On August 24, a long queue snaked outside a two-room space on the ground floor of the Government Medical College and Hospital in Latur. Most awaiting their turn were elderly people. Some of them coughed intermittently. Tired of standing, with the few available chairs already taken up, they squatted on the floor.

A banner outside the two-room space stated: “Post-Covid OPD”, or outpatient department.

As the second wave of Covid-19 winds down in rural Maharashtra, fever clinics stand deserted, but a new healthcare challenge is surfacing: villagers who have recovered from Covid-19 are now grappling with lung, heart, and neuro-psychiatric ailments. Such prolonged illness after coronavirus infection is commonly referred to as post-Covid or long Covid.

Globally, long Covid symptoms have attracted both research and medical care. But in India, there has been very little public attention on the aftermath of the coronavirus infection, even more so in rural areas, which have very few hospitals specialised enough to handle such complications.

After they were discharged from a Covid care centre, two elderly patients in Tuljapur district were diagnosed with Guillain-Barré syndrome, or paralysis spurred by post-viral infection neuropathy. A delay in treating the condition can even render it permanent. One of the two men, a 65-year-old farmer named Haridas Wakre, is bed-ridden and unable to work now.

Dr Shashikant Ahankari of the Halo Medical Foundation, which is providing financial aid to both the patients in Tuljapur, said post-Covid illness has been debilitating for many. “The full impact in villages will unfold slowly,” he said.

Many are likely to suffer silently.

Dr Smita Shahapurkar, a private gynaecologist in Osmanabad district, was diagnosed with Covid in April. She spent a week in a hospital, even though she had moderate illness which did not require oxygen support.

Days after she was discharged from the hospital, she started identifying changes in herself: acute weakness, sleep disorder, anxiety. “When weakness improved, brain fog took over. Then began hairfall,” she said. It has been five-and-a-half months since she was infected with Covid-19, but she still feels fatigued.

“I could identify these symptoms because I am a doctor,” she said. “Several in rural parts don’t even understand what is happening to them.”

Invisible cases

The Government Medical College and Hospital in Latur, one of the few large public hospitals catering to eight districts in the arid Marathwada region, has been running a post-Covid clinic three times a week since September 2020. But in June this year, doctors began to notice an uptick in the number of patients. This prompted them to create a dedicated post-Covid clinic that runs from 9 am till 1 pm daily.

“In some cases, patients come with no confirmed RT-PCR report but have a classic Covid history,” said Dr Vaibhav Kawade, senior resident in the chest medicine department. “We treat them as post-Covid cases too.”

Since its inception, the clinic has seen 584 patients – most of whom visited after June – but doctors believe this is just a fraction of actual patient load. “At least 50% of hospitalised patients have post-Covid problems that can last for months,” said Dr Abhijeet Yadav, the clinic in-charge. But unless the complications interfere with their daily routine, most villagers do not seek medical care, he added.

Those who do look for treatment, struggle to find it close to home. Post-Covid care requires a multi-specialty mix of chest medicine, physiotherapy and psychiatry, and district hospitals are not equipped to handle such patients.

Forty km from Latur is Murud village. Rural hospital superintendent Dr Prachi Haridas sees a patient or two with post-Covid complications every day. “We teach them breathing exercises, reassure them they will be fine and send them home. But for any further intervention we have to refer to Latur,” she said. “Most don’t end up going.”

Apart from the distance to urban centres, what deters rural patients from seeking treatment is the cost of travel, the loss of daily wages, and the fear of reinfection.

In Osmanabad district, Ranjana Jadhav, 50, had tested negative for Covid in April, and yet her symptoms were severe enough to warrant an eight-day hospitalisation in Solapur, the nearest city, about 50 km from Yedola village where she lives. Within days of getting discharged from the hospital, Jadhav started experiencing pain in her legs. But she waited for 15 days before returning to Solapur for consultation.

“Solapur is more than 50 kms from here,” she explained. “We needed to hire a private vehicle, since all state buses were shut.” Her husband had already spent Rs 1.5 lakh on her treatment. For a day ride to Solapur and back, he would have to shut his grocery store, losing income.

Dr Neelima Deshpande, head of the medicine department in Latur medical college, who is researching post-Covid patterns in the region, said typically patients delay their visit by three or four days after symptom onset. “Most have respiratory problems,” she said. “If delayed, it can complicate their lung functioning permanently.”

Ranjana Jadhav said lumps fall when she combs her hair, and she suffers from anger and anxiety problems. Photo: Tabassum Barnagarwala

Weak and helpless

Generalised weakness is among the most common post-Covid ailments, doctors said: three out of five patients who have visited the Latur clinic complained of it.

Doctors attributed the weakness to respiratory trouble. Constant oxygen support during Covid treatment, especially if it is through a high-flow nasal cannula, often scars and damages lung tissues leading to fibrosis. This reduces oxygen intake in recovered patients, said Kawade, the doctor in the chest medicine department in Latur.

