The uncontrolled spread of Covid-19 in India’s dense big cities has drawn enormous media attention. But the disease is also ravaging the country’s rural areas, home to the vast majority of the country’s population – and where healthcare infrastructure is ill-equipped to handle the rising numbers of severe cases that require intensive care.

The set of maps in this article illustrate the scale of the problem in Bihar, which has India’s lowest Human Development Index score of 0.576, and poor access to health care. Its ratio of one doctor for 43,788 persons in 2019 is the worst in the country. These maps show the scarcity of ICU beds in the state’s public hospitals.

As of May 10, there were no vacant ICU beds in 18 of 38 districts. Only five districts in Bihar reported having more than 20 vacant ICU beds, a number that was dwindling.

This crisis, as with most other parts of the country, reflects a failure to learn from the first Covid-19 wave and scale up essential public health infrastructure as cases dipped early in 2021.

Considering the fragility of Bihar’s public healthcare system and the fact that people in this low-income state rely a great deal on such affordable services, it is useful to look more closely at how vulnerable it is during the second wave of the pandemic.

Are there enough ICU beds in government hospitals to deal with the surge in severe cases associated with Covid-19’s second wave? Are these evenly distributed across the densely populated state?

We have attempted to spatially capture the disparities through these maps, which are derived from the Bihar’s government’s publicly-accessible online dashboard meant to provide up-to-date information about availability of beds across the state for Covid-19 patients.

Since April 27, Bihar has been recording 12,000 to 15,000 cases per day. On May 10, this dipped to 10,174 and the state reported 75 deaths, taking its total toll since the beginning of the pandemic last year to 3,357.

Since the second wave reached Bihar later than other states, experts say the state is yet to reach its peak and that cases could continue to rise. This would put even more pressure on its health infrastructure.

Bihar is now under lockdown until May 15. As the map below shows, districts with major urban centres like Patna, Gaya and Muzaffarpur have the highest number of active cases. The number of districts with 2,000+ active cases is also rising fast.

It is also important to note here that Bihar’s government’s official figures – which the map is based on – reportedly capture only a small fraction of actual cases due to poor testing and alleged manipulation of data

Number of active cases, averaged for May 7, 8 and 9.

Figure 2 below shows the total availability of ICU beds in all districts. As mentioned above, the state has a dearth of ICU Covid-19 beds. Nearly half the state’s districts – 16 of 38 – do not have a single Covid-19 ICU bed (occupied or vacant) because this critical infrastructure was not set up when there was a lull in the number of cases, forcing paients here to travel to hospitals in other already-overburdened districts.

These 16 districts, according to the 2011 Census, have a total population of 4,38,99,932.

Map showing total availability of ICU Covid beds across Bihar.

Apart from Patna, only four other districts – Muzaffarpur, Begusarai, Darbhanga and Bhagalpur – have more than 100 ICU beds in public hospitals. This may be causing loss of lives as it did in Supaul district on May 9, when a patient in a Covid Care Centre was not transferred to a hospital on time and died due to lack of oxygen.

At 7.30 am on May 10, there were less than 20 vacant beds available in 33 of the state the state’s 38 districts, of which 18 districts had none.

Map showing number of vacant ICU beds in districts of Bihar. Data taken from the state government's portal at 7.30 am on May 10.

Since the onset of the first wave of Covid, three major kinds of treatment infrastructure were created in India: Covid Care Centres, Dedicated Covid Hospitals and Dedicated Covid Health Centres (more info on this here).

Dedicated Covid Hospitals are supposed to be the best equipped type of facility, with ICU beds, ventilators and assured oxygen support. They are to be used for severe cases of the disease. Dedicated Covid Health Centres are for moderate cases and should ideally have non-ICU beds with assured oxygen support. The Covid Care Centres is for mild, very mild cases and suspected cases – these are makeshift facilities set up in hostels, hotels, schools, stadiums and lodges, both public and private.

The presence of these three types of Covid treatment centres in various districts is illustrated in the map below.

Map showing all available Covid beds – ICU and non-ICU – in Bihar across the three different types of centres. It also shows the distribution of the three types of treatment centres. Please note, that out of the 507 hospitals listed on the government portal, 156 do not have their location detailed. Therefore, this map is only annotated with the remaining 351 treatment centres. The other maps are based on information regarding all 507 hospitals.

Most districts in Bihar only have Covid Care Centres, which “offer care only for cases that have been clinically assigned as mild or very mild cases…”, according to the health ministry. They are equipped to deal with cases that do not require additional medical support such as ventilators and oxygen.

However, the second wave has had more people of all age groups requiring treatment beyond the facilities that can be offered in Covid Care Centres. Patients need ICU beds and Dedicated Covid Hospitals are the centres meant to deal with such severe cases. But there are only 12 Dedicated Covid Hospitals in the whole state.

These have been set up only in Patna, Bhagalpur, Darbhanga, Gaya, Madhepura, Muzaffarpur, Nalanda and Pashchim Champaran districts.

Distribution of different types of Covid facilities in districts of Bihar.

As the two figures depict, the distribution of beds (including non-ICU) is uneven across Bihar. With Covid-19 spilling beyond urban centres, district headquarters and major hospitals are stressed as they have to address the caseload transferred from rural areas.

As with the rest of India, these beds are filling fast. The map below depicts the bed situation as on May 10 at 7.30 am.

Number of all available beds in public hospitals.

Consider the example of just Muzaffarpur district. Here, there are 798 Covid beds and 248 ICU beds for the whole district with a population of 48,01,062, according to the 2011 Census. This works out to one bed for 6,016 people.

Patna, the capital of the state is doing comparatively better with 4,543 beds, of which 1,092 are ICU beds. Comparing it to the Census 2011 population, this equals roughly one bed per 1,285 persons (all beds and not just ICU).

The number of people per Covid-19 bed for the majority of districts (21 out of 38) is above 4,000. It is important to note that Patna does not only cater to the population of the district but is also under stress from patients from other districts that have fewer beds.

Total number of confirmed, active and deceased cases so far for districts in Bihar.

With people having to travel large distances to get the care they need and the state’s hospitals in larger cities being unable to handle the cases that stream in from rural areas, the situation in Bihar is becoming dire.

Operating under the assumption the worst was over as the first wave receded in early 2021 has proven to be costly. In states like Bihar where the baseline level of public health infrastructure is so low, a concerted effort is necessary to identify areas acutely affected, scale up (especially in terms of manpower) and strategically build capacity for an anticipated third wave, as well as put existing idling equipment and infrastructure to effective use.

Pratyush Tripathy is part of the Geospatial Lab at the Indian Institute for Human Settlements. His research focuses on understanding spatial inequalities at urban and regional scales.