NEW DELHI: With scant supplies and underpaid staff, one of India's poorest states is scrambling to prevent a "blast" in coronavirus cases that medics say could cripple its precarious health system.
The pandemic has already overwhelmed the medical network in the eastern state of Bihar, which has recorded more than 62,000 infections and nearly 350 deaths.
But locals fear the worst is yet to come.
Fuelling their anxiety – a slew of media reports and images of people struggling to access healthcare, including coronavirus patients languishing on oxygen support in hospital corridors.
The list of patient complaints – worse outside the state's capital city of Patna – is long: Too few beds, faulty oxygen cylinders, no doctors, zero tests and a dearth of effective medicine.
When village pharmacist Om Prakash Gupta became breathless last week, he waded through swirling flood waters to reach a local, district hospital only to wait hours for a coronavirus test, and a whole day for oxygen support.
The 42-year-old tested positive, and got a bed after his family faced initial apathy from hospital staff, threats from doctors and rejection from politicians.
"We got frightened and ... our family members started crying out of helplessness. (Then) hospital authorities called us and admitted him," his brother-in-law Manoj Kumar said by phone from his village in Madhubani town.
But it was too late.
"We were told that he was severely breathless overnight and other patients tried to call the doctor for him but nobody came. Finally he fell from his bed and died due to a lack of oxygen," Kumar told the Thomson Reuters Foundation.
Health experts say the death toll is set to rise, especially as annual floods complicate efforts to enforce social distancing and strain resources.
"The floods have decreased mobility. People can't leave ... testing teams are also unable to reach these areas," said SR Jha, a doctor in impoverished Araria district.
"The cases will spike a lot more. There will be a kind of blast."
Neither the state's health secretary and health minister nor the federal health ministry responded to repeated phone calls, text messages and emails over a week seeking their comment.
"MISSED THE BOAT"
India's coronavirus outbreak is the third worst in the world behind the United States and Brazil, with more than 1.9 million confirmed cases and about 40,700 deaths, according to a tally by the Johns Hopkins University.
The virus travelled from crowded cities to rural hinterland as millions of workers returned home under a strict lockdown, with Bihar receiving one of the largest migrant influxes.
Bihar lacks good hospitals, with facilities outside Patna woefully short on resources, doctors and medical experts say.
In Darbhanga district, which bore the brunt of floods, a coronavirus patient even staged a protest inside a local hospital, claiming medical negligence.
"No doctor has come to see me for 10 days. The situation is so bad the oxygen cylinder that they gave me ran out of gas ... I asked them for a replacement, but there's no response," Shailendra Sinha told local media.
Medical observers say the government failed to prepare.
Sunil Kumar, Bihar secretary of the Indian Medical Association that represents 325,000 doctors, said more than 40 per cent of state healthcare posts were vacant. This, he said, was despite doctors' requests to the government to fill the openings.
"The government missed the boat on preparation and planning and now you can see the fallout," said Kumar.
Officials had no response after a week of requests for comment. Yet Kumar said medics' pay was pitiful and that staff lacked basic kit such as protective suits, masks and gloves.
"How can you expect medical staff to work for 8,000 or 10,000 rupees (US$133) in COVID-19 wards in such conditions – only to risk their lives?" he said.
The state government says it will give health workers an "encouragement incentive" worth a month's salary.
"RELY ON GOD"
Home to 120 million people, Bihar is testing about 38,000 samples a day – compared to some 100,000 in India's most populous state of Uttar Pradesh.
Kumar said the virus was spreading undetected, with few people wearing masks or keeping a safe distance, despite a lockdown until Aug 16.
State Chief Minister Nitish Kumar says the virus is "definitely a threat to Bihar" given it has the top population density in the country – three times the national average.
Bihar's principal health secretary Pratyaya Amrit was not available for comment, but has told local media that his top priority was to ramp up testing to 50,000 a day.
He has vowed to make changes, including increasing the number of beds with oxygen support, ambulance services, round-the-clock availability of doctors and nurses and filling vacancies by appointing 1,000 specialist doctors.
Dr Shakeel, who goes by one name and heads the People's Health Movement in Bihar, a network of medical and civil society organisations, said private hospitals were out of reach for most people since they could charge up to 15,000 rupees a day – in a state where the daily per capita income is US$1.50.
Instead, ordinary people would have to make do with local "hospitals that are dirty, where beds are very few and any treatment for (the) coronavirus is not even available", said Jha, the doctor from Araria.
"The poor ... they have to rely on God."