Updated: May 12
Ghazipur (Uttar Pradesh): The irrelevance of privilege and absence of medical facilities in the unfolding second wave of Covid-19 in India‚Äôs most-populous state was made apparent on 19 April 2021, when Sheo Kumar Rai tested positive for the disease.
Rai, 67, political secretary to the Bahujan Samaj Party member of Parliament from Ghazipur, a district headquarters 340 km east of state capital Lucknow, received local medical attention, but his condition worsened. He needed, doctors said, a hospital bed with oxygen support.
There was none available‚ÄĒnot in the government hospital in Ghazipur, not in the neighbouring districts of Varanasi, Azamgarh and Mau. Though his sons managed to get a CT scan done at a private laboratory to confirm the infection, there was no doctor available at the district hospital in Ghazipur to have a look at it.
Rais' brother, who lives in Patna, 170 km to the east, promised to get Rai a hospital bed there. In desperation, Rai‚Äôs son and relatives set off on a journey that normally takes over five hours.
Rai died en route.
‚ÄúMy father could have been saved had he got proper medical attention in Ghazipur,‚ÄĚ said his 40-year-old son Shekhar Rai.
The district hospital at Ghazipur cannot cope with a flood of patients, reporting undiagnosed fevers. As in Delhi, Bengaluru and other Indian cities, oxygen here is in short supply, life-saving medicines and injections are unavailable, and there are no hospital beds to be had, but UP has access to far fewer resources.
Those who are lucky, said Ghazipur locals, get to share a bed and oxygen with two or even three patients. Some, like Rai, are not that fortunate, regardless of privilege.
Swamped By Second Wave, Unprepared For Third
The result of UP‚Äôs disregard is a rapidly growing Covid case and death toll, undercounted or uncounted, as the pandemic spreads through rural UP, where about 154 million of its 200 million people (77%) live, a region with some of India‚Äôs worst health infrastructure, by the government‚Äôs own admission.
The prognosis for a widely anticipated third wave of infections is not encouraging because no state or union territory has vaccinated a smaller proportion of its population than UP. On 8 May 2021, 4.68% of the population had received at least one dose (the leader was Ladakh, 29.65%, and among large states, Kerala, 17.45%).
UP has reported a falling number of Covid-19 cases since 24 April, but these are official records in a state where cases are being undercounted, said experts, as fever and death sweep the state, especially rural areas.
Infection and death data are ‚Äúgrossly‚ÄĚ under reported,‚ÄĚ a health department official acknowledged to Article 14, requesting anonymity since he is not authorised to speak to the media. ‚ÄúThe number is far more than what is being put out.‚ÄĚ
As on 8 May, UP was number four by confirmed Covid-19 cases and deaths, according to the latest available data, but it was 27th by testing rate, even though it has grown. UP is testing 962 people per million, a rate lesser than Sikkim or Tripura, which have populations 333 times and 55 times smaller, respectively.
‚ÄúThere is an old saying in global health,‚ÄĚ Ashish K Jha, MD, professor and dean of the Brown University School of Public Health in the US tweeted on 9 May. ‚ÄúYou can ignore, fail to test for, or undercount whatever disease you want. But you can‚Äôt ignore the dead.‚ÄĚ
About 20 km to the east of Ghazipur in the village of Yusufpur, Saeed Ansari, 67, described how death had become a part of daily life over the past month.
Ansari‚Äôs routine of gardening, reading, writing or occasionally fishing‚ÄĒhe retired to the clean air and lush environs of his native village after a working life with a US insurance company‚ÄĒis interrupted by the loudspeaker of the local mosque, asking people to congregate for funeral prayers.
‚ÄúEarlier it used to be once in a while, now we hear the call about 10 times a day,‚ÄĚ said Ansari, who, like others in Yusufpur, believed the Covid-19 pandemic was an urban phenomenon that would never reach the countryside.
That belief has been rudely and painfully shattered for the people of UP, who were frequently told that the pandemic was under control and that the state was prepared.
‚ÄúIt‚Äôs like a fire, spreading at breakneck speed,‚ÄĚ said former state minister Om Prakash Singh.
