Kerala, the second most densely populated state in India with a current population of 33,406,061, often finds itself in the headlines these days due to its success in containing the dreaded COVID-19.
The viral outbreak, which originated in Wuhan, China, has now been detected in 210 countries and territories around the world, with around 3 million cases and 2 lakh deaths to its credit.
As an active healthcare professional belonging to this state, it is a gratifying experience for me to analyse how this small state proceeded to effectively mitigate the impact of this pandemic more efficiently than not only other states in India, but also most of the developed world. Kerala was especially vulnerable to COVID-19 as it has a high population density compared to other states, with almost a tenth of the population living outside the state. Moreover, these non-resident Keralites visit their homeland at least once a year, adding to the hundreds of thousands of tourists who flock to the coastal state to enjoy its scenic beauty. Yet, against all these odds, the state has been able to not only prevent an all-out onslaught, but has also emerged as a text-book example of how to control COVID-19.
One of the biggest advantages that the state was able to leverage in this fight was its superior healthcare infrastructure. Kerala is comparable to developed countries in most of the health indices, including infant mortality rate, maternal mortality rate and others, and well ahead of most Indian states.
This is the result of continuous efforts over the last four to five decades to strengthen the healthcare system, especially that in the government sector. The state has a three-tier health system with Primary Health Centres (PHCs) at the grass-root level, community health centres at the taluk level and district hospitals, supplemented by referral medical college hospitals well equipped with efficient doctors and nurses.
Unlike many parts of the country, a large part of the population in Kerala still depends on the government sector for taking care of their ailments. Health workers at PHCs, like ASHA workers and health inspectors, go to individual houses and are supposed to know each nook and corner of their territories. Thanks to the state’s non-communicable disease control programme, they are also aware of the health status of each member of their village. This grassroot level penetration makes the implementation of the plans easy.
Another important societal factor that helped the initiative was the state’s high literacy rate. A well educated population translates to a highly receptive citizenry. Once the government took a decision, a proactive media publicised it widely and the literate and active citizens took up the mission with the seriousness it deserved. So, the implementation of such sensitive strategies and initiatives, where people’s involvement plays a major role, is easier here than in any part of the country.
While countries like China and Singapore benefited from their experience in dealing with SARS, Kerala’s encounter with the Nipah virus in 2018 and 2019 gave it some much-needed insights on how to control a deadly virus. With the experience of dealing with the Nipah virus fresh in its mind, the government machinery swung into action as soon as the viral outbreak was reported from the city of Wuhan. Since the government was aware that several students from Kerala were studying for various courses in the Chinese city, an exclusive control room was set as early as January 23, at a time when most of the states in India did not perceive the threat from this virus seriously. Every person who came from Wuhan was told to self-isolate and report to the authorities in case of symptoms. After a week of setting up the corona control room, on January 30, the first case in India was reported in a medical student who came back to Kerala from Wuhan.
As soon as the case was diagnosed, the government machinery swung into action. Health minister KK Shailaja travelled 300 km from the capital city to Thrissur where the patient was admitted and held a high-level meeting at 11 pm at night. This earnest approach from the top brass and the willingness to lead from the front brought home the seriousness of the situation to the entire health team. Within 24 hours, the contact tracing of the first patient was completed and all possible contacts were isolated. Following this, the state put in place facilities to surveil, identify, and conduct risk-based categorisation of all passenger arrivals from China, as well as those who had come in close contact with these travellers. As two more cases were confirmed on February 2 and 3, the state government declared a health emergency in the state. This was a very early response and turned out to be crucial, considering the rapidness with which virus spreads.
Thanks to a timely intervention, Kerala made sure that not a single person got infected from the students from Wuhan.
The second wave
The second wave of the epidemic started in the first week of March, when a non-resident Kerala family came from Italy and exited the airport without fully complying with government advisories. They subsequently visited several of their relatives, leading to the spread of the infection to several people through contact. This led to the government deploying a series of emergency measures, including aggressive testing, contact tracing and a massive quarantine of hundreds of people. It also put in place broader measures to deal with any such eventuality in the future:
1. With the help of the National Institute of Virology, the government set up multiple centres for testing in different parts of the state and activated the same for speedy testing. Once a person was tested positive, the district administration published the route map of the person within 24 hours and this helped to collect the details of all the places the patient had visited.
This also helped the public to identify if they had had any contact with the infected person. If so, they were encouraged to report on a toll-free number. Along with this, local health workers traced primary and secondary contacts and isolated them via in-home quarantines. They were given strict instructions not to move around, which was ensured twice a day by the local health worker via phone calls. For each case diagnosed, around 80 contacts were traced and isolated. This helped to contain the spread to a great extent.
2. As state authorities realised that the disease was spreading from one country to another, all foreign arrivals, even if asymptomatic, were ordered to be kept in isolation for 28 days, even though the WHO recommended duration was only 14 days. At one time, there were more than 1.80 lakh people under isolation. This was made possible only with the help of ground-level workers who ensured that even if a single person developed a symptom of COVID-19, it was reported to health authorities and testing was carried out immediately and the patient shifted to the hospital. Because of this, the time from the onset of symptoms to the shift of the patient to the hospital was very less. Due to this effective policy of quarantining high-risk cases, the reproduction ratio of the virus was kept below 1 at all times. This ensured that the epidemic was always under control.
With meticulous planning, Kerala state efficiently mitigates the heavy impact of the pandemic crisis
All non-medical educational institutions were shut down in early March 31, and exams were postponed.
Break the chain initiative
An initiative to spread awareness about the importance of hand washing and use of sanitizers was started in the second week of March via public and local media. Both social and mainstream media took up the campaign, and handwashing techniques were taught to even the children.
On March 23, Kerala announced a total state-wide lockdown, a day before Prime Minister Modi made a similar announcement for the country as a whole.
Communication with the public
The Chief Minister conducts a daily press conference at 6:00 p.m. to brief the citizens about the latest developments and lay out the measures taken by the government to control it. This ensured proper communication between the government and the citizens. The government took several measures to ease the problems created by the lock-down, including for the migrant labourers. Orders were also issued to set up community kitchens to ensure that no one would starve during the lock-down. As of April 20, a total of 339 community kitchens were functioning in 249 panchayats across the 14 districts of the state. They have served a total of 5,91,687 meals since April 4, 2020.
Enhanced welfare pensions were given to different sections of society, in addition to free rations.
To respond to the increase in confirmed cases, guidelines were issued to convert private hospitals into COVID-19 hospitals. The tenures of medical professionals retiring on March 31 were extended up to June 30. Temporary recruitment of health inspectors were also introduced.
Thanks to a scientific approach, Kerala has been able to reasonably contain the initial wave of COVID-19. However, as all of us know, this is only a trailer and the main movie will hit the theatres once lakhs of NRKs start returning home. Kerala has a plan for that too, and hopes to repeat its success in this phase too.
The author is Medical director at Centre for Arthritis and Rheumatism —CARE