On January 23, when Kerala’s health minister K.K. Shailaja chaired a high-level meeting of her department officials, worry lines had begun creasing her brow. China had announced a lockdown in Wuhan and other cities in Hubei province. Hundreds of students from Kerala were studying for professional courses in Wuhan, and there were fears they would carry the virus back to the state. The sprightly health minister, who had been at the forefront of the state’s battle against the Nipah virus in 2018, had the task of drafting the action plan against a possible novel coronavirus outbreak. Three medical students from the Wuhan Institute of Medical Sciences had returned to their homes in Alappuzha, Thrissur and Kasargod that day and were in home quarantine. A week later, on January 30, when one of the three became India’s ‘patient zero’, the state was prepared.
A control room had been set up on January 23 itself at the General Hospital premises in Thiruvananthapuram. The state machinery had its strategy in place to counter the spread of the infection, but there was every reason to worry.
Kerala is connected to the world in a way few other Indian states are. It has an expatriate population of 2.5 million people and four international airports servicing over 17 million passengers every year. A population density of 819 people per square kilometre makes it India’s eighth most densely populated state. But it also had two trump cards, a world-class healthcare system and experience in containing the 2018 outbreak of the lethal Nipah virus.
Today, January 30 appears to be a lifetime away. Over 128,000 people have since died across the world of COVID-19, 392 of them in India. Even as the disease begins to spike across the country, prompting an extension of the 21-day lockdown till May 3, Kerala is one of the few states that has managed to flatten the disease curve. The state has so far lost only three people to the infection. Of the 387 infected, 211 have recovered fully. On April 13, it reported just two new cases. The state has a recovery rate of 84 per cent, compared to 14 per cent in the rest of the country. It hasn’t been an easy struggle and the aftereffects will endure. The lockdown has reduced its major revenue streams, overseas remittances, revenues from the sale of alcohol, tourism and sale of lottery tickets, to a trickle. Preliminary estimates suggest the state could incur a revenue loss of Rs 50,000 crore (FY2021) due to the COVID-19 crisis. According to state finance minister Dr Thomas Isaac, the lockdown period itself has led to a revenue loss of Rs 4,980 crore (based on revenue collections for March-April 2019).
Illustration by Tanmoy Chakraborty
The state’s exemplary social indicators led to the coinage ‘Kerala Model’ in the 1970s, to note how a low-income state with high literacy rates and healthy citizens boasted a standard of living comparable to life in the developed nations. In 2018, it earned praise from the World Health Organization for ‘achieving impressive health outcomes at modest incomes compared to the rest of the states in India’. Kerala has consistently topped the country in the overall health index, from low neonatal mortality rates to total fertility rate. This is when it has the same number of hospital beds to people, 1.05 per 1,000 people, as national capital Delhi does.
Yet, it was more than just its fabled world-class healthcare system that delivered tangible results. What helped the state of 34 million people was a combination of factors. A leadership that geared itself up to tackle a pandemic with contingency plans and then relentlessly followed it up with communication strategies and social mobilisation even as it set up mechanisms to identify, isolate, test and treat the infected. Huge awareness campaigns were kicked off and hundreds of thousands of health workers dispatched through the 14 districts of the state to fight the epidemic. If Prime Minister Narendra Modi likened COVID-19 to a world war, Kerala was already on the frontlines. The Kerala Model 2.0 is a story the rest of the world can well take lessons from.
Anticipating the pandemic
Kerala was battle-inoculated against viruses in 2018. In May that year, it grappled with South India’s first case of Nipah virus, which often leads to acute respiratory distress, encephalitis, seizures and coma in its patients within 24 to 48 hours. The mortality rate was estimated at between 40 and 75 per cent.
The virus, thought to have travelled from the fruit bat to humans, spread rapidly through the two northern districts of Kozhikode and Malappuram with 17 deaths and 18 confirmed cases. The state health machinery acted fast with then Union health minister J.P. Nadda and Chief Minister Pinarayi Vijayan leading the day-to-day outbreak analysis and response. Key learnings in the fight were a focus on infection prevention and control measures based on isolating patients, the use of personal protection equipment and decontaminating surfaces. The WHO praised Kerala for ‘relying on the strengths of its health system to contain the outbreak. The leadership and commitment of all levels of Indian health authorities were seen’.
