When Santosh Kumar developed a cough and mild fever on July 6, he knew what to do. His village of Chakai, a collection of 200-odd residents in Bihar’s impoverished Araria district, was buzzing with news of the coronavirus and the 35-year-old shopkeeper suspected he contracted the infection.

But when he reached the local hospital in Jokihat, he was told there were no facilities to test for the virus. The next day, he took a bus to Araria, and spent five hours at the district hospital before a nurse came to take his swab. “It was not easy for me to undergo a test as there was no one in the district hospital to take notice,” said Kumar, who runs a small hardware shop.

On July 9, a phone call from the administration told him the test was positive, and he was admitted to an isolation centre at Forbesganj the next morning. At the centre, he met Mithu Kumar, Rinki Devi and Suraj Kumar – all residents of Araria district – who narrated similar tales of difficulty in getting tested. “When you are infected with the coronavirus, you better rely on god,” said Mithu Kumar.

Across the largely rural district where manual and agricultural labour are the main sources of employment, quacks — who have long capitalised on the poor health care system in the region — have come up with “corona cures” overnight. “We don’t know where to go for a test if I catch a cold or I am sick with fever,” said Munna, 40, who goes by one name. “We still take medicines from quacks.”

The district has 213 infections but even in villages with patients, there is little awareness of distancing protocols or the need to wear masks. The 100-bed district hospital has 11 regular doctors on roster against a sanctioned strength is 46. There are 15 nurses out of sanctioned 60.

The government says it has ramped up facilities to battle the infection. “We are doing our best for the patients infected with coronavirus,” said Araria civil surgeon Madan Mohan Prasad Singh. Officer in charge of Araria, Shambhu Kumar, said the administration will start testing at the block level in two days. “We are just waiting for kits,” he said.

Araria is not alone. Four months into the pandemic in India, the virus has travelled from urban centres into the hinterland, where a fractured health care system, low awareness and abject poverty are emerging as major impediments in the battle against Covid. Of India’s over one million cases, nearly a third are from 658 districts where the share of rural population is more than 40%, and a quarter of the cases is in the 584 districts that have more than 60% rural population. This means that while the majority of the infections are being reported from urban centres rural India is dealing with a significant caseload.

This is a heavy burden because some of the states with the largest rural populations such as Bihar and Uttar Pradesh, also have the lowest per capita hospital bed or doctor availability. In Bihar, which has the largest share of rural population — only 0.11 beds and 0.39 doctors are available per thousand people — as opposed to 0.46 and 1.54 for Maharashtra, the worst-hit state.

“Of course, there is an increase in cases in rural areas and that was to be expected. After the lockdown lifted, and jobs remained elusive, millions travelled home without facilities for testing, contact tracing and isolation,” said Dr Vivekananda Jha, executive director of The George Institute for Global Health, Delhi.

Testing is another problem. Compared to 38,188 tests per million in Delhi and a national average of 9,908 tests per million, Bihar conducted 2,907 tests, Uttar Pradesh, 5,891 tests and Odisha 8,287 tests per million.

“In cities, however crowded, migrants live and work with others who are relatively young, but when they go back to their multi-generational families and communities, they infect the old and vulnerable who have very often poor or no access to health systems,” said Dr Ambarish Dutta, associate professor, Indian Institute of Public Health, Bhubaneswar.

Uttar Pradesh and Bihar, which are the two biggest sources of migrants, also have daunting health care challenges. The health infrastructure of Uttar Pradesh and Bihar, for example, is 2.5 times lower than Kerala’s, according to Niti Aayog’s State Health Index 2019.

In many of these regions, decades of chronic underfunding of health care has brought the crisis to a head. For people living in rural areas, where private facilities are usually few, the government allopathic doctor-patient ratio is 1:10,926, shows the National Health Profile 2019 data. In the past two months, states have attempted to scale up facilities.

In Bihar, for example, health minister Mangal Pandey said there are now 441 Covid Care Centres. “All six medical college and hospitals have been asked to arrange 100 beds for Covid patients and 40,000 rapid testing kits have been sent to districts,” he added.

Experts agree there has been a degree of improvement over the years. “Some progress has certainly been made in improving service delivery in rural areas, but the focus has been largely on maternal and child care, with some good work in malaria and TB control. But by and large, the infrastructure capacity to cope with infectious diseases in terms of trained personnel, laboratory support and good district and sub district level hospitals continue to be poor. A lot more focus and investment is needed,” said K Sujatha Rao, former Union health secretary. A survey done by the National Health Authority, which runs the government’s flagship Ayushman Bharat health assurance programme, found 22 of 101 accredited private hospitals had remained inactive and 81 declined to provide Covid-19 treatment.

The bigger fear than rising cases in rural India, experts said, is the possibility of infections going unrecorded.

“It’s clear that testing is low in these states, and transmission will remain high as people are not tested. We have experience, not from coronavirus infection but other disease, which people get ill and die in rural areas without going to a hospital and the cause of death is not recorded,” said Jha. “Unless we test, isolate and treat and strengthen primary health care more widely, coronavirus in rural areas will remain unrecorded,” he said.

(additional reporting by Vijdan Mohammad Kawoosa)