Spread of COVID-19 in rural Bihar quickened by failure to test returning migrants

A large number of migrant workers arriving from Maharashtra rest outside Patna Junction railway station, on 10 April. In comparison to the first exodus of migrant workers in March 2020, this time, the Bihar government seems even more ill prepared to test and monitor returning residents. Santosh Kumar / Hindustan Times / Getty Images

On 20 April, Rajesh Pandit, a 40-year-old owner of a meat shop, returned from Ludhiana to Patna by train. He was running a steep fever. He spent that night at the Patna station, for lack of transport, but was not screened for COVID-19 by the state’s authorities. The next day, he took a bus from Patna’s Mithapur bus stand and reached Baruna Rasalpur village, in Samastipur district. He was not swabbed for the virus there either. “All my neighbours knew that he had fever and breathing problems, but no health worker turned up or arranged for either testing or treatment,” Ram Udesh Pandit, Rajesh’s younger brother, told me. Rajesh’s family got him medicines from a local shop, but his condition did not improve. “On 24 April, we took him to Samastipur and got him tested at private test centre,” Ram Udesh said. “It was positive.” The next day, a CT scan at another private centre showed that 35-percent lung damage. By then, his fever had worsened and he was struggling to breathe. He was admitted to a private hospital in Samastipur town and transferred three days later to Darbhanga Medical College and Hospital. Rajesh died on 4 May.

“He was a healthy man,” Ram Udesh told me. “If he was tested earlier then he might not have died.” He told me that his brother was the first death in the village, once the second wave of COVID-19 began spreading into the vast rural hinterland of Bihar. “The entire village have socially isolated our whole family after that,” Ram Udesh said. Despite this, others in the village too had begun showing symptoms of COVID-19. The medicine shop owner, who the family had bought medicines from, had been suffering from a fever and severe cough for a week. Ram Udesh said that many others in the village were exhibiting similar symptoms. He told me that despite the visible spread of COVID-19 across the village, no testing or general screening was being done.

In the last few weeks, as the second wave of the COVID-19 pandemic overwhelmed Delhi, Mumbai and the other major urban centres of India, migrant workers from Bihar began returning to the state for a second time, in a panic. However, in comparison to the first exodus of migrant workers following the sudden nationwide lockdown in March 2020, this time, the Bihar government seems even more ill prepared to test and monitor returning residents. Despite the second wave being more infective and taking a larger death toll in Maharashtra, Gujarat, Uttar Pradesh and Delhi, the Bihar government has failed to prepare for the wave even to the levels they had in the first wave. Very few bus stands and railway stations in the state have the infrastructure to test returnees, and the few that do are not consistently testing them.

This has allowed the virus to spread to rural Bihar. Healthcare workers in villages have not been given any instructions to quarantine or test returnees—both panchayat leaders and rural health workers told me that despite them reporting the spread of COVID symptoms in their villages to senior government officials, the state government did not give them any resources or orders to deal with the situation. Simultaneously, major hospitals in cities are also facing severe shortages of beds and oxygen.

Despite many criticising the unpreparedness of the Bihar government to manage migrants returning in 2020, transport, testing and quarantining seem to be even less organised this year. Last year, when a country-wide lockdown was imposed and reverse migration started, thousands of workers thronged to their villages. The railway ministry had started Shramik Special trains to bring stranded workers back to Bihar. By 2 May 2020, the Bihar government had established quarantine centres in nearly every panchayat in the state. Two-week quarantines were declared mandatory for migrants who returned between May and late June. Health officials, such as the Accredited Social Health Activists, or ASHA, were also roped in to monitor incoming migrants in railway stations, bus stands and in each village.

These precautions played some part in limiting the spread of the first wave. By 30 May 2020, 2,310 migrant workers had tested positive and were quarantined. On 31 May, the Bihar health department announced that its total number of COVID positive patients was 3,629. This meant that 62.56 per cent of total positive cases were migrant workers and the Bihar government was likely able to contain the virus spreading with them to the state’s vast rural hinterland.

This year, preparations seem far more muted. My reporting from two major bus stands in Patna, and conversations I had with a half dozen panchayat chiefs and ASHA workers, all pointed to major lapses in preparation for the second wave. There was barely any testing when migrants reached the state, and they quickly flew off the health department’s radar after that. A few railway stations like Patna have COVID-19 monitoring centres, but testing was not uniform, and was mandatory only for migrants returning from Maharashtra.

On 19 April, 42-year-old Sundeswar Sahani left Delhi for his village in Bihar’s Vaishali district. The fruit seller had made the arduous journey only a year ago when the Indian government had announced a total lockdown to stem the spread of the first wave of the COVID-19 pandemic. The Bihar he had returned to then appeared moderately prepared for incoming migrants, with special trains to transport them to their districts, testing facilities at railway stations and a mandatory two-week quarantine.

