As Covid-19 cases surge, Bihar’s health system collapses – and VIP culture makes things worse

Twenty-four-year-old Sudhanshu Shrestha, who works at a bank in Bihar’s Gopalganj town, phoned his manager on the morning of July 13. He wanted the day off. He had been running a temperature since the previous week. The paracetamol tablets he had been popping had stopped working and his condition had deteriorated over the weekend. He had thrown up several times and could barely get up from his bed.

The manager’s response confirmed Shrestha’s worst fears. He said he was ill too. So were several other employees at the branch. All of them had the same symptoms: a fever, a dry cough getting worse by the minute and debilitating weakness.

It was decided that the bank would keep its shutters closed for the day and all eight employees would instead go to the Gopalganj Civil Hospital to get tested for Covid-19.

A long wait (and self-medication)

This is when, the banker recalled, the horror began.

The civil hospital authorities told Shrestha and his colleagues that they had already done their daily quota of 75 tests. They suggested the group try the private hospital in the town that was also testing.

The same story played out at the private hospital: they were told it had already collected its daily quota of 50 samples. “We tried reasoning, but they were insistent that they had been instructed by the DM [district magistrate] to not test more than 50 people in a day,” said Shrestha.

Dejected, he decided to take matters into his own hands. He got himself hydroxychloroquine tablets, an anti-malarial drug that Indian medical authorities recommend for treatment and prevention of Covid-19, but with strict monitoring. “I was sure I had corona,” said Shrestha. “And HCQ is available everywhere in Bihar, anyone can get it.”

The next day, Shrestha and colleagues got word that a testing camp would be set up in a wedding hall in the town. They arrived to see hordes of other sick people waiting in line. Hours passed, but no one came to collect samples. The camp, they were told several hours later, had been postponed to the next day.

Meanwhile, Shrestha took some hydroxychloroquine.

On Wednesday, there was an even bigger crowd in the hall. By the time, Shrestha and his colleagues’ turn came, the daily quota of 50 was over yet again. “There were more than 300 people that day,” he said. “All of us pleaded with them to test us, but they would not relent.” The health workers said it was beyond them: “Upar se order hain”. There are orders from the top.

Shrestha took more hydroxychloroquine.

His symptoms worsening and patience dwindling, he figured he would never get tested like this. “I requested a government doctor who is an account holder at our bank to help,” he said. “Somehow internally he put our names on the list for Thursday.”

No report, no follow-up RT-PCR test

Finally, on Thursday afternoon, July 16, Shrestha’s swab was collected for a rapid antigen test.

But he is yet to receive a formal report for it. “Apparently, if there is no report, it means it is negative,” he said.

Protocol laid out by the Indian Council of Medical Research states that all symptomatic patients who test negative in rapid antigen tests should be made to undergo a follow-up molecular diagnostic test as the former could throw up false negatives.

Shrestha said he was not aware of the protocol and no one from the administration had informed him about it either. Convinced that he had tested negative and too sick to fend for himself, Shrestha has since moved to Koderma in Jharkhand to be with his family. “I have intense body ache and I am so weak that if I try standing up, I see blackness everywhere,” said Shrestha over the phone from Koderma, his voice hoarse with exhaustion and coughing.

The system comes unravelling

Shrestha’s account, distressing as it is, is not unique by any means in Bihar. As the pandemic finally strikes Bihar, the state’s beleaguered health infrastructure – considered one of the worst in the country – is not being able to keep pace. If many are struggling to get tested, others who have tested positive are finding it tough to find a bed for treatment and isolation.

In what many say is telling of the state of affairs, a senior state government official had to allegedly spend a night on the footpath inside the premises of the All India Institute of Medical Sciences in Patna. The official died days later of Covid-19.

“Being in Bihar right now feels like drowning in a river,” said Rupesh, a social activist from Patna who has been helping people get access to Covid-19 tests and treatment. “Not only don’t we know how to swim, there is no boat coming to our rescue either.”

No test, no cases

The state has so far reported 30,066 positive cases for coronavirus. Observers, though, say the real numbers could be much higher. The state has tested among the fewest people per million population in the whole of the country.

Its positivity rate – the proportion of people who test positive among those tested – is fairly high, indicating its numbers could sharply shoot up if testing were to be ramped.

The state is currently testing around 10,000 people on an average every day, significantly lower than states with comparable populations. To make matters worse, a large chunk of these are rapid antigen tests, which tend to throw up a large number of false negatives. Anecdotal accounts suggest they are not followed up by a confirmatory RT-PCR test.

Stung by criticism, chief minister Nitish Kumar has asked the health department to test at least 20,000 samples per day. But that seems far-fetched at the moment given that the daily capacity of the state’s government-run labs, health officials say, is less than 6,000 for reverse transcriptase polymerase chain reaction or RT-PCR tests, the gold standard for diagnostic tests for Covid-19.