On Paper, UP Is Doing Well, Not In Reality
Across hospitals and medical centres in UP, Covid-19 patients have been arriving on foot, in rickshaws, two wheelers and cars, desperately looking for a hospital bed, oxygen support and access to life-saving medicines, according to local media, officials and other sources.
However, official data indicate quite the opposite, claiming a peak on 24 April 2021 of 37,944 cases, with a seven-day average of about 35,000. That average is now down to about 32,000 cases. This decline, said health economist Rijo M John, PhD, comes despite increased testing.
‚ÄúWith the kind of poor health infrastructure UP has compared to the rest of India,‚ÄĚ said John, ‚ÄúIt is simply unbelievable that UP could manage the pandemic so well.‚ÄĚ
Indeed, the pandemic now appears to be spreading virtually unmonitored in the vast rural hinterland of this state of 200 million. With some of India‚Äôs scantest healthcare facilities, people are dying undiagnosed, without oxygen and other medical support, their deaths uncounted as Covid-19 casualties.
The Bharatiya Janata Party (BJP) government of chief minister Yogi Adityanath has consistently refused to accept that there is even a problem, even though media reports (here, here and here) corroborate our findings of a pandemic raging uncontrolled.
On 3 February 2021 Adityanath said his state‚Äôs Covid-19 situation was ‚Äútotally under control‚ÄĚ. On 22 February, he said the world was ‚Äúlaughing‚ÄĚ at Kerala for failing to control the pandemic as he had.
‚ÄúThere is no shortage of oxygen in any Covid hospital, private or government,‚ÄĚ Adityanath said on 26 April, a week each after Rai‚Äôs death, also a week after a 65-year-old journalist live-tweeted his fatal decline because he could not find a hospital bed or oxygen.
Chief Minister Tries To Criminalise Reality
The chief minister‚Äôs claims about his state controlling the pandemic and having adequate oxygen and beds have been repeatedly found untrue (here, here and here).
Instead of addressing the oxygen shortage, Adityanath not only threatened to use the National Security Act, 1980, against those who spread ‚Äúrumours‚ÄĚ on social media and tried to ‚Äúspoil the atmosphere‚ÄĚ, his police filed cases, including against a man who tweeted an appeal for oxygen and another against a man who was giving free oxygen.
These threats have cowed some people and groups who were trying to help citizens survive the pandemic and filling the state‚Äôs vast governance gaps. On 26 April, a volunteer group called the Citizens Aid Collective (CAC) announced it was ceasing operations in UP.
‚ÄúDue to recent guidelines of the UP government, we were no longer in a position to help with cases related to medicine or oxygen related to UP,‚ÄĚ said a CAC statement. New guidelines issued by the state government said anyone distributing oxygen cylinders or medicines would have to produce a prescription or face imprisonment or fines.
A representative, requesting anonymity, told Article 14: ‚ÄúWe felt it's not worth risking the lives of our volunteers working in UP‚ÄĚ.
Despite the threats, desperate hospitals have made public appeals for oxygen, and members of Adityanath‚Äôs own party, including a union minister, have complained about government laxity and oxygen shortages. The Allahabad High Court on 4 May likened the failure to supply UP hospitals with adequate oxygen and the deaths from its absence as being akin to ‚Äúgenocide‚ÄĚ.
It is evident the second wave of Covid-19 has hit the state in a manner it clearly did not expect or plan for. For instance, the state conducted local panchayat elections despite the pandemic: the result was that hundreds of teachers deployed as polling officers died with a teacher‚Äôs union estimating about 1,000 dead.
‚ÄúThis is turning out to be UP‚Äôs nightmare without end,‚ÄĚ said Pramod Tewari, former UP minister.
Graveyards are running out of space, and crematoria are running out of wood. In many cases, both are running out of space for the dead. In reaction to visuals of burning pyres, including on footpaths, the UP government has erected tin sheets and tied banners to block views of cremation grounds.
But the deaths are hard to hide, as thousands lose their loved ones.
‚ÄėEvery Second Day, An SOS For Oxygen‚Äô
On 24 April, Ali Hasan, 61, the son of 1965 war hero Abdul Hamid died after five days of cough and fever, the last two days of which were spent gasping for air because there was no oxygen available.
