"According to protocol, we should be given an N95 mask, a personal protective equipment (PPE) 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," Sanjeev (name changed), a doctor at the Jawaharlal Nehru Medical College and Hospital (JLNMCH) in the city of Bhagalpur in Bihar, told DW. 

He is fighting for his life every day while treating patients in the government hospital. His situation isn't different from other doctors across Bihar, one of the poorest states in India.

The Patna Medical College and Hospital (PMCH) is one of Bihar's largest hospitals. Here, beds are not available for potential patients of COVID-19, the disease caused by the novel SARS-CoV-2 coronavirus, a source from the hospital, who did not wish to be named, told DW. The hospital also doesn't have a designated ward for symptomatic patients.

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Testing for the coronavirus in Bihar is low, creating pressure on doctors, who may be dealing with coronavirus patients who have not yet been diagnosed. The state has just one research center that tests coronavirus samples, which are then sent to the western Indian city of Pune for a second confirmation.

Bihar's healthcare system is staring at a total collapse if the coronavirus spreads widely within the community.

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Poor planning

India has a dismal record of investing in public health and ranks 184 out of 191 countries in terms of share of GDP spent on healthcare, according to the World Health Organization.

On March 23, Prime Minister Narendra Modi pledged an investment of 15 billion Indian rupees ($196.5 million, €180.8 million) in India's healthcare system, to tackle a surge in cases of the coronavirus. India is also set to receive $1 billion from the World Bank to prepare medical staff for the coronavirus outbreak.

The Indian government has made strides since March 23 in indigenous manufacturing of testing kits and ventilators. But it has failed to provide basic safety kits to doctors on the frontline. Bihar faces an acute shortage of resources like PPE kits and protective masks. Locals from Patna claim that the state government has yet to receive any money from the federal government — headed by Prime Minister Narendra Modi — to tackle the health crisis. 

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

According to the recent census, Bihar has a population of 99 million people. However, it has less than 2,000 primary health centers and 150 community health centers to cater to such a large population. Bihar has consistently underinvested in its healthcare system in the past, leading to the proliferation of a network of private hospitals, which can only be accessed by the privileged.

Number of cases is much higher?

According to government estimates, Bihar has so far had just 32 confirmed cases of the novel coronavirus. However, doctors and locals believe the number is much higher.

"Some doctors in AIIMS Patna have told me that there are positive cases which are not being disclosed," a resident of Patna, who didn't wish to be named, told DW. "Many symptomatic patients are being turned away for lack of beds in my hospital," Sanjeev from JNLMCH told DW.

On March 23, the superintendent of the Nalanda Medical College and Hospital (NMCH) in Patna raised a request to quarantine 83 junior doctors who were showing COVID-19 symptoms. The United Resident & Doctors Association of India claims that the doctors have neither been tested for the coronavirus nor quarantined by their hospital.

In PMCH and JLNMCH, doctors are using HIV protection kits and surgical masks to protect themselves while treating patients. The state government has reportedly asked doctors in Bihar to use the HIV kit as the state has a scarcity of PPE kits.

"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," doctors at NMCH in Patna told The Hindu, an English-language daily, last week.

Administration trying to cover its tracks

The problems faced by doctors are exacerbated by a lackadaisical and ruthless hospital administration. On March 24, the administration of JLNMCH told all interns that according to guidelines provided by the Indian Council of Medical Research (ICMR), doctors in the operation and emergency department did not need to wear an N95 mask or a PPE kit for their protection. The hospital said that only normal masks and gloves would be provided, and action could be taken against those doctors who don't turn up for duty.

The ICMR guidelines state that all suspected coronavirus patients have to be moved to a separate isolation ward, which is why doctors working in the operation theater and emergency section don't need the safety equipment necessary to deal with coronavirus patients.

However, in PMCH, there is no separate isolation ward for coronavirus patients.

In other hospitals in Bihar, doctors and medical staff across all units are exposed to patients, irrespective of their duty in the isolation ward, as it is difficult to trace a potential patient with coronavirus.

"If doctors end up contracting this infection, then the rest of society is doomed," said Rohit Kumar, who runs a medical chain, Medicana, in Patna.

Problems are being exacerbated in Bihar as symptomatic patients are being turned away when they approach the hospital. In the city of Gaya, potential coronavirus patients are being turned away from healthcare centers, citing lack of doctors.

Despite attempts to silence them, some healthcare workers continue to speak up about the challenges they are facing. Last week, nurses and ward boys of the Indira Gandhi Institute of Medical Sciences (IGIMS) organized a protest against the hospital administration for their inability to provide safety equipment in isolation wards.

The government of Bihar has insisted that it has the funds to deal with the spread of the coronavirus pandemic. On March 23, Bihar's Chief Minister Nitish Kumar said that doctors and paramedical staff would be given an incentive equivalent to a month's salary. However, the impact of the funds and incentives is yet to be seen on the ground.

Ajit Sharma, a member of the legislative assembly (MLA) from Bhagalpur, admitted that his city lacks safety kits for doctors. "There are no facilities for testing of patients with the coronavirus. There is a lack of testing kits, masks and sanitizers for doctors. There is a shortage of PPE kits in Bhagalpur, and throughout Bihar. The nodal officer himself is given just one mask a day."

The superintendent of JNMCH, when contacted by DW about the lack of safety equipment for doctors, said that he can't divulge information about anything, before hanging up the phone abruptly.

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Low awareness can increase community spread

Low awareness among the masses about the severity of the coronavirus is expected to create further pressure on Bihar's fragile healthcare system in the coming days. People in several parts of Bihar continue to travel and gather despite the government directive to maintain social distancing.

"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," stressed Rohit Kumar.

However, local politicians say that people are venturing outside for fear of starvation. "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," said MLA Ajit Sharma. 

Bihar's first coronavirus patient has sent 110 people into quarantine. Further carelessness from the administration will likely create an endless chain of infections, which will be impossible to contain with a fragile healthcare system and infected doctors.