How Bihar’s weak public health and food infrastructure is failing its citizens

Used coronavirus testing kits are left on a table at a testing and isolation ward for suspected COVID-19 patients at a primary healthcare centre in Bihar’s Bhagalpur district. PHC’s in the state have been negligent in following COVID-19 protocols. Danish Siddiqui/REUTERS
07 November, 2020

On 12 October, a primary health centre held a COVID-19 testing camp in Fatuha, a satellite town in Bihar’s Patna district, which was to begin at 1 pm. By 2 pm, when I reached the camp, the camp had already wound up. The PHC had finished the COVID-19 testing and turned into a polio camp. The auxiliary nurse midwives, who are village-level health workers, told me that they had tested 130 patients for the coronavirus, of whom only one had tested positive.

The Fatuha PHC was negligent in following several COVID-19 protocols. None of the ANMs were wearing masks even though they were in close contact with newborns and infants during the polio camp. When I asked for sanitiser both at the PHC entrance and at the ward room inside, I was told it was not available. When I inquired about how 130 persons could be tested in an hour with all COVID-19 precautions being followed, I was asked to meet Brahmprakash, the PHC manager, who said, “We are doing tests every day, our staff has got in a habit to carry the tests faster by now.”

On my way to his cabin, I met Sugni Devi, an accredited social health activist, or ASHA worker. ASHA workers are designated community health workers who were instituted as part of the central government’s health mission, in 2005. “I frequently visit the PHC with people from the surrounding villages to get them tested for COVID and to get their kids polio drops,” she said. I asked her what protocol is followed when a person tests positive at the PHC. “So far, they ask me to instruct the COVID-positive patients on what medicines to take and what regulations to follow during home isolation which has to be 14 days,” Devi said. When I asked whether the PHC recommends that patients isolate in a nearby hospital, she answered, “Here, the PHC’s responsibility ends by letting the infected persons get guided on self-treatment through ASHAs.”

However, Brahmprakash told me that COVID-positive patients who are severely ill are immediately sent to hospitals such as AIIMS and other government hospitals, including Patna Medical College and Hospital and Nalanda Medical College and Hospital.  Devi contradicted this information. “I interact will all the patients I bring with me to the PHC,” she said. “I never saw any patient being referred to the hospital from here.”

There were no stretchers or trolleys in the wards at the Fatuha PHC. Sanitation workers were disposing the swab samples taken during COVID-19 testing by simply burning them in the open, outside the PHC. “I pity the sanitation worker who disposes the materials used in testing,” a staffer at the PHC, who had initially informed me about the testing camp, told me on the condition of anonymity. “She is neither provided any safety gears nor is trained in what protocols to follow for disposing them. Even the PPEs”—personal protective equipment—“used here by the one carrying tests is not up to mark. While testing, the protocols for COVID precautions are also flouted. They don't even keep a sanitiser for disinfection purpose while carrying out tests.”

On 20 July, Nitish Kumar, the Bihar chief minister, announced that all PHCs in the state would begin conducting COVID-19 antigen tests. More than three months after Kumar’s announcement, several PHCs in the state have not yet started conducting these tests. Social activists working in the Lauriya block of the West Champaran district told me that the majority of residents in the block had not heard of COVID-19 testing camps, were not aware of the pandemic’s severity. Nageshwari Devi, a resident of Ambedkar Nagar, a colony in rural Lauriya, told me, “Our villages are severely hit with floods and no help has reached us.” Floods had hit Bihar at the end of July. “When nobody in governance have cared about our survival since the lockdown, do you think they will provide us any healthcare during corona?”

Sanjeet Mukhiya, a resident of Nardiganj block in South Bihar's Nawada district, also described the poor condition of PHCs in Bihar. “In lack of facilities, minimum attendance of staff and in lack of doctors, what accuracy the tests being conducted must be having could be well imagined,” he said. “Nitish Kumar only announced all PHCs will conduct COVID tests, there was no word on how they will be made efficient to conduct tests, how the safety and attendance of the health workers will be assured. How many PHCs have to be made functional? Will any senior officer monitor the testing taking place at PHCs? No word.”

