Bihar: Death and deceit

As Bihar’s tottering health care system struggles to cope, its political masters remain in isolation, leaving a hapless people to fend for themselves.

Published : May 17, 2021 06:00 IST

A COVID  patient on oxygen support waiting to be admitted to Patna Medical College and Hospital, in Patna on May 14.

A COVID patient on oxygen support waiting to be admitted to Patna Medical College and Hospital, in Patna on May 14.

Dr Smriti*, a senior resident atagovernment hospital in Patna, is on the front line of the tidal second wave of COVID-19 that has caught Bihar unawares. One look at her face on video call and the gravity of the crisis hits home immediately. Her face swollen, punctuated by deep marks on her cheeks left by the prolonged use of the mask, betrays fear and fatigue.

She had not slept in six days as she had to go around looking for hospital beds for family and friends after work hours. “My maternal uncle’s condition worsened on the fourth day after he tested positive. It took me another four days and all my networks to find him a bed. After that, I struggled to find an ambulance, then oxygen, and finally ICU admission.” Her uncle did not survive. He was on a ventilator for a day and a half. Her aunt was beside herself, left to mourn alone as her son had to get the body followed by a seven-hour-long wait to cremate it.

“Every time the phone rings, my stomach begins to sink. I am inundated with phone calls from friends and acquaintances desperate to find a hospital bed. They beg and plead of me as if my lack of empathy was the problem here. I cannot take it any more. I only hear the siren of ambulances and wails of patients and their kin all day. Patna is witnessing a maut ka tandav [dance of death],” she tells me with a haunted look on her face.

After largely escaping the first wave of the pandemic, Bihar has found itself at the heart of the catastrophic second wave that has seized India. Ever since the case count began to surge in March 2021, the infection rate in Bihar has risen sharply. The movement of the reproduction rate (R0 in epidemiological language) indicates the rate at which the infection is spreading. In effect, R0 has to be brought to 1 or below in order to bring the disease under control; conversely, a higher number indicates greater transmission. From an effective R0 of 1.72 in the last week of March, it jumped to 1.97 by mid-April when the national average was 1.31. The intervening period was marked by two popular festivals in the State, Holi and ( Chaiti ) Chhath Puja. Almost immediately, the crevasses of Bihar’s health care system were in plain sight. The State government, as has been the wont of governments in India during the pandemic, did the only thing it knew—enforce a Statewide lockdown on May 1.

Also read: Government's all round failure to manage pandemic exposed

On May 5, Bihar recorded its first three-digit death toll in a day. However, from the very next day, the test positivity rate (TPR)—the number of positive cases as a proportion of tests conducted—began to fall. On April 30, the State recorded a high positivity rate of 16.14 per cent. Sceptics of the State’s official statistics pointed to the fact that the rate slipped by 6 percentage points within just 10 days. On May 9, Bihar recorded 5.91 lakh cases—totally 2.73 crore tests had been conducted—and registered just over 3,000 deaths for an estimated population of more than 12 crore. In contrast, West Bengal, with a similar estimated population and demographic profile, recorded 9.93 lakh cases—it had conducted a total of 1.1 crore tests—and the number of deaths was over 12,000. With half the number of tests being conducted, West Bengal seemed to be recording twice as many cases and four times as many deaths.

Official statistics in Bihar, known to be unreliable in the best of times, is obviously trailing reality. Dainik Bhaskar , the most widely read Hindi daily in the State, while citing official data and trends on its front page, now reports alternative figures and reports in its inside pages. For instance, the daily carries a small table titled “Corona Death Card” on page 2, which effectively contests the official mortality count for Patna, the worst affected district, through data collected at three cremation/burial sites (Gulabi Ghat, Baans Ghat, and Peermuhani Qabristan) in the city. The official death toll on May 9 was 67 for the State and 16 for Patna. DainikBhaskar reported that on the same day, 38 corpses were recorded officially at the above sites but 71 corpses were cremated according to COVID protocol, over four times the official figure of 16.

This is the situation in the State capital. At the time of this writing, a video of over 77 bodies floating in the Ganga around Buxar district was doing the rounds on television channels and social media. There are also reports of people dying of mere “ sardi-khaansi” (cough-n-cold) in the villages of Uttar Pradesh and Bihar. This is not surprising given that even in pre-COVID times, only 37 per cent of deaths were registered with a civil authority in the past three years, according to the National Family and Health Survey (NFHS)-5 (2019–20).