‚ÄúIn desperation we ran from pillar to post, knocked on every possible door , but all in vain,‚ÄĚ Noor Hassan, the late war hero‚Äôs cousin told Article 14. ‚ÄúThere was no oxygen.‚ÄĚ
It‚Äôs the same story playing out in other cities, although some, such as Lucknow, are now, anecdotally, and of course officially, reporting fewer cases. At the Jawaharlal Nehru Medical College in Aligarh, there are patients on stretchers and on the floor in the corridors. The College has an oxygen plant, but is now inadequate.
Despite Adityanath‚Äôs threats of criminalising oxygen shortages, ‚Äúevery second day an SOS goes out for oxygen‚ÄĚ, said a senior doctor, requesting anonymity. ‚ÄúWe are stretched beyond limits, everything is at breaking point.
Hasan died in Kanpur, a crumbling industrial city once called the Manchester of the East. If oxygen is scarce in UP‚Äôs major cities, said experts, there is little hope it can reach the state‚Äôs rural hinterland.
During the first phase of the pandemic in 2020, UP‚Äôs rural areas were relatively insulated despite the fact that thousands of migrant workers returned from their villages from cities nationwide. Many went into quarantine in makeshift shelters outside villages or in schools.
When the official number of Covid-19 cases appeared to reduce, the shelters were done away with and the schools, in March and April, transformed into polling centres for the panchayat elections. This time around, migrants are returning straight home, spreading infection to families in unprepared rural areas.
Unprepared At The Best Of Times
Health infrastructure in rural UP has always been poor. In 2020, rural UP was 51% short of primary health centres (PHCs) and community health centres (CHCs), among the bottom three states in India, according to government data.
In 2020, UP spent just over Rs 1,000 per capita on health, less than a third of the amount spent by Jammu and Kashmir and the northeastern states and less than half the amount spent by Kerala, according to Reserve Bank of India data.
Government sub centres, the first point of contact for those seeking healthcare, increased no more than 3.1% over 30 years to 2020, a period when UP‚Äôs rural population rose 56%, according to an Article 14 analysis of rural health infrastructure (here and here) and census data (here and here). Since 2007, there‚Äôs been no increase in primary health centres. The result is that the rural areas of a state ill-equipped to deliver normal healthcare has been overwhelmed by the virulence of Covid-19.
‚ÄúThere is a shortage of just about everything,‚ÄĚ said a senior medical officer in Varanasi, the prime minister‚Äôs constituency, requesting anonymity for fear of reprisal. ‚ÄúOxygen is scarce, and so are life saving medicines and hospital beds.‚ÄĚ
The Centre‚Äôs prediction is that UP‚Äôs situation will worsen, with a predicted peak in mid May with about 120,000 daily infections to become India‚Äôs worst-affected state.
UP will need 20,333 beds with oxygen support, but will likely fall short by 16,572; it faces a shortfall of more than 3,000 oxygen beds and more than 1,500 ventilators, according to a prediction made by a committee headed by V K Paul, member of the government think tank, NITI Aayog.
UP, by its government‚Äôs claims, was supposed to have addressed shortages during the first wave by arranging for 150,000 beds in about 500 hospitals statewide. Over 400 ‚Äúfirst-layer‚ÄĚ hospitals were supposed to have 48 hours of oxygen reserves; 75 ‚ÄúL-2‚ÄĚ hospitals were to have oxygen and ventilators and 25 ‚ÄúL-3‚ÄĚ hospitals with more advanced facilities, such as ICUs.
By February 2021, with numbers decreasing, as elsewhere in the country, the UP government declared the worst over and 83 of the 500 hospitals were scaled down.
Instead, religious and political congregations were allowed, there was no sign of Covid-appropriate behaviour in the state, and when the tide broke, Adityanath‚Äôs government consistently refused to accept there was a problem.
Quite the opposite.
On 4 May, the UP government announced health centres for every district, equipped with oximeters, thermal screening, masks and other protective equipment for staff. But these centres were not for human beings‚ÄĒthey were for cows..
(Javed M Ansari is a member of the Article 14 editorial board.)