This capacity has been further diminished of late. The microbiology lab at the Patna Medical College and Hospital has had to be shut down because several people working in the lab tested positive for the virus.

The underwhelming capacity means that test results could take as many as five days to emerge. This often leads to late isolation and consequently more infections.

The state, meanwhile, is trying to make up for the lack of its adequate RT-PCR testing capacity with antigen testing. Ragini Mishra, Bihar’s state epidemiologist and nodal officer for Covid-19, said 50,000 antigen test kits had been distributed to the districts. “That is more viable at this stage,” she said.

But even these are not being fully utilised, it appears. District health officials are quite open about not being able to “test everyone”. “We can’t test everyone if 1,000 people turn up obviously,” said Gopalganj civil surgeon, Tribhuvan Narayan Singh. “We have limited resources and it is difficult to keep wearing PPE [personal protective equipment] for too long in the heat.”

Singh said Gopalganj had a “fixed daily quota”: it conducts 150 antigen tests and 100 TruNat tests a day and collects 150 swab samples to send to Patna for RT-PCR testing. The district has no capacity of its own to conduct RT-PCR tests.

Given its lack of testing capacity, it is no surprise that like most other states, Bihar seems to have nearly abandoned contact tracing . In Patna, for instance, when a doctor at a non-profit private polyclinic tested positive earlier in the month, there was no attempt to trace and test close contacts including patients he had treated in the days prior to getting infected. “Nobody came to us,” said Shakeel, a colleague of the infected doctor. “As professionals, we took our own initiative and got everybody in our team tested at a private lab.”

But what about the patients who he may have attended to? “That is for the administration to find out,” said Shakeel.

The government labs apparently refused to even test healthcare workers who had come in contact with the doctor. “I even wrote everyone a prescription, but they refused on the grounds that they had no symptoms,” said Shakeel.

A senior government functionary said the lack of aggressive testing was dictated by political compulsions. The state is scheduled to go to polls later this year. “You don’t want to create alarm before the elections with high numbers,” said the official. “So, you underplay the situation for as long as you can.”

Struggle for a bed

If getting tested and getting a report within a reasonable time-frame is difficult, getting a bed for treatment and isolation is nothing short of an ordeal, say patients and their families.

To streamline the treatment of Covid-19 patients, the Centre has asked states to divide Covid-19 beds into three categories: critical care, moderate care, and isolation beds for mild and asymptomatic patients.

According to state epidemiologist Ragini Mishra, Bihar has “more than 49,000 beds” earmarked for Covid-19 care and treatment across districts. Despite repeated requests, Mishra and other health department officials did not provide a category-wise break-up of the beds.

Of the 49,000-odd beds, only around 7% were currently occupied, said Mishra.

Yet, complaints abound about people struggling to find beds. In Kateya, Dilip Choubey could not find an isolation bed for days for his brother who had tested positive last week. “The health department and the district administration kept passing the buck to each other,” said Choubey, adding that he was told that the new protocol in the state required patients to home quarantine.

“We live in a joint family with old people – there are 10 people who live in two rooms and there is just one latrine,” said Choubey. “How can the administration expect us to self-quarantine?”

Mishra, however, said that shortage of beds was “not an issue at the moment”. What then explains the testimonies of people who have struggled to get beds including a senior state official who ended up dead soon after. “The problem is everyone wants to be admitted to AIIMS,” she said.

But critics say there is more to it. “Beds are empty and yet people are not getting them because all powerful politicians and bureaucrats have beds reserved in their names,” said Shaligram Vishwakarma, a Patna-based doctor who heads the Indian Medical Association’s Bihar chapter.

Vishwakarma’s allegations are echoed by others too. Access to testing or treatment, many say, is contingent on whom you know rather than how serious your clinical symptoms are.

Panicked people, angry healthcare workers

Apart from panic among the public, the state is also having to contend with angry health care workers threatening to go on strikes every second day. “There is not even a PPE donning-doffing area in the hospital and we are a designated Covid hospital – just imagine,” said Manish Mishra, a doctor at the Patna Medical College and Hospital, announcing the beginning of another “cease work” protest.

A colleague of his added, “We want very basic things and if we don’t get them, we won’t be able to serve people,” he said. “There are no PPE kits and that has made them extremely vulnerable and on top of that there is reluctance to test us.”

This seeming breakdown of the system that the state is currently witnessing was inevitable considering the state’s sub-par public health system, some say. It has not helped that the private sector has almost completely recused itself from Covid-19 care citing safety concerns.

“Every state has a carrying capacity,” said a senior state bureaucrat. “That capacity has been breached in Bihar.”

Perhaps, the only silver lining amidst the gloom is Bihar’s demographics: nearly 80% of its population is under the age of 40. “If India is young, Bihar is younger,” the official said. “That is the only good part here.”

This reporting was supported by a grant from the Thakur Family Foundation. Thakur Family Foundation has not exercised any editorial control over the contents of this article.