Rural hospitals: The silent, frontline units in the war on COVID-19

These vulnerable centres are fighting the good fight despite the lack of resources

rural-hospital-covid-19 Triage desk at a hospital under EHA

They say necessity is the mother of invention. The medical staff at the Herbertpur Christian Hospital (HCH), Dehradun, has witnessed this aphorism spring to life in this time of COVID-19. HCH’s carpentry and fabrication unit started producing face shields for their staffers that cost them less than one-sixth the minimum market price. “The minimum price of a good face shield is around Rs 600. Being a rural setup, we couldn’t afford to get such expensive protective gear. The shields we make cost under Rs 100 and we currently produce it only for our hospital,” says one of the medical staffers at HCH.

The sudden declaration of the lockdown created panic and confusion, especially among the migrants who are stranded far from home and, not to forget, marginalised communities like daily wage labourers, widows, elderly and people with disabilities. With almost all services being shut down, there has been a loss of livelihood, compounded by food scarcity and increased morbidity and mortality. For city dwellers, life has not been so hard as the authorities have been quick to look into their concerns. But what about the ones who live in the isolated areas? The people from oppressed communities?


Situated in the foothills of the Himalayas in Uttarakhand, HCH is one of the hospitals that operate under the non-profit organistion Emmanuel Hospital Association (EHA). The EHA is a network of 19 hospitals and 42 community development projects in east, central, north and northeast India. It plays a vital link between primary health care, government services and tertiary hospital services, catering to the needs of rural India.

As of today, HCH has not been designated as a COVID-19 treatment or collection unit yet. But the hospital is prepared in case of an unforeseen situation. According to Dr Saira Paulose, EHA executive director, two units of the organisation—Nav Jivan Hospital, Satbarwa, Jharkhand, and Broadwell Christian Hospital, Fatehpur, Uttar Pradesh—have been designated as COVID-19 hospitals. “The rest of the units have become triage centres for COVID-19. Patients would be advised isolation, quarantine or will be referred to the nearest centre with an inpatient and or isolation facility. The hospitals with facilities have prepared isolation wards where suspected COVID-19 patients can be taken care of. The units that have community health programmes will provide support to the communities, providing advice for home quarantine in the community. We are also working towards converting some of our hospitals as training centres for health care,” she says.

Says Dr Viju John, medical director, HCH: “People from villages in and around Herbertpur, Himachal Pradesh and Punjab come to HCH for medical emergencies as most private hospitals are closed now. This is also because of the credibility of our institution and low charges. Our patients are mostly from the lower-income group—farmers, cattle herders and daily wage labourers. Most of the time, they don’t have the money to pay for medicines. There is a financial crunch, but the staff at our hospital are prepared to go through this challenging time despite limited resources. It was surprising to see how nobody had any complaints when their salaries were delayed. They were even willing to travel to villages for awareness programmes. I feel all of us are in solidarity to fight the virus attack and do our bit to help the ones around us.”

For now, the hospitals thoroughly screen patients before they enter the hospital. At the entrance, the patient is asked to fill a form about their travel history and symptoms. There are foot-operated soap dispensers and water taps at the entrance for the patients to clean their hands. COVID-19 suspects are filtered out this way. The only fear most staffers at the hospital have is of coming in contact with an asymptomatic patient.

Apart from their community awareness programmes, HCH has started giving care kits to patients who get discharged from the hospital. “As most of these patients might not have been working and not earning, it becomes difficult for them to get back on their feet, especially during this lockdown period. We provide them with food kits with 5kg rice, 5kg flour, lentils, onions and some vegetables so that they don’t have to worry about food for a couple of days. We also focus on patients with disability and make sure they have access to different schemes of the governments and other privileges,” Viju says. The team at HCH is also planning on setting up a community kitchen for the patients who come to the hospital.

