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 Table of Contents 
INVITED EDITORIAL
Year : 2020  |  Volume : 9  |  Issue : 4  |  Page : 1792-1794  

Restricting rural-urban connect to combat infectious disease epidemic as India fights COVID-19


1 Department of Community Medicine, Himalayan Institute of Medical Sciences (HIMS), Dehradun, Uttarakhand, India
2 Director, Generating Research Insight for Development (GRID), New Delhi, India
3 President, Academy of Family Physicians of India, Rishikesh, Uttarakhand, India
4 Department of Biochemistry and Molecular Biology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
5 Department of Community and Family Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
6 Director and CEO, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Date of Submission24-Mar-2020
Date of Decision29-Mar-2020
Date of Acceptance31-Mar-2020
Date of Web Publication30-Apr-2020

Correspondence Address:
Dr. Ajeet Singh Bhadoria
Department of Community and Family Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jfmpc.jfmpc_451_20

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  Abstract 


With declaration of 2019 novel coronavirus disease (COVID-19) as a pandemic on 11 March 2020 by World Health Organization, India came to alert for its being at next potential risk. It reached alert Level 2, i.e. local transmission for virus spread in early March 2020 and soon thereafter alert Level 3, i.e. community transmission. With on-going rise in COVID-19 cases in country, Government of India (GoI) has been taking multiple intense measures in coordination with the state governments, such as urban lockdown, active airport screening, quarantining, aggressive calls for 'work from home', public awareness, and active case detection with contact tracing in most places. Feedback from other countries exhibits COVID-19 transmission levels to have shown within country variations. With two-third of Indian population living in rural areas, present editorial hypothesizes that if India enters Level 3, rural hinterland would also be at risk importation (at least Level 1). Hence, we have to call for stringent containment on rural-urban and inter-state fringes. This along with other on-going measures can result in flattening curve and also in staggering 'lockdowns', and thus, helping sustain national economy.

Keywords: COVID-19, pandemic, rural-urban disconnect


How to cite this article:
Mishra S, Mohapatra A, Kumar R, Singh A, Bhadoria AS, Kant R. Restricting rural-urban connect to combat infectious disease epidemic as India fights COVID-19. J Family Med Prim Care 2020;9:1792-4

How to cite this URL:
Mishra S, Mohapatra A, Kumar R, Singh A, Bhadoria AS, Kant R. Restricting rural-urban connect to combat infectious disease epidemic as India fights COVID-19. J Family Med Prim Care [serial online] 2020 [cited 2021 Feb 26];9:1792-4. Available from: https://www.jfmpc.com/text.asp?2020/9/4/1792/283432



On 30 January 2020, World Health Organization (WHO) declared 2019-novel coronavirus (nCoV) disease (COVID-19) epidemic as Public Health Emergency of International Concern (PHEIC) under International Health Regulation (IHR).[1] It was the same day that India reported its first COVID-19 positive case – a student from Wuhan University (China) on vacation at his hometown in Kerala.[2] Since its start in December 2019 in Wuhan, China, the disease spread very quickly beyond country's boundaries. Today, around 199 countries and territories are seen affected by this pandemic.[3] Beyond China, the virus quickly spread and overwhelmed healthcare capacities even in high-income countries. Presently, United States of America (USA), Italy, Spain, Germany, Iran, France, United Kingdom, and Switzerland are worst COVID-hit countries.[3] To latest, absolute number of confirmed COVID-19 cases has crossed above 0.6 million worldwide [3], killing nearly 3 times as many people in 8 weeks than Severe Acute Respiratory Syndrome (SARS-nCoV) did in 8 months.[4]