Sahani said he knew he had to return the moment Arvind Kejriwal, the chief minister of Delhi, announced a week-long lockdown in the city, on 19 April. By then, most Delhi hospitals already lacked beds for COVID-patients, while several had chronically low supplies of oxygen. Crematoriums too were overflowing. “The Delhi government had imposed a night curfew,” Sahani told me. “I was selling fruits in the market. My business was totally shut.” With nowhere to go if he was infected and no hope of a stable income from his fruit stall, Sahani took a Bihar-bound bus from Rohini bus stand. The experience, he said, was alarming. “Three people were sitting on one person’s seat. It was packed with passengers. People were not wearing masks properly.”

He reached his village on 27 April, but was never tested for COVID. “I have no idea where to go and what is the process for COVID-19 tests,” Sahani admitted. “We need guarantees in the test. Someone should go with us and guide us in testing and results. They should also tell us what facilities are provided in the hospital. Poor people live at the mercy of God, without being able to get tested.” So far, he had no symptoms of COVID-19, but “that will not be the case for many others who returned to the state,” Sahani said. 

The Bihar government’s own data bears out Sahani’s fears that COVID is spreading across the state. On 3 April this year, Bihar’s health department had tweeted that 836 people had tested positive, and that one person had died of COVID-19. That number steadily grew over the month as more migrants returned. On 3 May, the health department reported 82 deaths and an alarming 11,407 new cases.

Overall testing also did not increase relative to the rate of incoming migrants. On 3 April, 63,982 people were tested for COVID-19. By 3 May, this had risen only to 72,658. These numbers could explain the sheer scale of undercounting that is likely in rural Bihar. The American media organisation NPR quoted Murad Banaji, a mathematician, whose research suggested that, “in some areas of rural Bihar, considerably less than 1% of infections were being detected.”

A reporter I spoke to said that suspected COVID-19 cases as well as deaths were climbing across rural Bihar. On 29 April, Neyaz Farooque, a reporter for the BBC who hails from Gopalgunj district’s Indarwa Bairam village, told me, “Four people died in my village in the last 24 hours, none had been tested for COVID-19.” He continued, “As per official figures there were zero COVID-19 deaths in the district.” Farooque said that, according to his local pharmacist, nearly 80 percent of the people who visited him had complained of fever and coughs, but testing and safety precautions were largely absent. When I spoke to him ten days later, he said, “The situation in my village hasn’t improved, in fact it deteriorates with each passing day.”

Several panchayat heads had similar stories of government unpreparedness and an exacerbation of the pandemic. On 3 May, Lakhendra Singh, the mukhiya of Muzaffarpur district’s Dadar Kulhua panchayat, told me that three persons in his panchayat had died in ten days. None of them had been tested though they all complained of the same symptoms—fever and cough. According to news reports, Muzaffarpur is one of the worst affected districts of Bihar, recording 21,768 cases and 141 COVID-19 deaths till 2 May. The three recent deaths, however, will not find their place in that tally, given that they were not proven positive. Singh said, “This would be similar in all of the surrounding panchayats, they have also had many deaths.” 

On 3 May, when I spoke to Leelawati Devi, the mukhiya of Siwan district’s Chakri panchayat, she said that, following the return of migrant workers, COVID-suspected deaths had climbed. Devi said that in the last ten days, around one thousand migrant workers had returned to the panchayat, and none had been tested. “I have so far met around 500 migrant workers who had recently come to the panchayat,” Devi said. “Not one had a test report. When I tell them to get themselves tested, they simply say that we go to the test centre but no one takes samples. They are roaming in the panchayat freely though we advise them to stay in isolation for two weeks.” She told me that one woman in her panchayat had died on 19 April while being taken to Siwan town for treatment. “She had a fever and breathing problems but since they didn’t test her, so her family still claims that she died of different disease and not corona.”

The panchayat’s nearest health facility is a primary health centre, six kilometres away in Raghunathpur village. The nearest COVID bed is 30 kilometres away in Siwan town. The Bihar government’s COVID-19 dashboard shows that Siwan has only 700 COVID beds, of which a vast majority are occupied, and completely lacks any ICU beds. This is to serve an entire district whose population exceeds 1.35 lakh. “Last year, the government was more vigilant but this year it is not doing much,” Devi said. “If things remain like this then corona will create havoc in our villages. I am planning to meet a block development officer and will demand to start coronavirus testing at block level so that migrant workers get themselves tested.”

Forty kilometres away, Panjwar panchayat’s mukhiya, Gopal Singh, was also struggling to monitor the return of migrants. “Migrant workers are regularly coming but the government is fleeing from its responsibility,” he said. “There is danger of spreading the virus at village level. People of the panchayat are afraid. I do advise them to use masks but to do anything else, my hands are tied.” Panjwar’s population is around fifteen thousand. Last year, Singh said, 23 positive cases were recorded in the panchayat. “But this year, so far, no new case has been reported. This is of course because they haven’t tested anyone at all.”

Many mukhiyas told me that the state government had not even bothered to communicate with them as the crisis deepened. Rajendra Paswan, the mukhiya of Kishangunj district’s Mahingaon panchayat, told me that the government had given no directions about how to deal with migrant workers who were returning from severely COVID-hit cities like Delhi or Mumbai. “Last year, there was clear direction regarding migrant workers,” Paswan said. “We knew what to do and the health department was very active alongside us. They used to sanitise the villages thrice in a week. People were distributed masks and crowds around shops were controlled. But nothing is being done this time.”