Several health activists and workers complained that Bihar was underreporting its COVID-19 tally with an eye on state assembly elections. The state went to the polls on 28 October and the results are expected on 10 November. I spoke to a Patna-based staffer of the Pradhan Mantri Jan Arogya Yojana—also known as Ayushman Bharat, a central-government health assurance scheme. “On paper, the government is even making claims of conducting over one lakh tests per day,” he told me, on the condition of anonymity. “But there are constant efforts to suppress the positivity rate on the surface instead of flattening the curve for real. One common strategy is to resort to antigen tests in large numbers instead of resorting to RT-PCR tests at the same rate.”

Shakeel, a doctor and the Bihar convener of the Jan Swasthya Abhiyan—a public-health movement—described problems with rapid antigen tests. Shakeel also runs a clinic for the welfare of the poor with a group of doctors in Patna. “Rapid antigen tests are sensitive but they have very low specificity,” he said. “If they correctly diagnose a person as COVID positive, the test has accuracy. But when it diagnoses a case as negative, its accuracy is 50 per cent doubtful.” Referring to the Indian Council of Medical Research, the nodal body framing India’s COVID-19 policy, he added, “That is why a protocol of ICMR also says a symptomatic person tested as COVID negative must opt for RT-PCR test. I personally know of many cases during my experience of treating COVID where those tested negative in an antigen test were diagnosed as positive in an RT-PCR test.”

The Ayushman Bharat staffer also said that COVID-19 testing numbers were being forged to show a higher testing rate. “Another eyewash health workers create is where people are listed as COVID tested without even being tested,” he said. “Lately, with contact tracing being cut down, health officials even carry frauds like listing all the family members of a COVID positive patient as tested after only testing the former. It's an alarming malpractice.” He added, “I know of cases where health volunteers were distributing health cards to villagers and at that opportune moment a number of health officials reached these camps and labeled the register entries of the persons receiving the cards as COVID tested.”

Health activists further told me that after the pandemic passed the peak months from mid-July to mid-September, contact tracing in Bihar had substantially reduced. They added that asymptomatic persons were being denied COVID-19 tests, even if they had been in contact with a positive patient. “I personally experienced this when I recently sent a few frontline health workers who were in proximity of COVID infected doctors for tests,” Shakeel said. “They were denied tests on grounds of being asymptomatic.”

The lack of efficient contact tracing and frequent testing for personnel at the frontline of COVID-19 fight had led to the death of a substantial number of paramedics, nurses and doctors in Bihar. “Doctors account for 0.5 per cent of the total deaths in India due to COVID-19,” Ajay Kumar, the senior vice president of the Indian Medical Association’s Bihar branch told the Hindustan Times in early August. “However, in Bihar, the percentage of doctors’ death is 4.75 per cent, which is nine times more than the national average.”

Social activists also told me about the poor condition of government hospitals in Patna that are treating COVID-19 patients. In September, Pankaj, a land-rights activist from West Champaran district was at the Patna Medical College and Hospital for 25 days attending to his wife Shachi, who was admitted in the general ward after a surgery. “I was shocked to see the condition of the toilets at PMCH,” he said. “Doors were broken, the trash was lying unattended and the stink was unbearable. When my repetitive requests to the hospital staff to clean the toilets fell on deaf ears, I asked them the reason. I was told the toilet has not been cleaned since 10 years, so nobody bothers anymore.” Pankaj added that on the morning of 19 September, his Patna-based activist friends, including Sumant Tiwari and Priyadarshi Priyam, held a protest by volunteering to clean the toilets themselves holding cleaning brushes and phenyl. “The initiative led the hospital top authorities to take cognisance of the problem and sanitation workers were sent by them,” Pankaj said. The PMCH superintendent, AK Chaudhary, did not answer several calls made to him.

I asked ASHA workers about the COVID-19 situation in Bihar after the massive influx of migrants returning to the state. They requested not to be identified by their surnames fearing repercussions from the government. Kusum, an ASHA worker in Rohtas district, said that the quarantine centres where the migrants were isolated were “mismanaged and pathetically facilitated.”  According to Kusum, the ASHA workers were supposed to screen the migrants, but there were no arrangements in place to test them. “Neither the persons who could have carried the infection from outside Bihar or could have contracted COVID at the quarantine centres were tested before being sent home,” she said. “There was no follow-up on whether they carried the disease home. The government didn't bother to assure adequate food supplies, toiletries or even social distancing to them at the centres as promised.” Kusum added, “If they spread the virus it was mostly because of how pathetically they were attended during their 14-day quarantine period. The plan was good but the implementation was pathetic beyond belief.”

