Bihar health workers say the state did little to prepare for the COVID-19 pandemic

Family members of COVID-19 patients wait outside the COVID ward (on the right) at AIIMS Patna. From the start of the pandemic, the Bihar administration failed at identifying and avoiding the spread of the virus, and also failed in ensuring that the state had the medical infrastructure to deal with a crisis of this magnitude. TARUN BHARTIYA
21 July, 2020

In the fortnight leading up to 16 July, the number of COVID-19 cases in Bihar doubled, reaching 20,612. Those infected included several senior officials of the state and political establishment, further slowing the state’s response to the pandemic. This was despite the state having one of the lowest testing rates in the country at 2784 tests per million people—compared to the national average of 9289. The state’s already poor medical infrastructure began failing to keep up with the rising number of patients. This situation, several senior doctors from the state told me, became more pronounced as little was done to test and accommodate the over 32 lakh migrant labourers who returned to the state after the announcement of the nationwide lockdown in late March.

The lack of medical infrastructure is far more pronounced in Bihar’s rural hinterland where the pandemic exposed the lack of doctors in primary health centres and the lack of testing centres or hospitals dedicated to COVID care. As of 20 July, the state had only four specialised hospitals for patients affected by the virus. The crisis was also magnified by the eagerness of the state government to ease all restrictions since the end of the nationwide lockdown on 31 May, in anticipation of the legislative election scheduled to occur later this year.

From the start of the spread of COVID in the state in March, the administration failed at identifying and avoiding the spread of the virus, and also failed in ensuring that the state had the medical infrastructure to deal with a crisis of this magnitude. Rural Bihar completely lacked even the most basic facilities to test and contain the spread of the virus. Many primary health centres lacked both beds and doctors. Quarantine centres in the state were often in squalorous conditions, lacking basic sanitation and food. Alongside this the state did little to ensure that frontline workers such as sanitation workers and Accredited Social Health Activists—government primary health workers at the local level, commonly called ASHA workers—were provided safety equipment.

One of the primary problems with the administration’s response to the pandemic was a complete failure to measure its magnitude and spread. On 15 April, Kumar announced that the state administration is aiming to screen the entire population of the state for the symptoms of COVID-19, including all returning migrants. On 23 April, health department officials reportedly claimed that the state’s healthcare workers had visited 65.61 lakh houses and screened more than 3.58 crore people. A report by the online news portal IndiaSpend suggests that these numbers are false and misleading. Their study pointed that in parts of Bihar entire localities were not screened, and in areas which were screened health workers did not document the travel history or symptoms of residents.

On 14 May, I spoke to 30 families in Patna to better understand how these screening procedures were conducted. All the families said a Patna Nagar Nigam—municipal corporation— volunteer had visited them, usually accompanied by an ASHA worker. The families told me that officials did not ask about their medical history. “The ASHA worker asked my father for the initial details of each member in our family, next she noted down everyone’s phone number and left,” Vivek Anand, a resident of Nehru Nagar, told me. “This seemed as if instead of being screened for COVID, we were duped into being registered for NPR”—referring to the National Population Register. “In the neighbouring colony, the health workers spoke to only one family, made them speak on behalf of every family and left.”

Contact-tracing procedures by the state government have been equally spotty. “In the initial phases of corona outbreak, contact tracing wasn’t planned well,” a senior doctor in Vaishali district hospital, who wished to remain anonymous, told me. “We kept on hearing that all healthcare workers, police officers, grocers, sanitation workers will be tested one by one in clusters in Bihar. But this wasn’t done as told.” He added that the sudden removal of lockdown restrictions after 31 May had made it even harder for the health department to conduct contact-tracing operations. The lack of reliable screenings or contact tracing mean that the Bihar administration had no understanding of the severity or spread of the contagion in the state.