Many health workers in rural Bihar I spoke had the same complaint—a complete lack of instructions from the government. Kiran Devi, an ASHA facilitator in Araria district who leads 25 ASHA workers, told me that they had been given one responsibility by the health department. “We get information on WhatsApp from the PHC”—the primary health centre—“about COVID-19 positive patients in the villages under our jurisdiction,” she said. “After getting information, we instruct ASHA workers to visit the area and survey how many families are residing near the COVID-19 positive patients. ASHA workers also survey if any family members of the patient have any symptoms. We put all these details in a format and send it back to PHC.” But very few test positive in the first place. “We have no order from the government about migrant workers,” she told me. 

Working conditions are also unsafe for ASHA workers. Kiran Devi complained that the government was not providing personal protective equipment, gloves, or even face masks to ASHA workers. “We are regularly visiting the villages and interacting with people, risking our lives,” she said. “But we have to use our dupattahs as masks. This is not only endangering our lives, it could also lead to the virus spreading to more people we visit.” 

Kaimur district, on Bihar’s border with Uttar Pradesh, is a major entry point through which buses and private vehicles enter the state. Last year, the government had set-up a screening camp at the state border. Buses and private vehicles would stop there and passengers were checked before being guided to the quarantine centres in their villages. A local reporter from Kaimur, who wished to remain anonymous, told me that for the past few months, the border has conspicuously lacked a screening camp. “There is no screening camp at the check-post,” Meena Kumari, the additional chief medical officer of Kaimur, told me, on 3 May. “We have not been told how to deal with migrant workers coming here. The orders we have so far is to ensure that persons who voluntarily visit district level quarantine centres get tested.” The rest slipped past the state’s lack of a safety net.

The government has since changed its instructions. On 9 May, when I asked Kumari how many people had been tested at the district quarantine centre, she said that testing was now happening at the PHCs. “Every day around 1,200 people visit the out-patient clinics at PHCs and those that show symptoms are tested,” she said.

Kumari too confirmed that COVID-19 had already reached the villages of the district. “Currently, most COVID-19 patients are coming to us are from villages,” she said. “But the problem is that when COVID-19 symptoms develop in rural people, they tend to go to the local dispensaries or quacks. Quacks treat them as a common flu and a crucial four or five days are wasted. Only when their health starts seriously deteriorating do they run to hospitals. And at that point, we are finding it difficult to treat them properly.”

Tertiary facilities in the state are already overburdened by the case load of the second wave. Even in Patna, the state capital, there is a serious lack of beds and oxygen. The Times of India reported on 28 April that nearly every COVID-19 bed in both private and government hospitals in the city was already occupied.

Oxygen supplies, too, are stretched thin. On 17 April, Vinod Kumar Singh, the medical superintendent of Nalanda Medical College and Hospital, the largest government hospital in Patna, sent the state government panicked requests for oxygen. The same day, he sent a letter to Pratyay Amrit, the state’s health secretary, requesting the government accept his resignation if they are unable to supply oxygen to the hospital immediately.

Public-health experts told me that even the current pressure on tertiary healthcare centres did not account for the wave of cases that would arrive from rural Bihar if the government did not immediately move to monitor returning migrants and organise primary care at the village level. “Given the nature of spread and the rate of transmission of COVID in the second wave, it is quite vital to test the migrant workers returning to the village from more affected states and cities,” Vikas R Keshri, a public-health expert who has experience working in Bihar, told me. According to him, the state government should isolate and quarantine all returning migrants for two weeks, even if they test negative. “In the absence of this, there is a high probability that the infected migrant will transmit the disease to their family and community members in the village, and thus pandemics can spread in the rural area even faster. It would be a serious proposition for states like Bihar, where nearly 88 percent of people live in the rural area.”

Sunil Kumar, the secretary of the Bihar chapter of the Indian Medical Association, told me that the state government had done very little to ready rural areas and smaller towns for the second wave. “The government didn’t strengthen block and panchayat level health facilities,” Kumar told me. “It didn’t take concrete steps to ensure uninterrupted oxygen supply when demand increased. The government acquired a few ventilators but did not bother training technicians to run them.” Effective testing, Kumar argued, was Bihar’s main failure in the first wave, and it had only worsened its approach by the time the second wave hit. “No new RT-PCR machines were made operational in Bihar in the past one year and this has resulted in a major slowdown in our COVID-19 testing capacity.” With little investment in testing, he argued, controlling rural spread was nearly impossible. Mangal Pandey, Bihar’s health minister did not respond to questions about the lack of testing or screening, and the lack of instructions to health workers. Neither did Pratyay Amrit, Bihar’s health secretary.

According to Keshri, rural areas in Bihar were spared the worst of the first wave of the pandemic. “But the second wave is different in terms of transmissibility and severity,” he said. “Rural spread can be disastrous for a state like Bihar, where the health systems infrastructure in rural areas is already very frail. Once the pandemic spread in the rural area, it would be practically impossible for the health systems of Bihar to respond effectively to demand.”