Befuddling figures

Since the beginning of the first wave, Bihar’s COVID numbers have befuddled epidemiologists and statisticians alike: how and why did Bihar escape the initial surge and after, despite the influx of migrant workers from across the country and the massive crowds thronging campaign rallies for the Assembly election held in October/November last year. Some have suggested that the preponderance of the rapid antigen test, with its low sensitivity and specificity, since August 2020 when testing picked up in the State resulted in substantial false negatives. The mathematician Murad Banaji posited faulty targeting of testing (to cause test positivity to fall) and demographic peculiarities of Bihar (largely rural and young) as potential factors. Then came the investigative report of Indian Express in February 2021 revealing significant fudging of COVID data in Bihar.

Also read: India’s gigantic death toll due to COVID-19 is thrice the official numbers

The people of Bihar propounded the theory of an innate and indigenous immunity brought about by their capacity to live and work under any (read unhygienic) condition. This was an unwitting admission of the everyday misery marking the lives of the vast majority in Bihar.

Delayed arrival

Since May 2020, my husband and I have been based in Bihar, moving between Fatehganj*, a small bazaar town in north-west Bihar, Patna and Muzaffarpur, for my mother-in-law’s cancer treatment. Fear reigned through the course of the unprecedented lockdown in the first wave. But in the absence of any information or wherewithal to deal with this phenomenon, coupled with a complete distrust of public systems, people took recourse to social isolation and surveillance against outsiders (be they migrant returnees or kin coming to stay with extended family). The loss of livelihoods for the Bihari working class, both within and outside the State, has been colossal. In Fatehganj and elsewhere, the various street vendors disappeared through the lockdown period only to return as vegetable vendors, the only way to earn a living in a precarious local economy.

However, fear soon turned into fatigue, and what proliferated in its place was a plethora of anti-science and anti-social hacks and theories. All of which were essentially understood as freedom from the need to follow precautions, such as wearing a mask, maintaining physical distancing, sanitising, even vaccinating. Those who did follow precautions were emasculated as cowards, heretics or suffering from the malaise of zyada padhal likhal (one who is too invested in the written word). Most people we encountered in daily life, including family, felt oppressed at constant requests to follow precautions because the “common sense” they encountered on a daily basis was at complete odds with our pleas based on scientific rationale. So, by 2021, life was back to “normal” in Bihar. The most common refrain in north Bihar being humni ke corona ke jaant ke mua dehni san (we have stamped out and killed corona here). But the bravado hid more than it revealed, and to disastrous effect. Those infected were merely tight-lipped about it. Cases were heard of only when symptoms turned adverse and hospitalisation became inevitable. The wife of the most prominent and popular doctor in Fatehganj was outed in this manner.

One morning in mid-April, the entire town had shut itself indoors and seemingly everyone had the “flu”. There was no testing and yet everyone knew it to be COVID. How, you may ask. Well, for one, overnight everyone was wearing masks, after insisting for a whole year humni ke na hoi (it won’t happen to us). Second, almost every household had more than one member down with “flu” symptoms. Third, all the local chemists had run out of flu-related medicines (even paracetamol and antihistamines). Finally, and conclusively, the local doctors were making a killing. The doctor in Fatehganj made a whopping Rs.3 lakh in just one day on April 15. Preposterously, he made Rs.1 lakh in consultation fees alone, which, for the fees he charges, implies that he would have seen about 350 patients that day. The remaining Rs.2 lakh was earned for the medicines he supplied. It was no wonder that he reported that day as his biggest payday ever in over three decades of practice.

Also read: Pandemic second wave deepens into unprecedented crisis

People refused to test for two reasons: fear of stigmatisation and fear of forcible hospitalisation and the prospect of dying without seeing one’s loved ones. These were baseless as we found out in a few days because the virus had affected village after village and town after town, making it impossible for neighbours or officials to take any action. In any case, there are no tests to be done in small towns like Fatehganj, which apart from its own population of 30,000 also functions as the only town serving 100 villages spread across four blocks with a population of about nine lakh. One must go to the district headquarters, at the least, to get a proper examination and/or relevant medicines.

Districts in dire straits

But district headquarters across Bihar are in dire straits. There are long queues outside hospitals, dispensaries and pathology labs. Testing services are under pressure with rising workloads and technicians getting infected, resulting in fewer tests than desirable and long lags in arrival of results. I spoke to Dr SK* practising in Siwan, a major district town in north Bihar. Of the 30 patients he sees in a day, he says that since early April every day at least 28 have been suspected cases of COVID, based on their symptoms and profile.