This was further accentuated by the massive influx of migrant labourers from other states which the Bihar government did little to plan for. “Before the government began running quarantine centres for returning migrants, the village communities in many parts of Bihar were already running quarantine homes as a collective initiative even without government’s support,” Manoj Kumar, a compounder from Muzaffarpur, told me on 28 April. Three days later, the chief minister announced a compulsory 14-day quarantine for the migrants returning to Bihar and announced that the administration would establish 5,000 quarantine centres.

Many government-run quarantine centres lacked basic sanitation facilities and no food was being provided by the government. On 15 May, a group of 40 men returned to Dobhi block in Gaya district, from Maharashtra. Uday Paswan, a 55-year-old member of the group told me, they were not provided food at the government quarantine centre in Dobhi, where they had been held for 14 days. “At the government quarantine centre, we received no facilities like bedding, food supply or kitchen with utensils,” Paswan told me. “It was only a vacant primary school building where we were on our own. From food to beddings, we had to arrange everything with the help of our family members and the villagers we knew. We were totally on our village people’s mercy.” Paswan told me that several representatives from their village had visited the district magistrate and the block development officer’s offices asking for food to be delivered to the quarantine centre, but were ignored. “It seemed as if we have been left to die in quarantine centres right after managing to skip death from hunger far away from home,” Paswan said.     

The situation is similar in quarantine centres in southern Bihar. On 21 May, a seven-year-old named Ankush Raj, who had returned with his parents from Mumbai four days before, died after being bitten by a snake while sleeping at a quarantine centre run in Kanchanpur High School of Matihani panchayat, in Gaya district. “This instance has left the migrants returning to south Bihar really scared,” Banarsi Alam, a Gaya-based activist I spoke to on 21 May, said. “The boy and his family, along with others, were compelled to sleep in the centre’s verandah with the rooms being overcrowded.”

Quarantine facilities also failed in testing those who had a contact history with patients of COVID, instead only testing those who were severely sick. “If the government-run quarantine centres cannot even provide medical facility and ensure COVID testing for the quarantines, how are they efficient or any better than those being run in lack of funding at village level?” a magistrate-on-duty posted at a quarantine facility in Pandaul block of Madhubani district, who wished to remain anonymous, told me. Local health officials I spoke to said that migrants avoided reporting about travel or symptoms of the virus in hopes of avoiding the poor conditions of quarantine centres. All quarantine centres in the state were shut on 15 June.

Women, too, have been unwilling to go to quarantine centres and isolation wards after a horrific case in the town of Gaya. On 27 March, a woman was admitted to the Anugrah Narain Magadh Medical College and Hospital, in Gaya, with complaints of excessive bleeding caused by an abortion she had had earlier. On 1 April, after showing symptoms, she was suspected to have COVID-19 and was shifted to the isolation ward of the hospital. She was discharged two days later after testing negative for the virus. On reaching home, the patient complained to her family that she had been sexually abused by a member of the staff at the hospital on the nights of 2 and 3 April. The patient died on 6 April from excessive bleeding. The Bihar police have since arrested one of the suspects in the case. “The incident still dissuades the womenfolk in rural Gaya to open up about showing symptoms of corona,” Rekha Anil, an activist from Gaya, told me. “They still don’t feel safe about being quarantined in Bihar hospitals. Even institutions to treat a deadly disease are not free from the clutches of widespread lawlessness in Bihar.”

On 22 June, I spoke to Abhishek Singh, the district magistrate of Gaya. “The sexual violence incident of the quarantined woman from Gaya was molestation and not rape as reported by many media organisations,” he said. “In her case, the accused was arrested immediately. Like incidents of sexual violence even happen in Indian households, this was a one-off case. The women across the district should not back off from seeking quarantine and treatment of COVID because of an exceptional case.”

