1 day ago - Special Report: Last doctor standing - Pandemic pushes Indian hospital to brink. BHAGALPUR, India (Reuters) - Guards armed with rifles escort Dr. Kumar Gaurav as he makes the rounds at his hospital on the banks of the Ganges River.
August 13, 2020 / 4:45 AM / Updated a day ago
Special Report: Last doctor standing - Pandemic pushes Indian hospital to brink
BHAGALPUR,
India (Reuters) - Guards armed with rifles escort Dr. Kumar Gaurav as
he makes the rounds at his hospital on the banks of the Ganges River.
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The
guards are there to protect him from the relatives of patients,
including those suffering from COVID-19. The relatives keep barging into
the wards, even the ICU, to stroke and feed their loved ones, often
without wearing even the flimsiest of masks as barriers against the
novel coronavirus.
“If we stop them, they get angry,” he says.
“They want to give homemade meals to their patients, and some even want
to massage their patients. And they are taking the infections from our
ICUs to the other people in the society.”
He stops to tell the
wife of a patient in the ICU she must leave. She obeys, only to return
after a few minutes from another entrance.
It’s the monsoon
season, and the humidity is reaching unbearable levels. But the few air
conditioners in the hospital aren’t working, and some relatives use hand
fans to keep their loved ones cool in wards dirty with garbage and
discarded protective equipment.
It wasn’t supposed to be like this for Kumar.
Nine
years ago, the 42-year-old psychiatrist moved his family back to his
hometown for a quieter life and better pay after three years in the
Indian capital, New Delhi. He accepted a job as a medical professor and
consultant psychiatrist at the 900-bed Jawahar Lal Nehru Medical College
and Hospital, named after India’s first prime minister. Life was
uneventful but rewarding, spent teaching classes and visiting his
psychiatry patients.
Now, with some doctors struck down by the
coronavirus and others refusing to work, he has been named the top
official at the hospital, despite being one of its most junior
consultants – and suffering from diabetes and hypertension, two risk
factors for severe COVID-19.
But he says he felt compelled to volunteer for the job.
“A lot of my colleagues refused,” he says. “I had to take up the responsibility.”
In
April, as the pandemic struck here in the eastern state of Bihar, the
hospital was selected as one of just four COVID-dedicated hospitals for a
population of 100 million people – at least in theory.
In
practice, Kumar says the nearest hospital with proper critical-care
facilities is around 200 kilometers (120 miles) away. And with proper
healthcare in the surrounding rural areas difficult to find, general
patients have nowhere else to go but his hospital.
In June, Kumar says, the district administration instructed the hospital to treat uninfected patients, too.
“In an ideal world, there should not be any non-COVID patients in this hospital,” Kumar says.
The healthcare system in Bhagalpur, like many other parts of Bihar, is on the verge of collapse, he says.
Interviews
with dozens of staff, patients and relatives at the hospital paint a
picture of conditions that might shock those accustomed to images of
hermetically sealed ICUs during the pandemic, with relatives not even
allowed to touch their dying loved ones.
They tell of a chronic
shortage of manpower and resources such as blood and medicines. All 37
beds in the ICU are occupied; on the floor next to one of the beds, a
relative sits on a brightly colored blanket he has brought from home, a
water bottle by his side.
Kumar says he feels powerless to prevent the lapses in isolation of the COVID patients.
“We
don’t know who is positive and who is negative,” the psychiatrist says.
“We don’t know their status and we cannot wait for them to be tested.
They just need the treatment. We are the most vulnerable population.”
Spokesmen
for India’s federal government and the Bihar government, as well as
several bureaucrats and ministers responsible for healthcare at federal
and state level, didn’t respond to detailed requests for comment. Pranav
Kumar, the top bureaucrat in Bhagalpur district, also didn’t respond to
a request for comment.
TROUBLED STATE
As infections
slow in many other countries, India is still reporting more than 50,000
cases per day. Its total of more than 2 million cases trails only the
United States and Brazil, and cases show no signs of slowing. Since the
pandemic struck India, more than 46,000 people have died.
Although
India’s major cities, such as New Delhi and Mumbai – the first to be
hit by the virus – have registered a decline in cases, numbers in
second-tier cities and rural areas continue to rise.
Bihar is India’s third-most-populous state; if it were a country, it would be the 14th-most-populous in the world.
The
state has a rich history, including the site where the Buddha is said
to have attained enlightenment beneath the shade of a Bodhi tree.
But today, Bihar has a reputation as one of India’s problem-plagued states.
