Mystery of the Missing Cases

- Jashodhara and Abhijit

The second wave of Covid suddenly overwhelmed the entire nation towards the end of the month of April 2021. It was not long since the Indian Prime Minister had declared victory over Covid at the World Economic Forum that the cases started to rise once again. While the first wave in 2020 had seen the peak of a little less than 1 lakh new cases daily, this year between mid-February and mid- April the rate of increase was far in excess: in fact, by early May 2021, more than 4 lakh new cases were being detected every day! The virus has mutated and is now much more infective than earlier. The second wave was first felt in Maharashtra but soon Delhi faced the brunt of the second wave.

Around that time, we were planning to move our household to Mukteshwar in Nainital District, Uttarakhand. Almost everything had been packed, most furniture been disposed off and we were negotiating with the movers, when on the 19^th of April, lockdown was announced in Delhi. The infection rates, and death rates were spiking all over the country but in Delhi the situation was particularly grim.

The news from Uttarakhand was also worrying with the Kumbh Mela emerging as a ‘super-spreader’ event. There was lockdown in Uttarakhand as well. We learnt that the infection had reached our little village and that two elderly gentlemen had succumbed to Covid, in fact within the space of one month seven deaths had occurred which was unprecedented in the village! All plans for moving to Uttarakhand were shelved for a few weeks. However, the second wave in Delhi waned as rapidly as it rose, so on the 1^st of June we moved into Uttarakhand for the next phase of our lives. 

Over the last three weeks or so we have been slowly settling in, while our neighbours in the village ply us with fresh fruits from their orchards and vegetables growing in their fields. Though far away from cities, Covid remains a daily reminder as there is a partial lockdown here and shops in the nearby market are open only for a few hours in the morning. We remember to pocket our masks when we go out for our walks and notice that while some people are wearing masks, many are not. We are careful to wear our masks when we meet someone or step closer, but most people find it strange or amusing.

A few days ago, we went to visit an old friend, let’s call her ‘Kamala’, who was one of the earliest Community Health Workers we had trained in 1990, when we set up a community health programme in this village 31 years ago. She was one of the most enthusiastic women we had met in our short careers till then: eager to learn something new, full of spirit, not afraid to take up challenges. In fact, when we had planned for a study visit to Comprehensive Rural Health Project Jamkhed in faraway Aurangabad in Maharashtra, she was the one who had mobilised all the reluctant Health Workers to make this long trip. We have always been in touch over the years and have witnessed her taking many leadership roles in the village, including being elected to be a member of the Block Development Council (BDC). Kamala had recently lost her husband so we went to pay our respects.

When Kamala came out to meet us, we were surprised to see her appearance. We knew she was grieving, but she looked uncharacteristically crumpled and worn out. We asked her how she was and learnt that when her husband passed away, she had been down with an acute attack of fever and extreme weakness. We had no idea that Kamala had had Covid! She had not been tested but she described her own condition as having high fever for which she had taken care to isolate herself in a separate room. She was unable to lift her head or eat or drink anything for a few days. It was during this time her husband passed away after a short episode of fever. Upon hearing of his death some of their relatives came on condolence visits and insisted on meeting her. In the month or so since then, she said there had been a steady stream of people coming to pay their respects, usually a couple of dozen people every day. Kamala said that she was feeling much better now and was able to come out and sit with them for a while.

On our way back we were reflecting on Kamala’s passing mention that many people in the village had had similar episodes of fever and had become extremely weak. We recalled how a week or so ago, our neighbour from up the hill Parvati had mentioned she was running a fever, but was out grazing her goats. We decided to check with the village ASHA about the Covid related data for the village. But then we learnt that our village ASHA, let’s call her Pushpa, was currently ‘alag’ (segregated for having her periods) and so would only be able to meet us after 4 days. Women here are considered polluting and expected to stay apart from their families during their periods, a tradition which has remain deeply entrenched despite the large-scale menstrual hygiene programmes that have become popular nowadays.

When Pushpa finally came to meet us, we got a quick Covid update about the village. Two seniors, whose deaths we had already heard of, were the two recorded ‘official’ COVID deaths in the village. Two younger men, who were taxi drivers and had tested positive, had died and been cremated in Haldwani, therefore their bodies had not come to the village. What of the seven deaths in the month of April we had been hearing about? There were indeed three other persons who had died last month, she admitted, but none of them had been tested. ‘Did they have fever?’ we asked. ‘Yes, all three of them had fever’, she confirmed, ‘but no one wants to get tested’.

We asked Pushpa how many people from the village had tested positive in the last couple of months. She first said fourteen, then she mentioned some other names, did some mental maths and then confirmed that there were eighteen people from the village who had tested positive. Was that all, we asked her again. She recounted some more numbers and names under her breath, then reiterated there were eighteen people who had tested positive. ‘Were there other families where people had fever?’ we asked her. ‘Many families had people with fever’, she confirmed. ‘Could they also have had Covid?’ we asked. ‘Yes, perhaps’, she agreed.

She said that she had advised many people to get tested, but the question was where and how. These tests were not available in the village and going to the health centre meant the expensive option of hiring a taxi, since public transport was not functioning. ‘There was a COVID-test camp organised in the village by the Primary Health Centre on 1^st June, but only seven persons turned up to get tested. No one had tested positive.’ Pushpa continued in a despondent tone, ‘What can I do, I have told so many people to get tested, but no one listens.’

Recalling that Pushpa hadn’t been able to meet us earlier because she had been ‘alag’ we joked, ‘As an ASHA worker you are supposed to put an end to practices like ‘alag hona’ but hey, you end up practicing it yourself! Can you blame others for not listening to your advice?’’ Pushpa pleaded helplessness. ‘What can I do? There are elders in the family who won’t hear of any change from us younger women.’ The conversation then drifted to other topics and soon Pushpa left.

As the second wave of Covid is abating there have been many concerns about data veracity and underreporting of cases and deaths. Our brief encounters were an eye-opener on how such underreporting takes place on a daily basis. According to ‘official’ data this small mountain village of about 160 households spread over a large area has seen 4 deaths and 18 cases till date. From our conversations it was clear that this was gross underreporting. All seven deaths that took place within a month were in all probability from Covid infections. Even if we accept the official number of deaths being 4, the number of infections should have been in excess of 150, as the number of infections in different states in India are between 40 to 100 times more than the number of deaths.

Ours is a small village with a population of little over 1000. There were no confirmed cases of Covid infections during the first phase, but the second phase had a strong footprint. Now there are talks of an imminent third phase. As we prepare for it, we felt that there are some lessons here that we cannot ignore. Vaccination and testing will remain a challenge and making apps like CoWin or Arogya Setu will not be enough to tackle the pandemic. In contrast to the urban middle class imagination which is main driver of policy solutions, rural people are often not as forthcoming in accepting technological solutions, for various reasons. It is important to understand some of these barriers if we want to promote community-based testing, isolation, monitoring and timely referral or to address the problem of vaccine hesitation.

We often treat ‘health education’ in the same manner as a school text which needs to be followed because it is the ‘ordained’ curriculum. But in real life people rarely do so: health related behaviours are entrenched within a socio-cultural context which we often do not acknowledge. Moreover the formal health system is barely functional in most remote areas, so the choices that people have are different from ours.

The Corona virus is a tricky microbe, and it seems it will continue to fool us for some more time. If we want to counter this microscopic ‘bahurupia’ successfully we also need to become smarter and more systematic in our approaches.