Most of the 28 people cannot afford testing at local private laboratories, which charge Rs.2,000 for an RT-PCR and Rs.1,100 for the rapid antigen test. At the Sadar Aspatal (district government hospital), both tests can be undertaken for free. First, an antigen is conducted and then a sample for the RT-PCR collected and forwarded to the Rajendra Memorial Research Institute in Patna for processing. However, given the daily loads of testing, patients inevitably only undergo the antigen test. Dr SK reports that the poor sensitivity of the antigen test can result in many false negatives. While these patients respond to and largely recover with symptomatic treatment, they do go undocumented in official records.

Of these 28, four or five cases every day turn out to be serious with moderate to high lung involvement and falling oxygen saturation levels. They have to be referred to Patna (five to six hours by road) or Gorakhpur (four hours away in the neighbouring State of Uttar Pradesh, where things are just as bad or worse). Most of them do not undertake the travel, some on account of lack of money and some frightened by the images they see on TV. Some of them who manage to travel die in transit.

Also read: The fiasco that is India’s COVID-19 vaccine policy

Most of Dr SK’s patients come from villages in Siwan district. He says they generally seek a first line of treatment at the local “compounder’s”, a “medical practitioner” with no formal training but running an independent practice after years of being on the job at some qualified doctor’s dispensary. “There is a high level of trust in compounders,” admits Dr SK. “As they are part of the community and as there is little else by way of health care in the villages, most of my patients have already sought treatment for the first six-seven days since the onset of the symptoms at the compounder’s,” he said. It was only after much delay that the patients reached the district hospitals, that too only if their symptoms persisted or worsened, he added.

Dr SK explains that the compounders’ lack of formal training in medicine and especially in COVID-19 routines has resulted in much misdiagnosis and maltreatment, even if unintentional. As a result, typhoid has become the standard euphemism for COVID in rural Bihar. Typically, most persistent fevers have been treated as typhoid in Bihar. While it has been proven to be the largest cause of the symptom in this region, it is also most often assumed to be so, especially among rural medical practitioners. Further, several COVID positive patients have also been testing positive on the WIDAL Test, typically used to diagnose typhoid, Dr SK informs. Nevertheless, with or without the WIDAL test, compounders (and doctors alike) tend to put patients with fevers lasting beyond the third or fourth day on a course of antibiotics and often steroids (for instant relief from the fever). However, the early prescription of steroids results in the development of opportunistic infections such as tuberculosis, bone fractures and hypoglycemia in general and fungal infections, more often than not in the lungs, in COVID patients in particular. By the time patients develop difficulty in breathing (rather late in some COVID patients, also known as happy hypoxia), it would be too late to seek any effective medical intervention.

In Siwan, Dr SK says, there are just three hospitals with 10 to 12 ventilators. One is the Sadar Aspatal, which has no doctor to operate the ventilator and hence it has not been used until now. The other two hospitals are private ones, one of which acquired its ventilators after the first wave. However, both these hospitals are essentially nursing homes run by a single doctor and do not have the manpower to monitor patients round the clock. Hence, they too seldom admit patients who require the ventilator. These 10-12 as-good-as-absent ventilators cater to about 75 lakh people belonging to Siwan and the neighbouring less-developed district of Gopalganj. On May 9, local papers reported 120 per cent spike in the positivity rate in five districts, including Siwan, Gopalganj and East Champaran, all along the north-western border with Uttar Pradesh. However, no news has been forthcoming on this rural shift of the virus in Bihar, although the trend has been confirmed by sporadic reports in the national media.

Creaking infrastructure

The second wave of COVID-19 has unleashed unseen horrors in Bihar’s urban centres. Unlike in the first wave and as opposed to the rural areas, nearly all private hospitals and nursing homes are open and accepting patients in Patna, Muzaffarpur, Gaya and Bhagalpur, the four biggest towns in the State. However, despite this, there is a massive shortage of beds, doctors and staff, medicines, oxygen and ventilators. This is partly due to the largest number of infections being concentrated in these cities, and partly due to the near-absence of health care infrastructure beyond these cities. So, the creaking infrastructure in these towns must bear not just the load of their own residents but that of the rest of the State. In a pandemic of such a proportion, where “compounders” in villages are not even trained to administer an appropriate first line of treatment and districts have no capacity to deal with even moderately critical cases, it is but inevitable that patients turn to the cities.