Several ASHA workers I spoke to said that in rural Bihar quarantine centres did little to stop the spread of the virus. The ASHA workers requested not to be identified by their surnames fearing repercussions from the government. On 17 June, I spoke to Kavita, an ASHA worker from Khagaria district. “Only returning migrant workers who show symptoms are taken to quarantine centres,” she told me. “After that, only those who fall seriously sick are taken to get COVID tests.” Anita and Kusum, ASHA workers from Muzaffarpur and Rohtas districts respectively, told me the procedure was similar in quarantine centres in their districts. This would mean that asymptomatic migrant workers would continue to spread the contagion.

ASHA workers also told me that they were not given any safety equipment throughout the lockdown. “On an average, hardly any ASHA in Bihar has been given anything more than one disposable mask in the name of safety gear till date,” Sashi Yadav, the president of the ASHA Karyakarta Sangh, told me. “The CM has turned a deaf ear to my repeated requests on behalf of all ASHAs to provide at least basic safety gears like ample number of gloves, N-95 masks and extra allowance for their services at the time of a pandemic. This has discouraged the ASHAs from being on the ground.”

Like ASHA workers, sanitation workers on the frontlines of the pandemic, too, complained about the complete lack of safety equipment. On 17 June, I spoke to sanitation workers carrying cleanliness drives in the prime localities of Patna, none of whom were given masks or gloves. Sadanand Ram, a sanitation worker of the Patna municipal corporation, seated in a garbage vehicle in SK Nagar, told me, “I was given only one mask by the corporation and it was a disposable mask. I haven’t even received any allowance for my services from the start of the pandemic.”

Praxis, a Patna-based non-profit organisation, conducted a survey of sanitation workers in the Rukanpura, Kankarbagh and Raja Bazar localities of Patna over the span of a week. Their survey found that since early March, sanitation workers had only been given one disposable mask which couldn’t be used beyond a few days. “As against receiving extra allowances for this high-risk work, the workers said that one-day salary was deducted from their pay during the lockdown,” Vijay Prakash, a member of Praxis, said. “The quality of the sanitiser they had received was also very bad.” Himanshu Sharma, the municipal commissioner of Patna, did not respond to phone calls.

Even prior to the pandemic, Bihar had one of the weakest health infrastructures in the country. In the 2019 Health Index report by the Niti Aayog—a think-tank that replaced India’s planning commission—which studied health indicators of 21 states and union territories, Bihar registered the most negative incremental change in nearly every public-health indicator. “In Bihar, this is reflected in the deterioration of most health indicators such as Total Fertility Rate, low birth weight, sex ratio at birth, institutional delivery, TB treatment success rate, ANM and staff nurse vacancies, functional 24x7 PHCs, birth registration, Integrated Disease Surveillance Programme reporting, Community Health Centre grading, accreditation of facilities and fund transfer,” the report stated. Despite these severe shortcomings in the Bihar health system, the state did very little to bolster its medical infrastructure during the first three phases of the lockdown, to fight the pandemic.

The COVID-19 pandemic laid bare the complete lack of health infrastructure in rural Bihar. Nearly 89 percent of the state’s 12.4 crore population live in villages. In mid-June, I had spoken to several activists and doctors from Rohtas district, in southern Bihar, who told me that the district’s threadbare health infrastructure was entirely unable to test, quarantine or monitor patients during the COVID-19 pandemic. The Sadar hospital, in the town of Sasaram, is the only hospital in Rohtas that has an isolation-ward facility to test and monitor possible COVID-19 patients. The district has 19 PHCs and 32 additional PHCs. “Even infrastructure for additional PHCs at the level of Panchayats within the prime blocks of Sasaram is lacking,” Ashok Kumar, an activist of the Grameen Mazdoor Union, said. “The situation is so pathetic at the panchayat level, most of the additional PHCs are being run in rooms in people’s houses.”

“In Bhadokhra and Sikaria panchayats of Sasaram, you will not find any doctor but only an auxiliary nurse-midwife at the additional PHC,” Ashok Kumar, said. “Even they do not visit the centre everyday and opt for weekly visits. If there is an urgency, they reach the centre on request of ASHA workers. However, in Senduar panchayat, there are four healthcare employees recruited at the centre but no one visits until called in case of a health urgency.”