On 11 March 2020, WHO declared COVID-19 as a pandemic.[1] India was the next country in line to be at high risk. Since then, India had scaled up screening at airports for those with travel history to countries that were afflicted by COVID-19. But almost after a month of no cases, suddenly in early March 2020, we reached Level 2 of COVID-19 local transmission which implied that close contacts/household members of those infected were at risk.[5] As of today (i.e. 28 March 2020), 933 individuals, both domestic and repatriated, have tested positive for COVID-19[3] with more than 50,000 populations already under surveillance [6]. Presently, Maharashtra is worst hit with 177 cases followed by Kerala (168), Karnataka (55), Uttar Pradesh (54), Rajasthan (52), Telangana (46), Gujarat (44), Delhi and Punjab (38), Tamil Nadu (34), Madhya Pradesh (30), Jammu and Kashmir (20), Haryana (19), West Bengal (15), Andhra Pradesh (14), Ladakh (13) with count adding up fast.[7] There is a high probability that we are in Level 3, i.e. community transmission, which means that people in different parts of country are testing positive but it is no longer possible to suggest who they got it from and how. This suggests that entire population of 1.3 billion is at risk. This can in due time easily overwhelm our health resources. Thus, it calls for interventions that are disruptive not just for virus transmission, but also for way we respond as a country.

To tackle unprecedented situation, the government of India (GoI) in coordination with State Governments has been taking multiple intense measures, viz., active airport screening, quarantining, provision of active 'work from home', scaling up efforts at public awareness and communication, and active case detection with even contact tracing in most places.[8] To further contain community spread of this contagion, all non-essential inter-state movement of transport services within India has been restricted with immediate effect.[8] On March 22 2020, India observed '14-hour self-quarantine' or 'Janata curfew' following Hon'ble Prime Minister's addressal to nation on 19 March 2020 as a measure to separate/restrict movement/activities of public at community level along-with on-going practice of one-meter social distancing.[8] The very same day, GoI announced complete locking down of 75 districts across India. Many States/Union Territories imposed Section 144 of India's criminal procedure code that restricts assembly of more than four people in public areas at any point of time, but are following suit with locking down major cities and districts one after other. Today, as we write this piece, protective and concerned Hon'ble PM announced a pan-India lockdown for the next 21 days.[9],[10] This is first time ever that India goes under complete lockdown for such a long time. This sets precedence for World what a powerful democracy and united peoples we are! In these testing times, country's anxiety levels could shoot up and economic challenges evolve. Still, this is much likely to help in flattening curve, bidding more time for healthcare preparedness, weaving optimism around changing weather conditions and developing a (questionable) herd immunity leveraging our demographic structure as a young population. Strategy will certainly be revisited and reviewed as COVID-19 situation unfolds in our country. Despite all above measures, India fears to be in Level 3, implicating active community transmission of virus and an exponential increase in number of cases that country is not well-equipped to handle.[5]

Since 15 February 2020, Indian Council of Medical Research (ICMR), New Delhi, has been closely monitoring for presence of community transmissions in India. Of 826 random samples tested, none was positive for nCoV.[11] Notwithstanding study methods and its sample size, it also suggests that situations may not be at equal risk levels across country. There is a rumor spreading in India that COVID-19 is a 'rich-man disease' and poor stands protected.[12] Even as this is sheer ignorance at play, could it also mean that community is hinting at invisible 'fault lines' that could be acknowledged to stratify our interventions. After all, isn't it a rich-man disease to start with – affecting only those who could afford to travel abroad and also access healthcare services for testing! Exclusive interventions by stratified between urban rich and poor may not be feasible since these are much intricately embedded into one another for coexistence. But are their other chasms that could be utilized as defenses? Yes, there is at least one such potential point of intervention – urban and rural (dis) connect!