What also helped was the ramped-up spending on healthcare, Rs 5,000 crore over the past five years. Since 2016, the state government has focused on developing infrastructure at government hospitals, right from the primary health centres (PHCs) to medical colleges. Around 600 doctors and 1,500 nurses were appointed in this period (fresh appointment orders for 276 doctors from the Public Service Commission rank list were issued on March 24). New buildings were constructed even as the state charted a plan to get National Quality Assurance Standard (NQAS) accreditation for government hospitals. This year alone, 12 of them got NQAS certification. Hospital development committees were constituted to monitor their functioning. The state also introduced ‘star ratings’ for its PHCs.
In January, as evidence began mounting of a large-scale pandemic, Kerala was already off the blocks. The state identified four priorities, checking community spread of the infection, insulating doctors, nurses and paramedical staff, home quarantining high-risk category people to break the chain and, finally, putting the state under high surveillance against the infection.
When the three medical students from Wuhan arrived, the state immediately placed them in isolation wards. Their fellow travellers on the Kolkata-Kochi flight were identified and also home quarantined. “Our battle began when the first travellers from Wuhan arrived in the state on January 23,” says Shailaja. On February 3, as a third patient tested positive for COVID-19, Kerala declared the virus a state calamity. It helped the government put collectors as point persons in the districts with magisterial powers to mobilise all manpower and logistics at their disposal. The battle had now escalated into a war.
Identify, test, isolate
On February 3, the state government requested the National Institute of Virology, Pune, to set up a testing facility at its field unit in Alappuzha to facilitate speedy testing for COVID-19. The state health department constituted three task forces, planning, execution and monitoring, to reinforce its battle against the disease. Principal secretary, health, Dr Rajan Khobragade was the coordinator for all the three task forces.
The state-issued guidelines to health workers and others on the frontlines about COVID-19 symptoms and alerted them about how it could be mistaken for viral fever or a common cold. Helplines were set up in all districts and the government appealed to the people who had returned from Wuhan or other Chinese territories to remain home quarantined for 28 days. The state also started testing and screening high-risk people who were in the contact lists of the infected on January 25. A team of doctors started contact tracking and home quarantined all contacts in the first phase. Above all, the chief minister directed local self-government bodies to get involved and scan their localities for people who had returned from the infected countries after January 14.
By January 30, the date when ‘patient zero’ was confirmed, the government had begun setting up isolation wards in all medical colleges, general and district hospitals. Doctors and nursing staff were deployed across the state after training. The government also set up 12 testing labs to enable early identification of COVID-19 patients.
The health department provided personal protective equipment (PPE) to all caregivers and paramedical staff and issued guidelines for sample collection, handling of swabs and testing procedures. Early screening had helped the three patients with COVID-19 to swiftly recover. On February 13, their tests turned negative and became a morale booster for the health department. “But we decided to continue our vigil as a large number of passengers were still coming in from the Gulf and other countries. We feared that despite the screening at all four airports, someone with an infection would slip through,” says Dr R.L. Saritha, director, state health services. There were many anxious moments after March 8 when an NRI family from Italy returned to the state on a domestic flight without declaring that they had come back from Europe.
The family triggered off the second phase of the COVID-19 outbreak. They arrived in Kochi on February 29, travelled to their village in Pathanamthitta district by car and visited several locations, including a local bar. Their primary contact list included over 800 people in three districts. Nearly 250 families in a single district were sent into home quarantine after seven members of the family tested positive for COVID-19.
The state had been anticipating community spread of the infection any time and had prepared an action plan. Soon, the health department notified 28 hospitals, including medical colleges, as COVID-19 specialty hospitals in the state. Meanwhile, four more testing centres opened in the state. “We decided to intensify surveillance across the state and charted a plan B and C for the future. We realised we had to set up corona care homes to quarantine passengers arriving from foreign countries and other states,” says the health minister. The state government identified hostels, educational institutions and unoccupied buildings and set up 635 corona care centres for isolation. Apart from this, around 125,000 rooms have been designated as isolation wards to accommodate suspected cases of COVID-19 during the quarantine period.
Today, anyone who enters the state has to undergo mandatory isolation. The period is 14 days if the traveller is coming from another state, and 28 days if he/ she is coming from outside the country (a Gulf returnee in Kannur tested positive on the 26th day, April 14, after arrival). “We have followed global norms and a targeted approach in this battle against COVID-19,” says Dr B. Ekbal, Kerala Planning Board member and a public health expert. Kerala has conducted 17,400 tests as on April 16.
