COVID-19 fallout: Rural-urban medical divide widens; emergency services under pressure

As the country tackles the unfolding COVID-19 waves, routine health services continue to face disruptions. Data released by the Health Management Information System of the National Health Mission shows the impact on crucial emergency health services, with a sharp rise noted in deaths recorded at emergency centres.

The data also underscores the widening rural-urban divide, with people in hinterlands having to approach urban, private centres for even emergency care, due to the paucity of medical facilities in their hometowns. A near-fivefold rise in deaths at urban emergency centres versus a drop of 20 percent in deaths recorded at rural centres strengthens the case to divert more healthcare resources to non-COVID services in rural areas, and a periodic mortality survey conducted to assess missed deaths at emergencies.

The National Health Mission's Health Management Information System aggregates data from 200,000 health facilities across the country, mostly government but also includes some private and urban centres and hence the nos are not exact. But it is a crucial link to understand the scale and patterns. Data only till May 2021 has been released till now.

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For the purpose of comparisons, fiscal of 2020-21 (COVID-impacted) was taken against 2019-20, which was largely a normal year.

We would hope emergency health services were available even during the pandemic but recurring local lockdowns, lack of access to health centres, meant admissions/registrations at emergency centres fell almost 38 percent between FY20 and FY21. Important is to observe that even with a lower base - deaths occurring at emergency rose sharply by 39 percent, largely indicating that patients reached emergency centres pretty late in their disease/injury cycle.

 

Emergency registrations fell sharply in the month of April - May 2020 and had continued to remain at that subdued level, recovering marginally in March this year, just when the Covid second wave was raising its head again. But by May 2021, it fell and even lesser people accessed emergency care.

When we look at deaths recorded at emergency, September - October period saw a surge. This was the peak of the first wave. Post these numbers, the number of deaths fell by March 2021, only to see a sharp rise in April and May 2021. There is a 124 percent jump in deaths at the emergency department in the month of May 2021 when compared to the same period last year. In April and May 2021, the virus was ravaging across the country, including rural areas. The deaths reported at emergency could have been prevented largely non-covid ailment related --- along with this, it also offers links to the excess covid mortality, missed deaths.

Talking of services affected, reporting of trauma cases fell 22 percent (some would be a reduction in accident cases owing to lockdowns). Fewer cases of burns, childbirth complications were reported. Even cardiac emergencies and those suffering cerebrovascular diseases lost out on treatment. These could all be life-threatening situations.

 

Up to 39 percent less people reached government emergency centres versus 19 percent less at private. There was a rise in reported deaths in both government and private centres but with a massive difference. Up to 34 percent rise in deaths at govt centres as compared to 182 percent rise in the number of deaths at urban casualty centres, largely bcoz public emergency centres were not available, particularly in rural areas.

An assessment of the rural-urban emergencies is the most telling tale of the divide. Rural emergency registrations fell sharply by 60 percent as compared to a 36 percent rise in urban areas, indicating no facilities were available for villagers. Remember, different parts of the country were under lockdown during the year and an already short rural health staff has been diverted to covid duties.

But it was the urban centres that took the load with a 372 percent rise in deaths at emergency units versus a 20 percent fall in deaths at rural emergency centres. This clearly indicates two aspects. First, since urban areas were affected more by the COVID-19 waves, a lot of COVID related emergencies also presented at the urban casualties, those untested cases with covid like symptoms, among others.

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Secondly, a bulk of COVID and non-COVID emergencies from rural areas were forced to travel the distance to urban centres. And in this many would have missed out on the ‘golden hour’, when lives can be saved with timely intervention.