It is primarily for the reason that about two-third of Indian population lives in rural areas.[13] A careful examination helps appreciate that urban and rural India can be considered as two independent yet cooperating models.[14] National Rural and Urban Health Missions, Urban and Rural Water supply/drainage systems and so on stand to validate this. Unlike urban India, rural areas have been fairly conserved with quite predictable ways of life. Some of these for example, preference for hot-served food, longer hours of sun-exposure, lesser overcrowding, ventilated houses, limited practice of handshaking hold distinct advantages for protection against COVID-19. Our public programs and policies have also traditionally been rural centric and this has led to a fairly self-sustaining administrative arrangement across sectors such as agriculture, education, rural livelihood, roads and transportation, etc., with penetration.[15]

For health, we have an extensive meshwork of primary and secondary health care services, community outreach through cadres of frontline workers, monitoring, data capture, tracking and bidirectional feedback system.[15] District being focus of decentralized planning under National Health Mission, there is a provision that sectors could act in convergence and with facilitation from Panchayati Raj Institutions (PRIs).[15] Agriculture continues to engage almost half of India's total workforce and contribute to almost 17% of its Gross Domestic Product.[16] With services and manufacturing sectors being impacted by lockdown, stratified approaches for urban and rural areas could help take off at least some proportion of economic burden and sustain longer period of restrictions in urban centers.

We have some proof of concept that urban centers could be locked down with success while sparing rural areas such as cities in Maharashtra could do it as in Delhi NCR, Odisha, Bihar and West Bengal around 21st March 2020, when only selective some of their major cities (urban) as well as some districts (rural and urban) were locked-down. With major urban centers in country being at Levels 2 and 3 of COVID-19 transmission,[17] and rural areas likely being at Level 1, preventive strategies should now be decentralized to district level. Coexistence of various levels of transmission of COVID-19 within the country is evident from data in USA and elsewhere.[18] This will also strengthen districts for developing their contextual combat strategies against COVID-19 given their respective access to resources, especially for tertiary healthcare to develop local monitoring and response capacity if eventuality spikes.[15] We should have capacity to quickly collate and respond to local data, a platform that Integrated Disease Surveillance Program readily provides.[19]

PM's call for complete lockdown of country limits in-country movement and gives opportunity to prepare and implement this strategy. It is upon states to appreciate the looming danger of COVID-19 and implement guidance effectively, but if they could we could protract our fight against COVID-19 to a time zone when we are better prepared. We do have a good hope!

Acknowledgements

None.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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World Health Organization. Rolling Updates on Coronavirus Disease (COVID-19). Updated 20 March 2020. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/events-as-they-happen. [Last accessed on 2020 Mar 28].  Back to cited text no. 1
    
2.
Unnithan PSG. Kerala reports first confirmed coronavirus case in India. India Today 2020. Updated: 2020 Jan 31. Available from: https://www.indiatoday.in/india/story/kerala-reports- first-confirmed-novel-coronavirus- case-in-india-1641593-2020-01-30. [Last accessed on 2020 Mar 22].  Back to cited text no. 2
    
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Worldometer: COVID 19 Coronavirus Pandemic. Available from: https://www.worldometers.info/coronavirus/#countries. [Last accessed on 2020 Mar 28].  Back to cited text no. 3
    
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National Centre for Disease Control. Novel Coronavirus Outbreak in China: Travel Advisory to Travelers Visiting China. New Delhi, India: Director General of Health Services. Ministry of Health and Family Welfare. Government of India. Available from: https://ncdc.gov.in/WriteReadData/l892s/34827556791580715701.pdf. [Last accessed on 2020 Mar 28].  Back to cited text no. 4
    
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Press Trust of India. Coronavirus: 54,000 People Across India Under Community Surveillance, Says Government. All India 2020. Available from: https://www.ndtv.com/india-news/coronavirus-54-000-people-across-india- under-community-surveillance- says-government-2196367. [Last accessed on 2020 Mar 28].  Back to cited text no. 6
    
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Ministry of Health and Family Welfare. Department of Health and Family Welfare. Government of India. Available from: https://www.mohfw.gov.in/. [Last updated on 2020 Mar 28].  Back to cited text no. 7
    
