By the time Prashant Suna, 42, called the doctor seeking medical advice, he had recovered from most of the symptoms of Covid-19. It had been twelve days since he had fever and cough, and ten days since he took an RT-PCR test. “But I got the reports only today,” he told me. “It says Covid positive”.

This was in April 2021, when India was in the grip of a deadly second wave of Covid-19. Cases were rising rapidly in Odisha. But the state had only 13 laboratories to conduct RT-PCRs, the molecular tests considered the gold standard for Covid detection. Of these, 9 labs were in the state capital Bhubaneswar. (The number has gone up to 20 centres now, out of which 11 are in the capital.)

As a result, the residents of most Adivasi-dominated districts like Nuapada, Nabarangpur, Mayurbhanj, Deogarh, and Kalahandi where Suna lived, had to wait at least 7-10 days for test results after their samples were sent to a lab, usually miles away.

While he waited for the results, Suna did not even have the option to fully isolate. His family lived in a one room house. “My father and younger brother are feverish now, and my three children have caught a cold,” he said.

The doctor asked Suna to check the oxygen saturation levels of all his family members. But he didn’t have an oximeter. “I looked for it in all the medical stores nearby. Is there any other way to get it?” he asked.

The next day, his brother Praful began to have breathing difficulties. The nearest oxygen bed was two hours away, but he needed an ICU bed with a ventilator. The entire district of Kalahandi, home to 1.6 million people, had only six ICU beds. All were occupied. In any case, a Covid-19 positive report was mandatory for admission, which he was still waiting for.

ICU Bed Distribution Across Districts in Odisha. Source: Odisha COVID Dashboard

Praful’s family took him to a hospital in Bhawanipatna. When he reached there, his oxygen saturation was 60%, even after he was plugged into the oxygen supply. The 32-year-old passed away the same night. His newly-wed wife received his RT-PCR report the day after his death.

Failure of triage

The state government had officially announced district helpline numbers for Covid-19 patients. But the Citizens’ Collective for Public Health, a public health organisation that works in Odisha, found that the “helpline” numbers were merely the landline numbers of the nearest government health centres where, in most cases, a peon would pick up and respond.

The lower-rung staff could neither direct people to the nearest testing centre, nor locate the nearest health facility with an available oxygen or ICU bed, nor even connect the patient with a doctor for teleconsultation, like the staff running the helplines under the municipalities of Bhubaneswar and Cuttack could. Dysfunctional helplines also implied that there was no provision of triage in most districts.

As per a notice by the Ministry of Health and Family Welfare, triaging essentially meant sorting patients according to the level of care they needed, to ensure optimal utilisation of available resources. Mild cases should be isolated in Covid Care Centres, moderate cases in Dedicated Covid Healthcare Centres, which have oxygen beds but no ventilators, and severe cases in dedicated Covid hospitals that had ICU beds and ventilators. This entire process should ideally be facilitated with real time updates about bed availability on a public dashboard online or through district helplines, monitored by district nodal officers.

The residents of Sonepur district said that even though the Covid Care Centres in their district were open, they remained empty, since there was no mechanism of patient referral. In Puri, residents informed me that 200 beds in the Dedicated Covid Healthcare Centre of the district were unoccupied.

With Covid hospitals being the only health facilities that were functional, patients often went directly from their homes to these hospitals. By this time, they were usually too sick, which in the absence of oximeters meant they were literally gasping for oxygen.

When the sarpanch of Mahulpada village in Sundargarh district, Gulab Nayak, showed symptoms of Covid-19, it took her family members two days to arrange an oximeter for her. Odisha Government had declared that sarpanches had been given the power of collectors for effective Covid management, but Nayak said that she had neither received any clear instructions or guidelines about the powers, nor funds to make Covid Care Centres functional.

The nearest Covid hospital from Mahulpada was located in Rourkela, three hours away. By the time Nayak’s family could arrange an ambulance, her oxygen levels were 70%. But fortunately, she found a hospital bed in Rourkela, and recovered in a few days.

Vaccine inequity

By May 20, the virus had spread among the particularly vulnerable tribal groups like Bondas of Malkangiri, Dongria Kondhs of Rayagada, Khadiyas of Mayurbhanj, and Paudi Bhuyans of Sundargarh.

These districts, with more than 30% Scheduled Tribe population, lag behind in overall human development, ranking among the bottom 50 districts on the Human Development Index. Even during the pandemic, they remain grossly underserved: of the total 2,849 ICU beds in the state, 1,378 are concentrated in two districts of Cuttack and Khorda, where state capital Bhubaneswar is located, while Rayagada, Malkangiri and Mayurbhanj have just 10 ICU beds each.

