Among India’s Poorest States, Bihar Unprepared For Coronavirus Epidemic

The health care system in Bihar, a state in northeastern India that is poor, populous and corrupt, may face collapse from the coronavirus pandemic due to poor planning and preparation, a dearth of sufficient equipment and low public awareness of the dangers posed by the virus.

If infections spread quickly in the province, its hospitals will not be able to cope with the likely deluge of people seeking medical attention. As it is, Bihar hospitals do not have enough space nor equipment to treat existing patients.

A doctor at the Jawaharlal Nehru Medical College and Hospital in Bhagalpur, Bihar, told German media: "According to protocol, we should be given an N95 mask, a personal protective equipment kit and sanitizer. Our situation is so dire that we use HIV kits to protect ourselves while treating patients. We also wear one pair or two pairs of gloves for eight hours. We reuse the gloves by sanitizing them. I am scared that I will contract the coronavirus if I continue to treat patients without proper safety equipment."

At Patna Medical College and Hospital, one of Bihar's biggest hospitals, beds are not available for potential virus patients, nor does it have a designated ward for symptomatic patients.

India ranks near the bottom of the World Health Organization’s list of countries in terms of spending on public health.

In late March, Prime Minister Narendra Modi vowed to invest 15 billion rupees ($197 million) into India's healthcare system to combat cases of the coronavirus. India is also scheduled to receive $1 billion from the World Bank to prepare medical staff for the outbreak.

But that is not nearly enough to handle potentially tens of millions of people who might become infected. In backwater states like Bihar, the lack of equipment is particularly acute – even protective masks and basic safety kits are in short supply.

Bihar, with a huge population of at least 99 million, has less than 2,000 primary health centers and 150 community health centers. The entire state also only has four operational Covid-19 test centers, three in Patna and one in Darbhanga.

"There has been poor planning of resources. The Bihar government doesn't have sufficient supply of [personal protective equipment] kit for doctors. Hospitals like the Patna Medical College don't have enough supply of medical equipment,” said Bhavik Doshi, senior product specialist at the Economist Intelligence Unit's healthcare unit. “Bihar also has 0.11 beds per 1,000 people, which is way lower than the WHO mandate."

Bihar does, however, boast a network of private hospitals, which are barred to the masses of its poor people.

While the Indian government claims that Bihar has less than 40 confirmed cases of the novel coronavirus, local doctors think the actual number is much higher.

"Some doctors in [All India Institute Of Medical Sciences in] Patna have told me that there are positive cases which are not being disclosed," said a resident of Patna.

"Many symptomatic patients are being turned away for lack of beds in my hospital," a doctor at Jawaharlal Nehru Medical College and Hospital said.

Doctors themselves have not received proper care.

In late March, the superintendent of the Nalanda Medical College and Hospital in Patna ordered the quarantine of 83 junior doctors who showed symptoms of the virus. However, the United Resident & Doctors Association of India said those doctors have still not been tested for the coronavirus nor quarantined.

Meanwhile, many Bihar doctors are being forced to use HIV kits and masks.

"The HIV protection kit does not fully cover the face up to the neck as compared to the triple layered N-95 masks. It also does not have goggles to protect the eyes," a doctor in Patna told The Hindu newspaper.

Health workers, who visit people in their homes, also lack protective equipment.

“We have not been given any masks or gloves or anything to protect ourselves when we go out and visit families where people have returned from other areas,” said Anita Devi, an accredited social health activist with the Ramgarh primary health center in Lakhisarai. “How are we supposed to go and meet people without any protection?”

Hospital administrators are making things even worse for physicians who are treating virus patients. For example, some hospitals do not even have separate isolation wards for coronavirus patients.

Ashesh Kumar, the civil surgeon at the 110-bed Sadar Hospital in Siwan, Bihar said he has been ordered by the government to create six isolation wards for potential Covid-19 cases.

“But just creating only a ward does not help...there is a lack of space, manpower and the medical supply is very limited,” he said.

The hospital also lacks personal protective equipment for health workers.

“We have to offer everything to the team in the field since they are examining the patients,” Kumar said. “So I do not have enough for the other staff or myself.”

Rohit Kumar, who runs Medicana, an online medical store in Patna, warned: "If doctors end up contracting this infection, then the rest of society is doomed.”

Last week, nurses and other employees of the Indira Gandhi Institute of Medical Sciences in Patna protested against the hospital administration for not providing safety equipment in isolation wards.

Some hospitals have even had to turn away symptomatic patients as they do not have adequate resources.

"There are no facilities for testing of patients with the coronavirus,” said Ajit Sharma, a member of the legislative assembly from Bhagalpur. “There is a lack of testing kits, masks and sanitizers for doctors. There is a shortage of [personal protective equipment] kits in Bhagalpur, and throughout Bihar."

Moreover, too many people in Bihar are ignoring rules of social distancing and self-isolation.

“People don't understand how dire the situation is. The police are trying to enforce social distancing among the poor, asking them to maintain a physical distance between each other if they want food," said Rohit Kumar.

But Ajit Sharma asserts that the poor are going outside simply in search of food.

"The poor won't think about the coronavirus when they are hungry. I have hundreds of people outside my home every day, begging me to help them procure food. These people can't practice social distancing when they want food," he said.

Another problem is that Bihari migrants who have returned home from larger cities across India are facing rejection and ostracism.

These migrants fled the cities just before or shortly after the national government imposed a 21-day lockdown. Many of these returnees have been accused of carrying the virus. Some migrants have reportedly been prohibited from entering their homes, or even their villages. In the event they are indeed infected the social stigma may discourage them from even getting tested – thereby placing more people in danger.

Millions of people from Bihar migrate to other states, especially Kerala, Delhi, Rajasthan and Maharashtra. Many migrate as far away as the Middle East.

“Most villagers think that anyone who has come from [the] outside is a coronavirus patient,” said Ravi Ranjan, the block development officer at Dhamdaha in Northern Bihar.

As a result, if a returning migrant even sneezes or coughs, he is reported to the authorities as a virus carrier.

“[Our] teams have been running around day and night due to this. Since the last two to three days, we are appealing to people to fight with the disease but not distort the social fabric of the villages,” said Ranjan.

Soumitra Pathare, a consulting psychiatrist and director of the Center for Mental Health Law and Policy in Pune, said: “The stigma around Covid-19 is not specific to rural areas and even cities and urban areas are witnessing this. If you have more stigma, the people are more afraid to come out and seek help or treatment. Our authorities have relied on this notion of fear to get everybody to act but the danger of that is it results in stigma.”

Some migrants and their families are illiterate and do not understand concepts like quarantine.

“Issuing instructions on paper does not work in our kind of set-up,” said a Patna-based social activist working with an international organization. “Returning workers are both scared and careless and do not want to go and stay in government buildings.”