The state introduced a lockdown on March 23 before it hit the 100 infections mark. The 21-day national lockdown came at a critical point for the state, government officials say. Else, there would have been a fresh wave of infections from its returning emigres.
Kerala promoted social distancing and use of masks by the public from January 30, the first state in the country to do so. A state calamity was declared on February 3. Schools and colleges were closed on March 10. The same day, the government appealed to all religious groups to cancel community gatherings at religious places after the second outbreak in Pathanamthitta district.
Illustrations by Raj Verma
On March 15, as the number of infections in the state touched 95, Chief Minister Pinarayi Vijayan convened a video conference with religious leaders of all faiths. The Christians readily agreed to close their churches. Muslim leaders also appealed to the community to stop daily prayers at the mosques. The Hindu temples closed down despite March and April being festival season in Kerala. Beginning March 10, all temple festivals had anyway been cancelled in the state. The few religious leaders who violated the code saw police cases slapped against them. The government also used the media effectively. On March 15, the ‘Break the Chain’ campaign was launched to check the spread of infections and promote social distancing and personal hygiene practices.
Social media played a pivotal role in the success of these campaigns. Superstars like Mammootty, Mohanlal and other popular actors promoted the campaigns on their Facebook pages. Youth organisations, merchant associations, resident associations, they all joined the ‘Break the Chain’ campaign. Even the Kerala police got into the act, with dance videos promoting masks and drone footage set to film music. “Washing hands, wearing masks and social distancing became the thumb rule for Kerala after March 15. Everyone followed it in the right spirit,” says Varghese Madassery, 49, an NRI businessman in Kochi.
On February 18, Kerala constituted three high-level committees and expert groups to advise the government on COVID-19. Among their members were specialist doctors, virologists, disaster management experts, software professionals, hospital administrators, former civil servants and retired defence personnel.
Also set up was a special monitoring group headed by R. Mohan, secretary to the chief minister, and officer on special duty (OSD) M. Sivasankar. State chief secretary Tom Jose was directed to coordinate with various departments and the Centre. At 3 pm every day, a dossier containing consolidated reports of statewide activities lands on the CM’s table before he begins his review meeting. The assembly session was also cut short on March 13 and legislators requested to undertake COVID-19 awareness activities in their constituencies.
Amid all these efforts, two northern districts, Kasargod and Kannur, became a health challenge for the state. These districts today account for 77 per cent of the infections in the state, mainly because of the huge presence of returning NRIs in the district. Their reluctance to follow social distancing and the quarantine code triggered the infection levels in the districts. The situation improved only after the district administrations intensified surveillance.
The state government has also now set up a dedicated COVID-19 hospital at the Kasargod Medical College to plug any deficiencies in the system. With 34 COVID-19 cases reported in a single day (March 27), the district had reported the single biggest spike in coronavirus cases in the state.
A mere government-led top-down approach would never have succeeded without the social mobilisation in the state. The state set up a 250,000-strong volunteer force in just two days on March 26. Over the next three days, these volunteers (all in the 22-40 age group and without criminal records) were made eligible for working with their respective local government bodies. After a brief training schedule, they are assigned voluntary work commensurate with their qualifications. The work includes being standby ambulance drivers, and nurses and paramedical staff to assist the 3,000-strong health workforce. Others are deployed to deliver food packets to the poor or keep surveillance on those under home quarantine. All of it is voluntary, with no one getting paid anything apart from a travel allowance.
Starting March 26, the state also set up 18,828 camps for its ‘guest workers’, the migrant labour from other states. Over 300,000 people are being hosted in the camps and provided free food and medical care. The state has set up 1,255 community kitchens; 280,000 food packets are distributed daily. Free ration kits of 35 kilos of rice and Rs 1,000 worth of essential commodities have gone out to 3.69 million families.
All this would not have been possible without the cooperation of civil society, the vigilant state police force and community volunteers. CM Vijayan admits as much while explaining how the state lowered the infection curve. But there will be no lowering of the guard. District administrations will remain on high alert till mid-May. “We will continue our vigil till the last patient recovers and completes the quarantine period,” the chief minister told India today. Kerala was one of the states which backed the Centre’s plan to extend the lockdown. The chief minister believes the next four weeks are critical. Complacency, clearly, has no place in Kerala Model 2.0.