8.
Government of India. Letter to Chief Secretary. Cabinet Secretory. New Delhi: Ministry of Health and Family Welfare. Government of India; 2020. Available from: https://www.mohfw.gov.in/pdf/ChiefSecyDOLetter.pdf. [Last accessed on 2020 Mar 28].  Back to cited text no. 8
    
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Ministry of Home Affairs. Government of India. MHA Order. No. 40-3/2020-DM-1(A). 2020. New Delhi. Available from: https://mha.gov.in/sites/default/files/MHAorder%20copy.pdf. [Last accessed on 2020 Mar 28].  Back to cited text no. 9
    
10.
Ministry of Home Affairs. Government of India. Consolidated Guidelines of MHA on Lockdown Measures on Containment of COVID-19. New Delhi; 2020. Available from: https://mha.gov.in/sites/default/files/Guidelines.pdf. [Last accessed on 2020 Mar 28].  Back to cited text no. 10
    
11.
ABP News Bureau. Coronavirus: No community spread in India yet, 826 samples checked by ICMR test negative. ABP News Bureau; 2020. Available from: https://news.abplive.com/news/india/coronavirus- no-community-transmission-in-india-yet-826- random-samples-tested-by-icmr-result- negative-1178397. [Last accessed on 2020 Mar 23].  Back to cited text no. 11
    
12.
Nidheesh MK. A rich man's disease, a poor man's burden, and the toll it's taking on self-esteem. Live mint 2020. Available from: https://www.livemint.com/news/india/a-rich-man-s-disease-a-poor-man-s-burden-and-the-toll-it-s-taking-on-self-esteem- 11584993132052.html. [Last accessed on 2020 Mar 28].  Back to cited text no. 12
    
13.
Provisional Population Totals. In: Rural-urban distribution: Series 1; Paper 2, Volume 1 of 2011. Census of India; 2011. Available from: http://censusindia.gov.in/2011-prov-results/paper2/data_files/india/paper2_1.pdf. [Last accessed on 2020 Mar 23].  Back to cited text no. 13
    
14.
National Health Mission. National Rural Health Mission. Ministry of Health and Family Welfare, Government of India. Available from: https://nhm.gov.in/inde×1.php?lang=1 and level=1 and sublinkid=969 and lid=49. [Last accessed on 2020 Mar 28].  Back to cited text no. 14
    
15.
National Rural Health Mission – Meeting people's health needs in rural areas. Framework for Implementation 2005-2012. New Delhi: Ministry of Health and Family Welfare, Government of India. Available from: https://nhm.gov.in/WriteReadData/l892s/nrhm-framework-latest.pdf. [Last accessed on 2020 Mar 28].  Back to cited text no. 15
    
16.
Arjun KM. Indian agriculture- Status, importance and role in Indian economy. Int J Agric Food Sci Technol 2013;4:343-6. Available from: https://www.ripublication.com/ijafst_spl/ijafstv4n4spl_11.pdf. [Last accessed on 2020 Mar 28].  Back to cited text no. 16
    
17.
News18. Urban India to be Shut: Full List of 80 Coronavirus-Affected Districts Under Lockdown Till March 31. 2020. Available from: https://www.news18.com/news/india/delhi-mumbai- chennai-hyderabad-bengaluru-full-list-of- all-75-coronavirus-affected-districts-under- lockdown-till-march-31-2546469.html. [Last accessed on 2020 Mar 23].  Back to cited text no. 17
    
18.
Centre for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19): How Corona Spreads. Available from: https://www.cdc.gov/coronavirus/2019-ncov/prepare/transmission.html. [Last accessed on 2020 Mar 28].  Back to cited text no. 18
    
19.
Integrated Disease Surveillance Programme. National Centre for Disease Control. Directorate General of Health Services. Minsitry of Health and Family Welfare. Government of India. Available from: https://idsp.nic.in/. [Last accessed on 2020 Mar 28].  Back to cited text no. 19
    



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