Ashok Kumar said that even basic first-aid was not accessible at these PHCs. “These health workers seem to be ornamental appointments,” he told me. “Even before the days of corona, they used to refrain from touching a patient and would treat them with neglect. For any treatment, one will be referred to Sadar hospital. For corona test, the Sadar hospital doctors refer the patients to Patna’s prime government hospital NMCH.” He was referring to Nalanda Medical College and Hospital in Patna. Bhola Shankar, an activist of the Communist Centre of India—a left-wing organisation functional across the state—who is based in Sasaram, told me that none of the additional PHCs in Sasaram had a single hospital bed. According to the Indian Public Health Standards laid down by the union ministry of health, PHCs are expected to have at least six beds, with more in high population areas like Sasaram.

The 18 block-level PHCs in West Champaran district of northern Bihar fare as badly. “Most of the primary health centres are either non-functional or run in shortage of staff,” Pankaj, a land-rights activist based in the district, told me. “Hardly any health centre has a doctor on duty 24-7. From healthcare to the nexus of bureaucrats with the government, the entire system in Bihar reeks of corruption and chaos. A pandemic will not bring them to their toes. It’s a scary state of affairs.” Pankaj said that MBBS doctors were not available at all health centres. “Dr Shambhu Sharma is an Ayurvedic doctor taking care of additional PHC in Jogia panchayat, Ramnagar block for the past 25 years continuously,” Pankaj told me. “In rural Bihar, there is a dearth of dedicated doctors. Corruption and lack of intent to provide service is the norm.” Pankaj said that PHCs had more patients in the period between 2007 and 2014 with the Nitish Kumar-led government giving some attention to improve their infrastructure with newly painted buildings and some improvement in availability of medicines across rural Bihar. However, he said that in the last five years, the condition of these PHCs had rapidly deteriorated again.

On paper, the additional PHC run by Sharma has three doctors. However, a staffer at the Jogia panchayat additional PHC who wished to remain anonymous, told me that the MBBS doctor appointed at his centre practices at Ramnagar Block PHC. “According to healthcare-centre guidelines, there should be two ANMs at Sharma’s centre. But only one has been appointed,” he said. “The other two additional PHCs under Ramnagar PHC do not have a doctor available. They are run by ANMs alone.” Unlike Sasaram, several additional PHCs in West Champaran have hospital beds. Without indicating there would be any improvement of basic infrastructure or staff availability in PHCs, the chief minister, on 20 July, announced that all PHCs will begin conducting COVID tests.  

“Bihar government doesn’t have unavailability of workforce. It has ASHA workers, Mamta workers and Jeevika volunteers,” MK Nirala, a Gaya-based social activist, told me. Jeevika volunteers refers to women’s self-help groups formed under the Bihar Rural Livelihoods Project and Mamta workers are health workers tasked to provide healthcare of mothers and newborns. Nirala continued, “These volunteers are in regular touch with the village society and know of their superstitions and status of health awareness. Only if the government had the intent of communicating with them round the clock and facilitating and training them well during such grave times, it could have led to a lot better preparedness during the COVID-19 pandemic on the grassroots.”

Till late March no district hospital in southern Bihar had been converted into a specialised COVID centre. All patients had to be referred to the NMCH in Patna. On 7 April, the government converted ANMCH in Gaya district and the Jawahar Lal Nehru Medical College in Bhagalpur district into specialised COVID hospitals. In late June, the All India Institute of Medical Sciences at Patna was made the fourth specialised COVID hospital and the health ministry directed its administration to reduce the intake of general patients. Currently district hospitals have only testing facilities and provide isolation wards for COVID suspects. In comparison, by 20 April, Odisha had ensured that every district had at least one specialised COVID-19 hospital.