Based
on indicators including infant nutrition, Bihar’s level of development
has more in common with sub-Saharan Africa than India’s prosperous
southern states. Almost half of children under 5 in the state are
stunted from malnutrition, with more than four in 10 underweight for
their age, according to federal data.
Bihar also has the highest
population growth in India, and one of the worst education systems,
scoring poorly on indicators including adult literacy, the percentage of
children attending school and exam results.
Dr.
Kumar Gaurav, 42, a medical professor and consultant psychiatrist who
has been named the top official at Jawahar Lal Nehru Medical College and
Hospital during the coronavirus disease (COVID-19) outbreak, despite
being one of its most junior consultants, is helped by a colleague to
put on personal protective equipment (PPE) before entering the Intensive
Care Unit (ICU) for COVID-19 patients at Jawahar Lal Nehru Medical
College and Hospital in Bhagalpur, Bihar, India, July 26, 2020. "If I
stand in front of a COVID patient for two minutes, and I see 20
patients, I have exposure for 40 minutes," Gaurav says. REUTERS/Danish
Siddiqui
The healthcare system was
overburdened even before the pandemic struck. Dr. Sunil Kumar, the Bihar
secretary of the Indian Medical Association – the main healthcare union
in India – said more than half the doctors’ posts in the state are
unfilled. That’s because many doctors don’t want to serve in rural
areas, according to Bihar’s top court, which urged the state government
to do more to fill the roles in a ruling in May.
There have been
around 87,000 confirmed cases of coronavirus in the state and 465 deaths
– relatively small compared to other states. Given the low testing
levels in the state, the numbers may be conservative. Still, Bihar’s
healthcare system is already close to breaking point, unlike places such
as New Delhi, which has had many more cases but enjoys better
resources.
The state government’s response to the outbreak has
prompted public interest litigation asking that India’s federal
government, led by Prime Minister Narendra Modi, take over management of
the pandemic here.
One case, filed by local businessman Aditya
Jalan, says “incalculable” lives will be lost if action isn’t taken
soon, especially with the pandemic spreading into less developed and
more rural areas.
His petition cites a “complete breakdown of the
public health infrastructure in the state of Bihar, including the lack
of COVID-19 hospitals, the lack of hospital beds, the insufficient
testing, the unsanitary quarantine centres, the lack of enforcement of
social distancing measures, the insufficient medical personnel, [and]
the failure to provide PPE to front-line workers.”
India’s Supreme Court is due to hear the case Friday.
The
state’s healthcare problems are particularly stark in rural Bihar,
where government infrastructure is even more rudimentary. In Ismailpur, a
village an hour’s drive from Bhagalpur, the ongoing annual floods have
cut off the main road to the highway. The floodwaters have reached the
doorstep of the dilapidated primary health centre there, which caters to
more than 52,000 people.
There are no beds or oxygen cylinders,
and a dog and her litter rest on the discarded PPE kits in the corner of
the coronavirus testing hall.
“It’s a very backward area,” says
one of the two doctors in the center, Dr. Rakesh Ranjan. “People are
scared to even get tested. We have to sometimes take police to get
people tested.”
HOSPITAL CHAOS
Psychiatrist Kumar’s
hospital backs onto the Ganges River, the holiest in India and swollen
by the summer monsoon. Next to water buffalos bathing on the banks,
private ambulance operators wash their vehicles with clanking buckets.
On
the approach road to the hospital, there is a huge pothole, and
vehicles carrying patients often get stuck there. Outside the main
doors, relatives sit with the bodies of their loved ones waiting for
private ambulances to take them for burial or cremation.
The
workers who push the trolleys carrying incoming patients to the general
emergency wards don’t know the history of the new arrivals, most of whom
haven’t been tested yet for the virus. Often wearing only gloves as
protective gear, the workers wheel them inside, take their oxygen levels
and leave them on trolleys in the corridor, where some people are
treated until they can find a bed.
In the corridor, an exhausted
woman rests her head on a wall as her husband’s blood sample is
collected while he lies on a stretcher next to her. Inside one of the
emergency wards, a woman drags her husband from a stretcher to his bed
as their relative holds an IV bottle.
Kumar tries to be visible,
touring the wards to motivate patients and staff. But it’s a game of
constant mental arithmetic. Patients expect to be seen by a senior
doctor, but it isn’t always possible.
“If I stand in front of a COVID patient for two minutes, and I see 20 patients, I have exposure for 40 minutes,” he says.
With so few doctors, that kind of exposure is a risk he can’t often afford to take.
