have increased. The rural population of India is poorer compared to its counterparts. According to the 2011-12 Consumer Expenditure Survey (latest estimates available) the average monthly per capita expenditure was ₹ 1,430 in rural areas compared to ₹ 2,630 in urban areas. This is directly related to the ability to access health services. India has one of the highest out-of-pocket shares (62.4%) in the world’s total health spending (average 18.2%). The health infrastructure in rural areas is also significantly worse compared to urban areas. According to the 2019 National Health Profile, there were 1.2 government hospital beds for every 1,000 people in urban areas compared to just 0.3 in rural areas.
An analysis of HT based on data compiled by How India Lives yields a counterintuitive result. Rural areas appear to be improving in terms of fatality rate (CFR). CFR is defined as the cumulative number of deaths as part of the cumulative number of cases.
The analysis classifies districts into five categories according to the proportion of the rural population: entirely urban (less than 20% of the rural population), mostly urban (20% -40% rural), mixed (40% -60% rural ), mainly rural (60% to 80% rural) and completely rural (more than 80% of the 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 that of the districts in which they were formed. The analysis shows that the CFR drops dramatically from urban to rural districts. It is from 2.66% in the 16 “entirely urban” districts to a minimum of 0.98% in the 357 “fully rural” districts.
As a result of this variation, urban areas account for a disproportionate share of Covid-19 deaths. Forty-nine ‘fully urban’ and ‘mostly urban’ districts have reported 39% of India’s Covid-19 cases, but a 54% majority of the country’s Covid-19 deaths. Similarly, districts with the largest rural population have a higher proportion of confirmed cases and a lower proportion of deaths.
What explains the drop in CFR from urban to rural areas? Experts are divided on the issue. Some believe this is the result of poor data collection on the cause of death in rural areas, while others think that the cause could be lower comorbidity and a relatively younger population in rural areas. The truth, as is often the case, could be somewhere in between.
Dr. T Jacob John, professor emeritus and former director of virology at Christian Medical College, Vellore, said poor data reporting could be a possible reason. “At best, India’s health management system does not monitor deaths. Also, the quality of the data will be much better in urban areas than in rural areas, ”he said.
Data from the Ministry of the Interior support this line of argument. While 86% of deaths are recorded in India, the cause of death is medically certified in only 21% of recorded deaths. A statewide analysis shows that the proportion of medically certified deaths in total recorded deaths was lower in states that have a higher proportion of “primarily rural” and “fully rural” districts. Of India’s 584 “mostly rural” and “fully rural” districts, 211 are in five states: Uttar Pradesh, Bihar, Assam, Madhya Pradesh and Odisha. These states are among the laggards in terms of the proportion of deaths that have a medically certified cause.
“A lot of non-Covid deaths in rural India are underreported, do we know this is not true for Covid-19 either?” asked Satyajit Rath from the Indian Institute of Education and Scientific Research, Pune. “It is possible that we are underestimating the deaths … It is very possible that confirmed Covid-19 patients who stay at home die there and are not reported,” he said.
The experts also cited a lower proportion of the population with comorbidities in rural India as a possible reason for the lower death rate there. “People in the villages are relatively healthier and the prevalence of diseases such as diabetes and high blood pressure is lower in rural areas,” said Dr. Suresh Kumar, medical director of the Maulana Azad School of Medicine in Delhi. “People in rural areas generally have a healthier lifestyle, breathe cleaner air, have good food and also do a lot of physical activities,” he said. People with diseases like diabetes are at higher risk of developing serious consequences and dying from Covid-19.
According to the fourth National Family Health Survey, conducted in 2015-16, diabetes and hypertension were more prevalent among both men and women in urban areas. For example, in urban areas, 2.6% of women and 2.1% of men reported diabetes compared to 1.2% of women and 1.5% of men in urban areas. rural zones.
Indeed, even when the prevalence of diseases such as diabetes is lower in rural areas, life expectancy at birth (the number of years a newborn 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 2011 census data shows that rural areas in India have a slightly higher proportion of younger population than urban areas. For example, almost 52% of people in rural areas were under 24 years old, while this figure was 46% in urban areas. But the proportion of people over 50 was similar in both urban and rural areas, around 16%.
Other evidence suggests that data from rural districts may not be as good as data from urban areas. The “completely rural” districts have not caught up with the trend of reducing death rates in India.
In the three months between June 1 and September 1, death rates declined in all district groups except the 357 “completely rural” districts, where it hovered around 1%. It fell by almost a percentage point elsewhere. Here, only the period after June 1 has been compared, as all district groups had at least 15,000 confirmed cases of Covid-19 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 better combat the pandemic.
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