The first case of SARS-COV-2 was reported in India on January 30. The government of India announced a sudden lockdown with effect from midnight on March 24. The clampdown on travel resulted in millions of migrant workers being trapped in cities. Faced with a loss of wages, separation from their families and a lack of food, lakhs of workers started walking or cycling hundreds of kilometres back home. Along the way, they face exhaustion, vehicular accidents and police action for violating the lockdown.

At least 10.4 million Indians left cities to return to their village homes, the government estimates.

But even when they got home, the migrants and their families faced great misery on account of the abrupt loss of wages, the lack of food, and the fear and stigma around Covid-19. Many people with illnesses were not able to access treatment because routine health services, public and private, were stopped or significantly reduced in scope because of the lockdown. It resulted in significant reduction in utilisation of even essential health services such as immunisation, detection and treatment of tuberculosis and continued care of cancer.

In weeks following the lockdown, it was expected that the misery would be short lived and would improve as “unlocking” progressed. However, as we are observing in rural, tribal areas of south Rajasthan, the misery of the migrants continues even six months after lockdown was imposed. Loss of livelihoods, low availability of food, disrupted transport, intermittent localised lockdowns and interrupted healthcare continue to significantly hurt health and well-being

Because of the small landholdings, erratic rainfall and scanty local employment opportunities, large numbers of men migrate from villages of south Rajasthan to cities such as Ahmedabad, Surat and Mumbai for work. In such locations, we run a network of six not-for-profit primary healthcare clinics in remote, rural and high migration communities in Udaipur district in South Rajasthan, India. Called AMRIT Clinics, they provide preventive, promotive and preventive care to isolated communities of about 12,000 people each, 90% of which are tribal. About 60% of the households have at least one man who has migrated to the city.

Based on our first-hand experience of providing healthcare among these communities, we describe how migrant families and communities continue to be quite fragile and affected by the pandemic and its aftermath. It is clear that they will require continued attention and support for long time to come.

Impact on tuberculosis and HIV

From migrants and their families, we receive a large number of patients with tuberculosis. This is because of their exposure to dust and silica in their workplaces, poor nutrition status and overcrowded situations in which migrants live in cities.

Following the lockdown, the notification of new cases of tuberculosis has decreased in all tribal districts of south Rajasthan. In our clinics however, we are seeing a huge increase in numbers of patients with tuberculosis as compared to pre-lockdown months and compared to the similar period last year.

Many of them have been symptomatic for many months but were not able to seek treatment. Many others were on treatment in cities and towns, but their treatment was disrupted. Common reasons for disruption and delay are: the absence of transport, fear of catching Covid-19 in transit or at the hospital, being denied treatment even after reaching the health facility and a lack of money to buy drugs or travel to hospital. Many of them are reaching us with advanced tuberculosis, with poor nutrition and very little money.

Soon after the lockdown, patients with HIV were unable to reach from their villages to the Anti Retroviral Treatment centre located in the city. In one of our clinic areas, we transported the medication to the doorsteps of 16 HIV patients for three months. But even six months later, many patients continue to find it difficult to reach the center and collect medication.

Food availability and child malnutrition

In May, we conducted a survey to assess food availability among the families who are dependent on labour and migration in our field area in the month of May – 47% of interviewees reported that they have to skip meals occasionally or often. Food availability in households was extremely low: they had a median amount of pulses sufficient to last for only eight days.

We have also been monitoring the growth of about 1,000 children under five years of age, all of whom are tribal and most of whom belong to migrant families. While we did not monitor the growth of children for three months after lockdown, we took due caution and resumeds measuring their weights from the month of June. While the median proportion of severe underweight (weight-for-age less than -2 standard deviation) children over 12 previous measurements was 68%, in June, child malnutrition had increased to 76%.

Reproductive health

The return of migrant men to villages for prolonged periods and their loss of livelihoods appears to have created fertile ground for domestic violence. We have been witnessing increased cases of women with wounds due to domestic violence as well as cases of domestic violence reported to our outreach staff.

There has also been a surge in women presenting themselves to us for contraception and medical termination of pregnancy. Women seeking termination of pregnancies at our clinics increased from an average of 40 per month in the first quarter to 48 in the second quarter and 53 in the third quarter. This is both on account of increased need due to men staying for longer periods at home, as well as difficulty in reaching accredited public facilities.

We have also been seeing an overall increase in morbidity due to conditions such as diabetes and hypertension, and interruption in treatment due to the same problems mentioned above. We are receiving patients with uncontrolled diabetes and severe hypertension much more than before.

Spread of Covid-19 infection

We had earlier reported that when migrants walked back soon after the lockdown, there was no spread of Covid-19 infection in these communities. However, since the authorities had forced them to stay back in the city for more than a month before allowing them to return home, Covid-19 was seeded in these communities. Since then, we have been seeing a frequent travel back and forth of migrants between cities such as Ahmedabad and Rajko, and their villages in south Rajasthan. This has led to an insidious increase of Covid-19 infection in rural areas. This chart below shows a sharp increase of Covid-19 numbers since August in Dungarpur district, a high migration district.

Patients with TB linked to treatment at AMRIT Clinic.

Much of the increase is likely to be due to exposure in the city: for example, at one of the construction sites in Ahmedabad city where we manage a day-care-center for children of migrant workers, 49 out of 450 workers screened were found positive for Covid-19.

Action is essential

Pictures of migrants walking back on the highways shook the conscience of the nation. Six months later, the misery of the migrants and their families continues, though it has receded to the back of our minds. There is an urgent and continuing need to ensure access to nutritious food, resume assured transport, provide healthcare, generate local livelihoods and enhance surveillance for Covid-19 among high migrant communities.

Additional grain through the public distribution system helped many migrant families survive, but it was not sufficient for staying healthy. Anganwadis, which are a source of supplementary nutrition for young children, remain closed. There is an urgent need for resuming supplementary nutrition to young children, and to include oils and pulses through the public distribution system.

Affirmative action is required to ensure that healthcare reaches more remote populations. For example, to ensure the timely detection and treatment of patients with suspected tuberculosis, it would help to transport sputum instead of patients, make mobile X-rays available closer home, and distribute drugs at the doorstep. Connecting peripheral healthcare workers such as Auxiliary Nurse Midwives with tele-consultation would help them deal with the basic healthcare needs of the families they serve. This is the time to strengthen primary healthcare in rural, high-migration communities.

Closer engagement with migrant men, helping them cope with the situation arising out of limited mobility and loss of livelihoods is critical. We have found that such engagement helps them come to terms with the situation, and take action to promote the well-being of themselves and their families. At the same time, their families, more than ever before require counselling, healthcare and support. Empathetic community health workers, tele-counselling services, and helplines would be required for a long period of time to come.

Sanjana Brahmawar Mohan and Pavitra Mohan are pediatricians and co-founders of Basic Health Care Services, that provides low cost healthcare in rural, high migration areas of South Rajasthan. Arpita Amin is a public health professional and coordinates research at BHS.