Bihar’s junior doctors forced to continue treating COVID-19 patients despite showing symptoms

On 23 March, the Junior Doctors Association of Patna's designated COVID-19 hospital wrote a letter to the hospital's superintendent and appealed to send 83 junior doctors to home quarantine, as they were exhibiting symptoms of the disease. (This representative photo is from MMG Hospital in Ghaziabad on 16 March 2020.) Saqib Ali / Hindustan Times / Getty Images
27 March, 2020

The Nalanda Medical College and Hospital, in Patna, has been designated by the Bihar government as the state’s primary hospital to treat cases of COVID-19. The government claims that the hospital’s isolation ward has 600 beds. On 23 March, the hospital’s association of junior doctors wrote a letter to the NMCH’s superintendent. Signed by a dozen doctors, the letter said that most of the junior residents working in the hospital’s out-patient department, emergency and isolation wards had come in contact with the coronavirus patients and were exhibiting symptoms such as fever, cough and sore throat. On consulting senior doctors, the letter added, “we have been advised to go for home quarantine for a period of 15 days.”

After receiving the letter, the NMCH superintendent wrote to the principal secretary of the state’s education department, asking for directions from the health department for quarantining 83 junior doctors who were showing symptoms. Although two days have passed, no concrete directions have arrived. Neither have samples been taken from the doctors for testing. The junior doctors continue to treat patients in the meantime.

The first COVID-19 cases in Bihar were reported on 22 March, when test results for two patients were found to be positive. One of them, 38-year-old Saif Ali from Munger district, had been admitted at the All India Institute of Medical Sciences, Patna, on 19 March. He died the night before his test result came back. The other patient, who was also admitted at AIIMS Patna, was a woman whose son had recently returned from Italy. The police have kept her son under quarantine. On 23 March, a third patient, Rahul Kumar, tested positive for COVID-19. Kumar had recently visited Scotland, which had already seen 499 cases, of whom 14 had died. He was admitted at NMCH, and the junior doctors seem to have contracted the coronavirus while treating him.

The only laboratory in Bihar testing possible COVID-19 samples is Patna’s Rajendra Memorial Research Institute. There are plans to open a test lab at Darbhanga Medical College, but there has been little progress in setting it up over the past ten days. “The test kit has not even arrived yet,” Dr Ragini Mishra, the state epidemiologist, told me. “Once the kit arrives, it will be calibrated, then sent to Pune. Only once we get approval from Pune can we start testing. The entire process will take at least fifteen days.”

Although Bihar did not have any COVID-19 cases until 22 March, the number of positive test results is increasing. One patient initially tested negative, but is clearly showing symptoms. According to the RMRI director, Dr PK Das, another sample was taken from the patient and sent to the National Virology Laboratory in Pune, and the NVL has found the test to be positive.

At NMCH, the junior doctors told me that, despite being designated the state’s only coronavirus hospital, they do not have even basic facilities for treatment, which is why 83 of them are showing symptoms. “Doctors here aren’t provided post-action kits, N95 masks, HAZMAT kits”—which include gloves, masks, shoe covers, gowns and protective goggles—“or even sanitisers,” Ravi RK Raman, the president of the junior-doctors association, told me. “We are using surgical masks and surgical kits for our own protection.”

Bihar has a population of 104.1 million, according to the 2011 census. As per population norms, it should have 3,470 primary health centres—one for every 30,000 people—but has fewer than two thousand PHCs. It should have 867 community health centres—one for every 120,000 people—but has only 150 CHCs. This shortfall in primary and secondary care increases the pressure on the state’s Sadar Hospitals, which provide tertiary care. With the COVID-19 pandemic striking panic, these hospitals are being overwhelmed by people with flu- or cold-like symptoms.

However, several doctors at Sadar Hospitals told me, on condition of anonymity, that they are woefully underequipped. “More than fifty patients are coming here every day, but we don’t even have masks or sanitiser,” a doctor at the Samastipur Sadar Hospital told me. “We are wearing three surgical masks at once to protect ourselves while treating patients. We’ve made sanitiser by mixing equal amounts of surgical spirit and saline water. Doctors wash their hands with it after seeing every patient. I don’t know how effective it is, but we don’t have any other choice.” He said that when he returns home after a shift, he tries to stay away from his family to protect them. “But the kids don’t agree,” he said. “They want to play with me.”

Nine medical colleges in Bihar have been authorised to collect samples to test for COVID-19. Anybody who goes to a PHC or CHC having recently travelled abroad and exhibiting symptoms is sent to a Sadar Hospital, where doctors can refer them to one of the nine medical colleges. “There is so much panic that people are going to the hospital and demanding that we examine them using the infrared temperature sensor,” the doctor at the Samastipur hospital said. “They think that the sensor is a machine to test for the coronavirus.”