Kavita, an ASHA worker in the Khagadiya district, echoed a similar experience. “I haven't seen a more heartless government. They treated lakhs of returnee migrants like lesser humans when they were hoping for some relief back home after enduring a very painful lockdown away from home,” she said. Referring to the government, she continued, “Then they were only bothered about putting up a delusion of health safety measures to hide the health sector's inadequacies. Now they are bothered about elections.”

In addition to its weak health infrastructure, Bihar also has poor access to healthy nutrition for the public. In a memo on healthy eating published on its website, the World Health Organisation noted that high nutrition can strengthen immunity. “While no foods or dietary supplements can prevent or cure COVID-19 infection, healthy diets are important for supporting immune systems,” it said.

In March, following central government guidelines, Bihar announced a mandatory free supply of five kilograms of rice and one kilogram of pulses for the month of April to 1.47 crore ration card holders. However, as I reported in July, the supply was ineffective—it either never reached the intended beneficiaries or was significantly delayed. The state’s health crisis was compounded by a food crisis.

In my reporting, I have found that for most of the economically disadvantaged families in Bihar—in particular, those who have lost their livelihood due to COVID-19 and the subsequent lockdown—an average meal means only rice. The Kharif season has also been being disappointing for farmers this year, in part due to the floods—many are in debt and have failed to even produce vegetables for their own consumption. In the current situation, getting a proper meal is a far-fetched reality for many unemployed and marginalised communities.

“We have been surviving only on free rice, the only relief which has reached us through the government,” Omprakash Yadav, a resident of Ambedkar Nagar in West Champaran district told me. “I hope that with such poor food supply, we will be able to fight the infection if it reaches us. With how less food we have been eating since April, if there are deaths here, they would because of lack of food.”

I spoke to Rupesh, the secretary of the Koshish Charitable Trust, a Patna-based nonprofit that works on the right to food, among other human-rights issues.  “Since the lockdown, Bihar doesn't even have plans to identify malnourished children in place,” he said. He cited findings from a study that a Koshish team is currently working on. “We found that between March to May, no child in Bihar was referred to a Nutrition Rehabilitation Centre, with all these centres across the state's 38 districts being shut since the lockdown.” NRCs are government-run health facilities that admit and provide nutrition and care to children with Severe Acute Malnutrition. Rupesh continued, “About 17 percent vacancies for doctors and 17 percent for nurses in NRCs have not been filled in the last five years. Thirty four percent rehabilitation counsellors”—staffers who care for the children at the NRC’s— “vacancies lie vacant since five years.”  

In March, the Bihar government decided to compensate children in government schools who would lose access to their mid-day meals, a free lunch meal provided by the school, due to the lockdown. It announced a paltry compensation of Rs 114 and Rs 171 for a 15-day period for students from classes one to five, and six to eight respectively. Rupesh said that this compensation was insufficient to meet the children’s dietary needs.

“Only about 30 percent of Bihar children have received mid-day meal compensation since the lockdown announcement,” he said, referring to data he said he learned through his field work with the right-to-food campaign, a movement run by a network of food-rights activists. “Even the Anganwadi workers”—village-level health and education workers—“who used to map the nutrition and immunisation requirements of children below six years after checking their height, weight, health are not carrying these responsibilities since the lockdown.”

Unlike states such as Kerala, which launched a protein, iron and calcium packed nutrition bar that they are distributing to tackle malnutrition among children, Bihar has no plan to provide food to its malnourished children amid a pandemic. “The government's failure to prepare the state to fight the pandemic has left the disadvantaged population without food, health and financial security,” Rupesh said. “An election will pass by while people survive with no support from their government. It will take a very long time for Bihar to overcome the fight against hunger. Overcoming the COVID fight seems to be an impossible aim in such a situation.”

Mangal Pandey, the state health minister, and Pratyaya Amrit, the principal secretary at the Bihar Health Department did not respond to emails seeking comment.