Several senior government doctors I spoke to said they were alarmed at the absolute lack of support they had gotten from the government. “There is lack of interaction between the top management of hospitals and the state government,” the senior doctor from Vaishali district told me. “The government has never bothered about investing in public health and the corruption is deeply rooted even at top hierarchies in hospitals. So yes, PPE”—personal protective equipment—“and testing kits are being supplied but with no round-the-clock communication with state healthcare staff. There is hardly any record of the supplies visible for public access. This means absolute lack of transparency about supply of safety equipment and testing kits.”

Doctors were also concerned that even in the few COVID-specialised hospitals in the state, doctors were skipping duty to continue their private practice. “A good number of doctors in public healthcare in Bihar do not work for their passion,” a senior doctor at AIIMS Patna told me, requesting anonymity. “They instead work from proxy during COVID-19 duty, skipping crucial services at the hospital and thriving on private practice. They know corruption.” A press release from the Bihar health department dated 6 May noted that as many as 362 doctors of public hospitals were absent from duty in the period between 31 March and 12 April. They were served a show cause notice over dereliction of duty during a pandemic.

On 18 July, I spoke to Dr Shakeel Ahmed, the Bihar convener of Jan Swasthaya Abhiyan—the Indian chapter of the People’s Health Movement. “From a few public hospitals which provide quarantine facility and have reserved a few beds for COVID patients to the three specialised COVID hospitals run by Bihar government, each of them lacks staff,” Ahmed told me. “Hundreds of posts for medical staff are lying vacant. So, the patients don’t get adequate care. It is sometimes next to impossible for even people with political contacts to get admission in AIIMS, which has relatively better health facility, so common people getting a bed there is less likely.” He told me that on 18 July, a COVID-testing lab in Patna had to be shut for three days as the lab technicians had contracted the virus. “So, imagine how vulnerable each of us are, we have been left by an indecisive government to rely on our misery.” Uday Singh Kumawat, the principal secretary for health as well as Mangal Pandey, Bihar’s health minister, did not respond to questions about the state’s health preparedness when contacted over the phone and by email.

Following the formal end of the nationwide lockdown on 31 May, the Bihar government ignored any precautions to slow the spread of the virus. Large gatherings such as weddings and party meetings were not prohibited, leading to an accelerated spread of the virus. In early July, 113 guests at a wedding in Patna were found to be positive, including the groom who later died. “Neither were gatherings at weddings and markets regulated with any strict steps nor were the ruling party alliance leaders made to take COVID precautions while assembling during virtual rallies for the forthcoming assembly elections,” Basant Chaudhry, an advocate based in Patna, told me.

The spread has shown no signs of slowing down—Bihar recorded its highest daily increase of coronavirus cases on 14 July. The administration was in a state of absolute panic, given that a range of senior officials and members of the ruling coalition, had tested positive for the virus, including Sanjay Jaiswal, the state president of the Bharatiya Janata Party, Devesh Kumar, the BJP’s state general secretary and Amir Subhani, an additional chief secretary in the Bihar government. As many as 75 BJP leaders in Bihar, and Gulam Gaus, a member of the legislative council from the Janata Dal (United), have been found COVID positive. The chief minister Nitish Kumar’s niece also tested positive on July 6. Following this, a room in Kumar’s 1 Aney Marg residence was turned into a ventilator-equipped temporary hospital. The hospital would have three shifts of doctors who were shifted out of Patna Medical College Hospital.

The scene was chaotic on 14 July, when I went to visit Kumar Ravi, the collector of Patna. “It is impossible that sahab would meet you,” a government staffer at the collectorate told me. “Even the chief minister’s officials and allies have contracted COVID, there is extreme tension in the state’s circles of politicians and administrators today.” Two days later, the state government announced an impromptu lockdown till 31 July.

At the Patna secretariat, I came across a group of peons sipping tea. “When the district magistrate contracted corona, the power shifted to deputy district collector,” one of them joked. “Then DDC was also infected, the power was shifted to his junior. This will go on till all the administrators are afraid of contracting corona and the peon can see himself as the future DM.”