Also read: COVID second wave: Clueless Centre cannot hold

By the time patients make their way up the medical service chain to reach city hospitals, it is already too late. Dr Ranjan*, posted at a public hospital in Muzaffarpur, says that “most patients that arrive here are already quite critical with oxygen saturation levels at 50 or below”. He said: “Chest examination only confirms severe lung involvement. At that point, there is little to do. Patients are being admitted despite little to no chance of survival. The lack of information and fear of the virus adds to people’s desperation and helplessness, and especially so for rural folks.”

Hospitals as superspreaders

Dr Smriti expressed concern that hospitals (public and private) were in fact turning into superspreaders of the virus. “Hospitals are admitting more patients than the available bed strength,” she explained. “This,” she pointed out, “is partly because of the scale of this wave and partly due to the fear of patients’ kin turning on hospital staff, not an unhead of situation in Bihar.” COVID wards are no longer out of bounds for patients’ caregivers. This is because of the shortage of both staff (who have themselves fallen prey to the virus) and resources (caused by the relentless influx of patients) at hospitals. Every patient needs at least three to four attendants by their side, one to refill the oxygen cylinders multiple times a day, one to buy medicines (hospitals are running out of them), one to bring food and water, and one to monitor the patient. “While everyone is fussing over the patients, the attendants go completely unnoticed. In almost all cases, the attendants too are COVID positive, but all energy and attention is focussed on the one with adverse symptoms.” This, Dr Smriti warns, only serves to further the spread of the pandemic, not quell it.

Several news reports have recorded doctors’ reluctance to go close to patients. Doctors have been left to fend for themselves in this crisis. They have no State-backed insurance cover. The bulk of the staff are on contractual employment, so there is no semblance of job security. In the event that they contract the virus, there is no guarantee of a hospital bed or oxygen for themselves. Many have lost their colleagues and kin. Doctors are traumatised by the scenes they have witnessed in the past month, which they can never again “unsee”. Yet, as front-line workers they bear the brunt of the anger against the system.

In the eyes of the common people, COVID hospitals have become death chambers. This serves to further discourage early admission of the infected and, upon admission, results in heightened aggression directed at hospital staff, mistakenly reflecting vigilance on behalf of one’s patient. In our own experience, a mantra that has come to define everyday life in Bihar and apparently the key to getting things done here is: “power lies in the aggression of the beholder.” This mantra has particularly been true for those with access to powerful networks and/or any claim to social privilege in Bihar. For those lacking it, they try and get someone to wield power on their behalf. These are usually the dalals (brokers) who help poor families coming from far-flung areas to navigate the labyrinthine health bureaucracy of big government hospitals. Doctors (small and big), too, have a strongman each beside them at all times to guard against the threat of caretakers’ outrage. The sheer scale of the patient load in this wave has broken down all time-tested hacks and shortcuts in the system.

Disaster waiting to happen

Whatever may be the reasons for its escape from the first wave, there is widespread consensus that Bihar undertook no measures to augment its health care capacity in the interim. Dr Shakeel, a public health activist and non-profit practitioner in Patna, observed that “this was a disaster waiting to happen. When States with advanced health care infrastructure are struggling, then how would we not? Our lack of capacity is not just about physical infrastructure but also of human resource.”

Also read: Ramanan Laxminarayan: ‘Vaccination the only way out of the pandemic’

Even before COVID, Bihar’s health system was a shambles. The NITI Aayog’s Health Index listed Bihar as the worst performing large State, a step lower than Uttar Pradesh. Its index dropped by nearly seven percentage points in 2017-18, compared with 2015-16, the base year. There are about 70 community health centres for a State with one-tenth of the country’s population, when it ought to be 1,200. Except for a few big public hospitals in Patna, there is little by way of advanced health care in the rest of Bihar. There are only 2,500 ICU beds in all of Bihar, of which one-third are in public hospitals. The daily rates for the majority of such beds, which are in private hospitals, is about Rs.50,000; even these are overcrowded now despite less than 15 per cent of the households having any health insurance cover. Ironically, in the scramble for resources, government hospitals have moved the Patna High Court pleading for oxygen supply.

Further, the shortage of doctors and staff in public (and private) hospitals is stark. Vacancies ranging from 30 per cent up to 94 per cent persist across various categories and levels of health care service providers. Says Dr Ranjan: “500 dentists had been recruited two years ago to various public hospitals after a gap of 37 years. There are but two dentists on permanent employment across all the medical colleges in the State. The only government dental college in Bihar has no known permanent employee. Yet, dentists, permanent and contractual, are playing an integral role in battling COVID-19.” This is the plight of just one stream of medicine. “The State administration had become so lax after the first wave that it did not even bother to recruit senior residents this year,” Dr. Smriti said.