According to Viju, even though there was confusion and a dearth of PPE kits, the government officials were kind to the institution by helping them reach out to the community. “We got our tailoring unit up and running for making gowns and masks since we could not afford to buy the expensive PPE kits. The masks are made with two layers of cotton cloth and a layer of polypropylene fabric. All our staffers are given two sets of these washable gowns and masks. We make sure that these are autoclaved every day,” he says. The team is also planning on setting up a kiosk for collection of samples. But then they will have to transport the samples to the Government hospital, which is about 45km from there. “There are private labs that do the testing but the proposition is still on talks. We need to consider factors like transport media and whether it is feasible,” he says.

Another hospital under the EHA is Kachhwa Christian Hospital in Mirzapur district, Uttar Pradesh, which is also in a rural setup. It is located 30km from Varanasi and has the state’s largest concentration of scheduled castes, poor and marginalised group of people. According to Shankar Ramachandran, senior administration officer, Kacchwa Christian Hospital, the lockdown has brought down the number of patients compared to the inflow previously. The hospital serves people from around 90 villages having a population of about 1,20,000. The team at the hospital provided dry ration to almost 900 families in Mirzapur when the lockdown was declared. “We made a count of the number ‘chulhas’ (small earthen or brick stove) and provided food kits and other basic necessities to these families. One of our main focus groups is the Musahars, an aboriginal Dalit community. Their name means ‘rat-eater’ due to their main former occupation of catching rats. We try our best to reach out to them and help them in every way possible,” he says.

Shankar feels that it would take a couple more months than estimated for things to calm down and get back to normalcy. “I am not sure how long it will take but until then it is our responsibility to take care of the ones around us. We want to be consistent in providing ration and medical treatment for the ones who really need it. We have had hiccups in between but that has not stopped us from looking forward or coming up with new plans to uplift the downtrodden,” he says.

Saira feels that with such operations in full flow, it could soon become hard to sustain the institutions. About 75 per cent of their hospitals’ income depends on patient footfall. “The pandemic has drastically reduced this revenue stream and daily sustenance is now a challenge apart from salaries. We are aware of various government orders that have been passed covering COVID-19 patients under the Ayushman Bharat Schemes and that PPEs would be provided to COVID-19 hospitals and are therefore assured of the government’s support to our endeavour to fight the virus,” she says.

Standing with the government

Talking about the sustenance of hospitals with reduced revenue, Rev Dr Mathew Abraham, director-general, Catholic Health Association of India, agrees with Saira. “There is a financial crisis everywhere. Hospitals are already struggling to sustain. Some of the smaller hospitals were spending about Rs 20 lakh per month for salaries. They were managing because of the patients that were coming. Now, suddenly the patient load has come down as the other departments in hospitals have been closed. Most of the patients go to government hospitals or dedicated COVID-19 hospitals. But if the situation worsens and the government hospitals are not able to handle the cases, they may come to us,” he says.

The CHAI and the EHA are two of the members of the Christian Coalition for Health (CCH), which wrote a letter to Prime Minister Narendra Modi on March 25, declaring that their hospitals would remain committed to fighting the pandemic. “We are prepared. We wrote to the prime minister showing our willingness to be proactive in the fight against the virus as we have a big network and reach. The PM invited me for a conference call. The concerns we raised were about protecting the caregivers. If the caregivers are not protected, and if they become infected or become serious and die, it can demotivate others. The health care system will be paralysed then,” says Rev Abraham.

According to him, the Centre may give directives, but the ultimate action happens at the district level by the district authorities. “Confusion can happen at the rural level. They may not be aware of the directives. So, we also brought that up with the PM that there should be some kind of collaborative mechanism or planning, where the public and private sector should work together,” he says. There are about 1,000 hospitals with about 60,000 beds under CCH and the team is currently developing their own plans for a wider network.