“When they walk, they exert more, and their oxygen demand rises,” he explained. “Since the airway is obstructed, oxygen intake is not enough and they start panting and get breathless. This leads to weakness.”

The patients visiting the post-Covid clinic are made to undergo pulmonary function tests to assess whether they have an airway obstruction. Based on how badly scarred their lungs are, they are advised breathing exercises, and in some cases, additional oxygen support and medication.

Rahibai Jadhav, a 65-year-old who lives in Yedola village, spent a month in the Omerga sub-district hospital. She was discharged in July, but her lung function remains so poor that she still requires oxygen support for a few hours daily.

“Electricity supply is erratic here, we can’t use a concentrator. So we bought a cylinder for Rs 25,000,” said her son, Kisan Jadhav. Refilling oxygen requires an hour’s ride to the city.

Rahibai continues to experience extreme fatigue. “I have chest pain, I feel sleepy, and I don’t feel like talking to anyone,” she said. “If I walk I get tired and go to sleep again.”

Kisan hired a private vehicle twice, spending Rs 1,200 each time, to take his mother to the Omerga, 40 kms away. “I am a farmer,” he said. “To take my mother to a doctor means spending an entire day travelling.” Since his mother’s condition has not improved, they have decided to stop further visits.

Their neighbour, Vilas Jadhav, 60, who is also experiencing post-Covid symptoms, is similarly wary of spending more money on his treatment. A month-long admission to a private hospital in May had already cost him Rs 3.10 lakh, he said. When he returned home in June and tried to work on his family farm, he found he could not last beyond an hour.

“My legs hurt, I feel weak,” he said. He travelled to Solapur, paying Rs 2,000 for a private vehicle, he was given medication and asked to return after a month, he said.

Yadav, the person in charge of the clinic in Latur, said few patients came back for a follow-up. “It is possible they are getting better, but I believe several postpone a follow-up until they become severe,” he said.

Activists said this reflects the long-running deficits in the rural healthcare system. In July, the Jan Arogya Abhiyaan surveyed 122 primary health centres and 24 rural hospitals in Maharashtra and found 46% posts for specialist doctors in rural hospitals were vacant and 49% centres had no permanent medical officer. “This means there is one regular doctor for 30,000 people, instead of WHO mandate of 1 per 1,000,” said Bhausaheb Ahir, a member of the public health advocacy organisation.

Rahibai Jadhav, a resident of Yedola village in Osmanabad, requires oxygen support for a few hours every day. Photo: Tabassum Barnagarwala

The neglected symptoms

While lung fibrosis, breathlessness, body pain and thrombosis are commonly diagnosed as post-Covid symptoms, there is more that goes undetected. Several patients suffer from anxiety, sleep disorder, brain fog, irritability and phobia – very few are able to communicate this to doctors.

Dr Ashish Chepure, head of psychiatry in Latur medical college, said patients visiting the clinic spoke about the physical manifestations of post-Covid illness, but not its psychological aspects. “We have to probe, ask specific questions to understand if they suffer from neuro-psychiatric problems,” he said.

When she consulted a doctor in Solapur, Ranjana Jadhav, the 50-year-old resident of Yedola village, spoke about how even walking to her neighbour’s hut left her breathless and tired, and lifting her right arm caused her pain. But she did not discuss what bothers her the most – hair fall, bouts of anger and anxiety. Sitting outside her hut, she said, “Lumps of hair fall when I comb. I feel angry and tense, I can’t understand why.”

Dr Milind Poddar, psychiatrist and founder of Sawali Centre for Mental Health in Latur, said Jadhav’s silence about her anxiety is understandable. Awareness about mental health is low in rural areas. “But what concerns me is that even general practitioners fail to identify these symptoms and refer patients for counselling,” he said.

In Latur medical college, Dr Chepure, head of psychiatry department, said during the first wave of Covid-19, an internal study in the hospital showed 10% of healthcare workers and their families suffered from anxiety. “These are people who did not get infected,” he said. “I believe in the infected population, the anxiety will be seen in 20% cases.”

Depression, anxiety, stress, brain fog, sleep disorders are common problems, but villagers seldom report them unless asked. “They don’t see it as an illness at all,” Chepure said.

The public health department has instructed district hospitals to sensitise recovered Covid-19 patients about post-Covid complications and suggest rehabilitation before they are discharged from hospital. “We have even trained ASHA workers on mental health problems,” said Dr Padmaja Jogewar, heading Maharashtra’s mental health cell. “But with complete attention on Covid treatment, post-Covid work will take time to start in district and rural hospitals.”

This reporting was supported by a grant from the Thakur Family Foundation. Thakur Family Foundation has not exercised any editorial control over the contents of this article.