In the third week of April 2021, most of these districts, away from the coast of Odisha, were reporting test positivity rates in the range of 24-50%, higher than the state average of 16.6%. The test positivity rate is the parameter used to evaluate if adequate testing is being done (the number of positive results divided by the number of total RT-PCR tests done, as acknowledged by WHO and the Centre). Yet, the vaccination drive, which could have helped contain the spread of infection, had come to a standstill here.

More than 1,000 out of the 1,400 vaccination centres in the state had been shut down. The situation was particularly dire in districts like Koraput, Jharsuguda, Nuapada, Sambalpur and Deogarh. Of the 427 vaccination sites scheduled in the state, zero were planned in these districts.

Only one centre was open in Balangir, two in Keonjhar, three in Balasore, six each in Nabarangapur and Rayagada, and seven in Kandhamal.

The World Health Organisation states that in supply constrained situations, vaccine allocation should be prioritised for communities which have a higher vulnerability. Within India, this approach is visible in Kerala’s decision to introduce vaccination prioritisation based on the comorbidities within age groups. No such policy was implemented in Odisha.

Instead, the Odisha Government restricted the administration of Covaxin to capital Bhubaneswar, where one million of the state’s 42 million people live. Since doses of Covaxin were around 11.6% of total vaccine doses allocated to Odisha, reserving it for Bhubaneswar meant 2.5% of Odisha’s population received five times their share of doses. The uninterrupted supply of vaccines ensured Bhubaneswar became the first city in India to achieve 100% vaccination coverage.

As per data on CoWIN dashboard, Khorda district, where Bhubaneswar is located, had administered 7,30,000 vaccine doses between June 1-30, several times higher than other districts with an equal population: for instance, Mayurbhanj had received just 1,60,000 doses in the same period; Sundergarh, 2,20,000; Balasore, 1,83,000.

Another way to put it: about 2.2 million people in Khorda district had a vaccine share equal to 13 other districts with a cumulative population of 12 million.

Public-supported privatisation

In April 2020, soon after the pandemic began, two government-run companies, the Mahanadi Coalfields Limited and the Odisha Mining Corporation Limited, sponsored the creation of 1,000 new ICU beds – in two private hospitals, both of them in Bhubaneshwar. In one swift move, 40% of the state’s Covid ICU capacity came to be concentrated in two private hospitals located in the capital.

This year, another government company, the Indian Oil Corporation Limited, funded the addition of 100 ICU beds and 70 ventilators to the privately-run Vikash Multi-Superspeciality Hospital in Bargarh, despite government hospitals in the district having less than 20 ICU beds.

Odisha already has the third highest out-of-pocket-expenditure on health among all states, as a percentage of its Gross Domestic Product – 5%, according to National Health Accounts 2017. This was the case even as only 18.7% of the state’s people sought hospitalisation at private hospitals. The national average was 3.7% that year (2015-16) with better performing states like Gujarat and Haryana scoring 2% and 2.3% respectively.

Additionally, Odisha Government is covering the cost of Covid-19 treatment for all patients being treated at Dedicated Covid-19 private hospitals on a per bed per day basis, which means the hospitals will be paid from the state exchequer for every bed, every day, even if it isn’t occupied and regardless of the quality of treatment.

In one such hospital managed by Kalinga Institute of Medical Sciences in Mayurbhanj, a viral video captured patients lying naked in their own excreta and sleeping in toilets on May 23 this year.

Underreporting deaths

Odisha has reported 9,95,433 confirmed Covid-19 cases as of August 16, 2021 – 3.1% of India’s total case count. However, the official death count since the start of the pandemic for a population of 42 million is 6,953, or 1.6% of India’s total death count.

Right to Information activist Pradeep Pradhan has gathered data that suggests the state government has grossly underreported Covid-19 deaths. In June-October 2020, it was officially reporting just 12-17 Covid deaths every day in the entire state, while data from a single crematorium in the state capital – the Satya Nagar crematorium, where all those who died of Covid in Bhubaneshwar were being cremated, was 27-30.

According to Pradhan, similar underreporting would have taken place in the second wave as well, since the state government acquired new cremation grounds, despite its official death count from Covid-19 remaining the same.

Bijaya Biswal is a medical doctor and public health researcher currently studying the intersections of public health and indigenous rights in mining-affected areas of Odisha. This story was reported under the National Foundation of India Fellowship for Independent Journalists.