Complaints
from junior doctors are constant. During one meeting about a lack of
medicines, Kumar promises them he will convince the government that more
resources are needed. He later admits it will be difficult.
Kumar
weeps as he describes his worst moment since he took over, when a
friend of his father who needs blood transfusions at regular intervals
asked for help.
“I had to say no, as we don’t have enough blood
in the bank. We just have just a minimum for emergencies,” he says. He
finds such refusals painful. “I don’t know how to say no to a patient.”
COMING HOME
Born
in Bhagalpur, Kumar moved to the northern city of Chandigarh for his
medical training, where he met his wife, Mili Jaswal, a psychologist.
After marrying, the young couple moved to New Delhi, where they adopted a street dog, Faith.
Kumar worked in a private hospital but couldn’t handle the culture.
“Their
orientation is how much financially you can give back to them,” he
says. “It’s difficult for a doctor to work [like] this.”
And so in 2011, Kumar, Mili and Faith boarded a train back to Bihar.
“Financial security was a big factor, and I had my family here,” Kumar says.
His 6-year-old daughter, Iti Swara, was born a few years later. He dotes on her.
He
recently had his two-bedroom government bungalow painted pink inside
and out at her request. But these days, the hugs he gives his daughter
each morning before he goes to work have changed. Now he has fear on his
mind, not love.
Mili worries that the long hours and stress of Kumar’s work are taking him away from their daughter.
“When
he is home, she wants to speak to him, but he can’t,” she says. “She
wants to share her thoughts and play with him, but he is not able to.”
Kumar
watched cases in the district slowly rise over a number of months, but
the call to take over the running of the hospital last month came
suddenly. The previous hospital superintendent had tested positive for
the virus, and to Kumar’s surprise, he says some of the more senior
doctors refused the post. Attempts to get comment from the doctors were
unsuccessful, but lower-ranking doctors at the hospital confirmed
Kumar’s account, and an official letter from the previous superintendent
cited one of the refusals.
He thought about his extended family,
whom he stopped visiting as the virus began to spread through the
district. Who would run the hospital if they were admitted, if not him?
“For the people of Bhagalpur and nearby districts, it was my responsibility,” he says. “That is why I raised my hand.”
A PATIENT WAITS
Fear of the virus – and anger at the lack of resources – also haunts the patients and their relatives.
One
Sunday in July, Parsada Sah, a gaunt, 67-year-old shopkeeper, tested
positive for the coronavirus in a village 50 kilometers from Bhagalpur.
Sah, along with his wife, Vimla Devi, and son Manoj, reached the
hospital in an ambulance that afternoon.
Manoj showed his
father’s positive test to the doctor on duty. He says he was told there
were no beds in COVID wards, and was asked to find himself a bed in an
already overcrowded 20-bed general emergency ward.
“We were told
that this is the only place we can have for now, as there is no space,”
Manoj says. “We pleaded with them a lot. They told me that everyone
wants a bed.”
Even though they know he’s infected, the family goes inside the ward to feed Sah.
“The
staff just puts the food on the bed; they don’t feed anyone,” Manoj
says. “If the patient can’t eat himself, he has to get someone to help.”
Kumar says their concerns are genuine.
“We don’t have
separate staff for taking patients to washrooms or feed them,” he says.
“The problem is, we don’t have enough human resources, from bottom to
top.”
BEARING WEIGHT
Eventually, almost a day later, a
bed is found for Sah in the isolation ward. When he is moved, Sameer, a
22-year-old medical attendant sent to help with the transfer, hurriedly
changes into his plastic overalls. Instead of protective goggles, he
uses a pair of cheap sunglasses.
He gestures to his overalls.
“We
only get these once we are moving positive patients from the general
ward to a COVID ward.” Otherwise, he says, “we are the first people to
receive a patient as they enter the gate, but we don’t have any
protection.”
After collecting an oxygen tank for the transfer,
and fiddling with the cylinder for a few minutes inside the ward, Sameer
and his colleague discover that it’s faulty. They take a new one, but
the rusted trolley they mount it on barely moves. It screeches as the
men try to drag it through the hospital corridors.
The tube
attached to Sah’s oxygen mask strains as Sameer tries to keep pace with
the stretcher, with the man’s wife and son trailing behind.
Eventually,
the wheels of the trolley stop turning altogether. So Sameer hoists the
hulking canister onto his shoulders, and bears the weight himself.
Reporting
by Danish Siddiqui. Additional reporting by Alasdair Pal in New Delhi.
Writing by Alasdair Pal; editing by Kari Howard.
Stephen Lewis (left) with chest physician Dr. Zarir Udwadia.