rural-hospital-3 A hospital under the Emmanuel Hospital Association

A farmer’s cry

When the big C-word gripped the country with a fear of uncertainty, the lights focussed on strict restrictions, conspiracy theories associated with it and, how can we forget, social media fitness and diet trends. Some called it a time for the ecosystem to take a breather from the degrading anthropogenic activities while others simply tagged it as a break. “Neither!” says Kashinath who works as a farmer in Fatehpur, Uttar Pradesh. He feels that the lockdown is like a prison for the poor and a vacation for the rich. “The harvest is plenty; the farmers are ready. But we are asked to stay home,” he says. The need of the hour is food supply. With the lockdown, most daily wage workers have been laid off. “Either way, we are going to die. My family and I will die of starvation and debt if I don’t work in the farm and if I do, they say I will get infected and die,” he says. Kashinath used to work as a gardener in Kochi, Kerala, for over 10 years. He came to Kochi as a teenager and earned quite well doing gardening and other household work. It was only last year that he decided to come back to his hometown and get into farming. The initial days were hard for him and just when he thought that things were falling into place, the lockdown was declared. His life got even more difficult with the birth of his second child, a week into the lockdown. “I wish my son was not born during this time or maybe he could have been born in another house. There were days when I would skip meals so that my wife can have more food because she needs to feed the baby. Although things are not great here, the rural hospitals have been a big blessing for us. They not only provided healthcare but also gave us dry ration; the staff working in these hospitals regularly check on us and see if we need anything. In a way, I  am happy that I am in my hometown and in my own house with my family. I cannot forget the fact that the NGOs here have graciously helped us in this time of crisis. If not for these groups and private mission hospitals, I don’t know what I would have done. I would have probably killed myself and my family,” he says.

One of the villagers in Mirzapur with dry ration provided by the team at Kachhwa Christian hospital One of the villagers in Mirzapur with dry ration provided by the team at Kachhwa Christian hospital

Kashinath’s elder brother and family currently reside in Kochi and works as a gardener and house help. “My brother sat at home for a week but then he got called to nearby houses for work after that. Here, in my village, nobody needs a house help or a gardener; all the posh houses are far away and our only income is working on the fields or cattle-rearing. Also, it’s so unsafe here as people don’t really follow the practice of wearing masks or washing their hands regularly. Even social distancing, for that matter, is not maintained,” he complains. Kashinath feels that people even in the rural parts of Kerala follow the safety precautions strictly which makes living there better. Looks like a classic case of ‘the grass always looks greener on the other side.’

But Dr Sharath Thomas Roy, consultant physician, General Hospital, Pathanamthitta, Kerala, feels otherwise. “In the town area everyone follows the drill strictly but I feel it is a little laid back in the interior areas. The other day when I went to the market, I found that about 70 per cent of the crowd there wore masks but there were still that 30 per cent who refused to wear it,” he says. Working in a COVID-19 treating hospital, Sharath believes that the state has been very efficient in the sense that it has been able to contain the virus to a large extent. He says even the rural parts of the state have dealt with the virus effectively. “Compared to the other parts of the country, we are doing quite well in fighting the virus. The authorities have been looking into minor details keeping in mind the effects their actions could have on the vulnerable groups. We got a sufficient number of PPE kits and medicines unlike other parts of the country. There was initial confusion and lack but I think the authorities and the healthcare sector really worked hard to resolve it in no time,” he says. Even when it comes to treatment, Sharath says the hospital staffers were given training as to how to deal with patients. “We had a total of 13 cases and 11 of them are ready to be discharged. A few of the cases were among people who travelled from Italy and their contacts. There were a couple of high-risk exposure cases and we were successful in treating them,” he says. However, he fears that the tables might turn when expats return to their hometown once the lockdown is lifted.

It is interesting how there is a dramatic difference in the situation in different regions of the same country. Collectively, the major part of the country is definitely struggling in terms of financial crunches and lay-offs, especially the rural areas of north India. But thanks to charitable hospitals, selfless medical  workers and efficient NGOs, many downtrodden still get to see that ray of hope at the end of the tunnel.

(With inputs from Reuben Joe Joseph)