The Bihar government has also ordered its Accredited Social Health Activists to collect information from outsiders in their villages and send them to the nearest PHC or sub-divisional hospital. Bihar has about four thousand ASHA workers. They have not been provided masks or hand sanitisers either. “When we received the order to identify people coming from outside, we had asked the hospital to provide masks and sanitisers,” Manju Kumar, an ASHA worker in the village of Kerai in Jehanabad district, told me. “The hospital management told us that they themselves didn’t have masks or sanitisers, so what could they give us? I spent Rs 250 from my own pocket to buy a mask and a hand sanitiser. When I walk in the village, I carry them with me.”

“A lot of ASHA workers were not able to buy these things, because they had run out in the markets,” Meera Sinha, a member of the ASHA Workers Sangharsh Samiti, told me. “They are using their dupattas as masks.”

India’s first COVID-19 case was reported on 30 January, in Kerala. By 20 March, there were 236 cases throughout the country, but the Bihar government had not taken any action besides making a few formal announcements. This inaction is illustrated by two incidents.

The first is the death of Saif Ali. On the night of 12 March, Ali returned home from Qatar, but no official from either the district’s government hospital or the Bihar government contacted him to check whether he was showing symptoms or had visited the hospital. In a video uploaded to social media, his relatives say that he met several people over the next four days. According to Dainik Bhaskar, on 16 March, after Ali faced kidney trouble, his family took him to a private hospital in Munger. The doctors there asked them to take him to Patna. Ali was admitted at a private hospital in Patna for the next two days. He was then taken to Patna Medical College and Hospital, on 19 March, but not admitted there. Instead, he was admitted at AIIMS Patna, where he died two days later. It was only after his family returned to Munger with his body that they were told he was infected with the coronavirus.

In other words, Ali was taken to four hospitals in five days, but none of them asked for his travel history. His sample was only collected at AIIMS Patna on 20 March. A scientist at RMRI told me, on condition of anonymity, that they received the sample around 11 pm that night. “We checked the sample on the morning of 21 March and got the result by evening,” the scientist said. “We shared the results with the Indian Council of Medical Research and state secretaries.”

Another doctor at a Sadar Hospital told me, “We had not received instructions to take the travel history of patients showing coronavirus symptoms earlier. It was only on 20 or 21 March that we were told that if a patient has a cough, fever, sore throat or trouble breathing, we should prepare their travel history.”

After Ali’s death, the district administration prepared a list of over sixty people who had come in contact with him and collected samples from them for testing. PK Das told the media that two of the samples had tested positive. This meant that thanks to the administration’s mismanagement, Bihar had reached Stage 2 of the outbreak: local transmission.

The other illustrative incident pertains to a young man who returned from China on 13 January. He asked me not to make his name or address public. “Two months and ten days after I returned from China,” he said, “block-level officers asked me, and a few others who had returned from China in the past week or so, to report to the local police station. When we went to the police station, the police asked us to go to the PHC. When we went to the PHC, the doctors asked us if we had a cold or a fever. When I told them I was fine, they asked me to go to the Sadar Hospital.”

The youth went to the Sadar Hospital that very day, but no one there would tell him what to do. “So I called the phone number publicised by the government, and I was asked to go to the emergency ward,” he said. “Again, they asked me whether I had any coronavirus-like symptoms. When I said no, I was told to go home and isolate myself for 14 days.”

Until recently, the ICMR guidelines had said there were two criteria for someone to be tested for COVID-19: whether they have returned from an affected country and are showing symptoms, or whether they have had contact with someone who had traveled and was showing symptoms. On 20 March, the ICMR expanded these guidelines to include those with severe respiratory illnesses, healthcare workers, and asymptomatic persons who may have come in contact with suspected cases. According to the doctors I spoke to, Bihar has followed the earlier guidelines. By 25 March, 275 samples had been examined, of which six were found to be positive.

Dr Arun Shah, a well-known physician, told me that the state government should test as many samples as possible in order to identify as many patients as possible, because once the coronavirus reaches community-level transmission, it will be very difficult to control. Scientists at RMRI told me that they can test a hundred samples at once, but the health department does not seem to be in the mood to test more aggressively.

When I asked Ragini Mishra about testing a hundred samples at once, she said, “That cannot be done. But, along with the previous conditions, we have added that if a person shows strong signs of coronavirus infection even without a travel history, they can be tested.”

This report first appeared in Karwan, The Caravan’s Hindi website. It has been translated and edited.