Covid-19 coronavirus: India's cities are under siege - now its rural areas are in the firing line

India's devastating Covid-19 epidemic, which is killing thousands of people each day in major cities including Delhi and Mumbai, is now spreading uncontrollably in its most vulnerable rural hinterland, home to 800 million Indians.

Decades of underfunding in India's healthcare system has left the nation's rural areas facing widespread shortages of oxygen, tests, medication, and, in many areas, a medical professional, creating a vacuum of critical care and leaving openings for quack doctors.

The imposition of lockdowns in cities such as Mumbai and Delhi over the last fortnight again sent thousands of migrant workers back to their home villages, some carrying the virus with them.

Thakurtola, a village in India's central state of Chhattisgarh, is one such village that has been radically changed by the arrival of Covid.

Its 1000 inhabitants work largely as subsistence farmers and are poor by Indian standards, and have strong family ties. Locals speak of a wave of grief that has overcome the village.

Ramesh Yadav is mourning the loss of his brother, Poonam, who returned to his home village at the start of this month after Nagpur, the city he worked in, was put under lockdown.

Bodies lined up outside a crematorium in New Delhi on April 24. Photo / AP

He returned to Thakurtola complaining of a severe cough and flu-like symptoms, which quickly worsened. His worried family took him to see the village's doctor but, as in the case of two-thirds of doctors in rural India, he was a quack and had no medical qualifications.

"He started saying that there was no need for a Covid-19 test and just to take medicines, like paracetamol," Ramesh says.

Overnight, Poonam began gasping for air but there was no oxygen supply in the village. The nearest government hospital was over 30 kilometres away but an ambulance couldn't be arranged to take Poonam for four hours, due to short staffing.

People queue to refill oxygen cylinders in New Delhi on April 23. Photo / AP

"Shortly after that, his breath started to dissipate and he suddenly died. My brother would have been able to reach the hospital for treatment if there was any oxygen provision nearby," said Ramesh. "His death came like a storm, everything happened so quickly."

It was never confirmed that Poonam had Covid-19 because the village did not have any testing kits. But, under pressure from villagers, officials sampled 48 people Poonam had come into contact with and 25 people tested positive for Covid.

A nationwide shortage of kits and testing delays means the majority of Covid-19 deaths in India are not officially recorded, and the actual daily death rate is estimated to be at least 20 times higher than official figures suggest.

"I work with people in rural areas in Chhattisgarh and I am aware of every village in Rajnandgaon," explains Motilal Sinha, a leading social activist in the state. "Today, the situation is that between 15 and 20 per cent of people from every village in Rajnandgaon are Covid-19 positive but these cases aren't on any government record. They would only be revealed if house-to-house testing is done in villages."

While India's second wave began in urban areas, the three states which showed the highest weekly growth in cases now have predominantly rural populations – Uttar Pradesh, Bihar and Rajasthan.

Data also indicates a comparable rise of Covid-19 cases in rural India when compared with the country's first wave, with the epidemic now believed to be driven by new, more contagious variants.

For example, in the Hoshiarpur district of Punjab, which contains the state's highest percentage of rural residents, the number of monthly Covid-19 infections in March had doubled from September, during the peak of India's first wave. India's public healthcare system is one of the most underfunded in the world.

People queue to board trains at Lokmanya Tilak Terminus in Mumbai on April 14. Photo / AP

Approximately £1.50 (NZ$2.88) is spent per citizen and these meagre resources have largely been focused in large cities. Only one-third of India's hospital beds are in rural areas, despite containing three-quarters of the population, and the majority of villages do not have any oxygen supply.

"I bought an oxygen cylinder with my own money to make it available to villagers here," explains Anand Sahu, a community leader in Surgi, a village in the Rajnandgaon district, which also secured two emergency cylinders from a former politician.

"But, the population of the village is 5000. Suppose if ten per cent of the villagers are infected with Covid-19, then there are three cylinders for 500 people. Now tell me, how will the villagers be treated in this situation?"

According to one study published in The Lancet, 83 per cent of surgeon and physician roles are vacant in India's rural areas, and doctors in Chhattisgarh said the availability of staff to treat Covid-19 is already "negligible".

"All the important things are missing here, all the S's – space, staff, and stuff – rural areas are clinical deserts," said Dr Yogesh Jain, a rural health expert from Chhattisgarh.

"We will see a big rise in deaths in rural areas, there is hardly any care for people who require oxygen and that is around 15 per cent of cases."