With rising infections among medical staff and 27,000 contractual health workers threatening to go into home isolation failing the institution of a Rs.50 lakh insurance cover and revision of honorariums, among other demands, the State has begun a drive to recruit 2,580 doctors. According to local dailies, the new recruits will serve year-long contracts. However, doctors in Bihar inform this writer that it is likely to be effective for only three months.

In the face of utter apathy of the state, what has prevailed in Bihar before and during the pandemic is social anarchy. For instance, rumours about hospitals killing patients or using the dead for illegal organ trade has resulted in frenzied scenes, with survivors insisting on bodies being uncovered to check if their eyes and kidneys are intact. Even in such a deep humanitarian crisis, black marketing of essential resources such as oxygen cylinders (selling at up to Rs.1 lakh when a patient needs multiple refills a day), remdesivir (selling at Rs.50,000 a vial when each patient needs four or five), thermometers, antibiotics and even supplements such as zinc and vitamin C are being sold for up to Rs.100 above the markup price. Shopkeepers, medical representatives, journalists, and even young graduate and intermediate students have been caught in police raids.

Also read: Opaqueness in India’s National Task Force for COVID-19 shows the government did not prepare for the second wave of the pandemic

Given the immense time and money costs in pursuing any treatment in Bihar and the significant trust deficit in institutional health care in the State, health choices and outcomes can take convoluted forms. In sickness and health, treatment and meal portions in households are prioritised for the earning male members. Women, through their reproductive years, remain at the bottom of the family hierarchy and priority in terms of health expenditure. The fear of stigma during the pandemic causes most people to seek doctors outside their immediate circle of contacts and caste-community networks, at appropriate social distance; the non-COVID, everyday sort of social distance in India, observed and transgressed as per the needs of the occasion. But this only causes delays in treatment while making it more expensive. The result of such decision-making for health care is reflected in the NFHS-5, which reports anaemia among 70 per cent of children below the age of 5, and 63 per cent of women and 30 per cent of men between the ages of 19–49. One quarter of all women and one-fifth of all men in the State have a below par body mass index.

Whither accountability?

“This is a story of complete state callousness,” Dr Shakeel asserts. He substantiates his anger thus: “The fudging of data, including undercounting cases and the inordinate delays in patient reports, is criminal. There is no audit of oxygen and medicines coming into the State. Where is at all going? Which office is responsible for disbursement of these supplies? Grievance redressal is near absent and the government helplines are dead ends. As for vaccination, at the present rate, it will take Bihar three years to vaccinate the whole population.” Far from providing answers, the Central and State governments have failed to respond in any meaningful way.

After having spent the entire first wave in electoral machinations, the second wave hit the self-assured ruling National Democratic Alliance between its eyes. Chief Minister Nitish Kumar and Health Minister Mangal Pandey’s desertion, in the midst of a pandemic, fuelled fear of the disease in the minds of ordinary people and effectively transferred all responsibility to the bureaucracy. Any political backlash was sought to be deflected by a shuffle in the office of the Principal Health Secretary. One celebrated officer was replaced by another, while the politicians scuttled from public sight. A senior academic from Bihar recently tweeted about how people on the streets of Bihar directed most of their criticism and expectations to the prashasan (bureaucratic administration) instead of the sarkar (political executive). This dichotomy in popular discourse reflects the nature of democratisation in Bihar: the lack of accountability that exists or can be claimed of the political class, and where the local bureaucracy is seen as mai-baap (benefactor).

Also read: Lessons from the ‘first wave’

Dr Shakeel points out that “because of the pandemic, health has become a political agenda in Bihar, and India itself. Until two years ago, neither political parties nor common people spoke about health. The middle class and elite were happy that they did not need to go to public hospitals given improving facilities in private ones. But the pandemic has changed this notion permanently. You have money, you have resources, but you still cannot get facilities. The system has been exposed like never before.” As for the poor of Bihar, Dr SK laments, “even after all this misery, they are unlikely to revolt against the state. Most just shrug it all off saying, it is their naseeb [fate].”

Such is the tragedy of Bihar, unchanged since the cholera epidemic hit the region 200 years ago, the plague epidemic in the late 19th century and early 20th century, and the influenza epidemic almost a century ago. Proper estimates of the true extent of casualties in those epidemics took decades and even centuries to unravel. How long will it take to realise that too many have died of wanton neglect during the COVID-19 pandemic?

Anisha George is a Commonwealth doctoral scholar at the University of Edinburgh, U.K. *Names of individuals and places have been changed to preserve anonymity.

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