India's coronavirus crisis is spreading outside major cities, with rural districts in at least 10 states recording a surge of cases and deaths in April.
Rural districts recorded more COVID-related deaths than urban districts for the first time last month, despite urban areas having higher overall cases, according to the "How India Lives" data repository.
In 2020, the first wave of the pandemic in India was initially limited to densely populated cities. The ongoing second wave in 2021 is ravaging wide swathes of rural India, which is starved of public health resources.
Shortages of available emergency services have also prompted some villagers to travel to cities, sometimes to other states, in a desperate attempt to find care.
Bharti Sharma, a public health consultant, told DW that reports from the ground show a huge swath of the rural population will be at risk if health care deficits are not addressed "immediately."
Which rural areas are suffering?
India's federal officials have also acknowledged that the pandemic is shifting toward smaller cities and rural areas.
Rural areas in Maharashtra state in India's west are perhaps the worst hit, and are contributing more cases to the state's total tally than its urban areas. The state is home to business hub Mumbai.
Rajasthan in the northwest is also reporting a rapid increase in COVID cases in rural areas.
The spread in rural Uttar Pradesh in the north is also seeing a steady uptick.
Rural West Bengal, after the recently concluded regional state elections, is now reeling under a surge of infections.
Health department officials in the central state of Madhya Pradesh have said that sick villagers are traveling long distances to hospitals in Bhopal and Indore.
Many of them were returnees from the Kumbh Mela festival who had tested positive for the coronavirus.
Civil society organizations say that cases are spiking in rural Uttar Pradesh and Rajasthan, where millions who also attended the Kumbh Mela last month have returned home.
Over 9 million pilgrims visited Haridwar for the Hindu religious congregation. The mega event was widely criticized for rampant violation of pandemic protocols.
Rural communities downplay pandemic
Another challenge health organizations report is the belief among the rural communities they work with that the pandemic is over and that it is an urban disease.
Consequently, COVID symptoms are increasingly being interpreted as a regular sickness.
"But now, as infections have climbed during the second wave, villagers have begun to recognize the seriousness of the pandemic and are seeking treatment," Anand Karia of the National Rural Health Mission told DW.
Many people living in villages in Meerut, Ghazipur and Ballia of Uttar Pradesh have also had similar complaints about sick family members needing urgent treatment after having ignored warning signals.
"Many people were afraid of getting the test done because they believed that they will certainly contract the infection while getting tested. Now, their situation is critical," Manoj Verma, a doctor from Ballia, told DW.
"Unfortunately, resources are scarce to mitigate the COVID threat looming ahead," he added.
Mass-testing campaigns underway
Given the exponential rise in infections in Uttar Pradesh, the government on Wednesday launched a five-day campaign for the early detection of COVID in patients in the villages.
The campaign will run in 97,000 villages in Uttar Pradesh, during which a team of health workers will go door to door.
However, health infrastructure in rural India is substantially weaker compared with the cities.
There are chronic shortages of medical professionals including doctors, nursing staff, paramedics, as well as hospital beds and equipment.
Over 65% of Indians live in rural districts, according to the World Bank.
However, only 37% of beds in government hospitals are in rural India, which would mean 3.2 beds for every 10,000 people in rural areas, according to the National Health Profile 2019.
Epidemiologist Prabhat Jha, who is a lead investigator of the "Million Death Study in India," told DW that millions of deaths, and their causes, go unrecorded every year in rural India.
Jha is carrying out an ongoing study to quantify the causes of premature mortality in India. He says the majority of deaths occur at home and without medical attention.
He added people are also fleeing high COVID infection rates in packed cities and carrying the virus to rural areas.
"In this viral wave, thousands have fled urban areas to the rural villages, and we can again expect a big increase in deaths. But we simply do not know how large this will be yet," Jha added.