When the coronavirus pandemic eventually reached India, it was always going to pose a challenge of epic proportions for a country of 1.3+ billion people, with such a dense population domiciled  in such close quarters, and with a widespread underbelly of poverty. The Spanish flu of 1918 inflicted a death toll on India in the many millions, something no doubt in the back of the minds of public health officials. So, two or three months into the crisis, on paper, India’s COVID-19 record, on paper, doesn’t look as frightening as many other nations. As at 17-May-2020, so far it has had a shade under 91 thousand confirmed cases and a total of 2,872 deaths (www.worldometers.info).

(Photo: Indranil Mukherjee / Agence France-Presse – Getty Images)

There is a perception within medical circles however that these figures don’t portray the full extent of the outbreak. India’s urban areas are packed with masses of people living face to face, beset with poor sanitation conditions, up to 100 people sharing the same toilet in some cases, adding up to a recipe for catastrophe in plague time. Obtaining a test for coronavirus in India has tended to not be straightforward, thus the level of testing has lagged woefully behind what is desirable, eg, by well into March India was averaging only five tests per ten lakhs (= one million) people, compared with South Korea which had managed 4,800 per ten lakhs.

Too many migrant workers waiting for too few buses to take them home after the lockdown was announced (Photo: Yawar Nazir – Getty Images)

Containment measures have been far short of perfect, and with some glaring omissions…there has been passive resistance to the lockdowns from sceptical Indians, and the ban on public gatherings has from time to time been skirted round (some ‘scofflaw’ political parties continue to hold mass rallies). Although India’s borders were closed fairly promptly, some have been critical of the procrastination of Indian leaders’ during the crucial early days of the crisis, one Indian epidemiologist characterised it as a “let’s wait till tomorrow” attitude [‘India Scrambles to Escape a Coronavirus Crisis. So Far It’s Working’, (J Gettleman, S Raj, KD Singh & K Schultz), New York Times, 17-March-2020, www.nytimes.com]. This early reticence to act emanated from Delhi. The Modi BJP government, initially seemingly more concerned with the impact on India’s under-performing economy, issued no public health warnings or media briefings at the onset of the pandemic [‘What the world can learn from Kerala about how to fight covid-19’, (Sonia Faleiro), MIT Technology Review, 13-Apr-2020, www.technologyreview.com].

(www.anayahotels.com)

Kerala, leading from the periphery
Kerala is one state that these general criticisms of Indian public health efforts against COVID-19 cannot be levelled. The small southwestern Indian state is one of the most picturesque parts of the land with its coconut trees and irenic and serene back-waterways. Known as a tourist mecca, Kerala, population 35 million, is more affluent than many parts of India (GDP per capital GB£2,200). 20% of India’s gold is consumed here, and it produces over 90% of the country’s rubber. Literacy is nearly 20% higher than the overall Indian average, and life expectancy too, is higher (www.holidify.com). All of these were contributing factors buttressing Kerala’s capacity to cope with the disease when it came.

Local vulnerabilities to the epidemic
Kerala was coronavirus “ground zero” for India’s very first patients. Three students returning from Wuhan were tested positive and hospitalised (in all 70% of the state’s total virus patients have come from outside India). Certain preconditions pertaining to the state exacerbated the risk of disease outbreak, including a large number of Keralite migrant workers in the Gulf states, a huge expat population (working in Kerala from other Indian states), porous borders, and an early summer monsoon season (contributing to Kerala’s high rate of annual communicable diseases) [‘Coronavirus: How India’s Kerala state flattened the curve’, (Soutik Biswas), BBC News, 16-Apr-2020, www.bbcnews.com].

Preparation and planning
Kerala was prepared for COVID-19 before the onset of the disease. The earlier Nipah viral outbreak (NiV) In Kerala (2018) proved a good trial run for the health service, giving the local authorities an opportunity to iron out chinks in it. Kerala’s communist-left coalition  government had established a strong social welfare foundation, investing in the state’s infrastructure with a focus on health and education, and on tackling the state’s poverty✺. [‘How the Indian State of Kerala flattened the coronavirus curve’, (Oommen C Kurian), Guardian,  21-Apr-2020, www.theguardian.com].

Minister Shailaja (Source: www.manoramonline.com)

Shailaja ‘Teacher’, a woman with a plan
When the epidemic arrived in Kerala, the proactive state health minister KK Shailaja took charge. With the full backing of Kerala chief minister, Pinarayi Vijayan, she had already organised a rapid response team to focus on targeted clusters, and liaised with the provincial councils. Kerala adopted the WHO protocols of test, trace, isolate and support. Rigorous contact tracing was employed, utilising detailed “route maps”. Testing of suspected carriers was decisive, with a quick, 48-hour turnaround of the result [‘Kerala has best coronavirus test rate in the country, but is it enough?’, (Vishnu Varna), The Indian Express, 01-Apr-2020, www.indianexpress.com], allowing them to move quickly on to the quarantine phase. 17,000 people were quarantined under strict surveillance, the poor without quarantine facilities were placed in improvised isolation. Recovered patients were duly released back into the community. Quarantine compliance was achieved through an admixture of phone monitoring (>340,000 calls and a neighbourhood watch system [‘The coronavirus slayer! How Kerala’s rock star health minister helped save it from Covid-19’, (Laura Spinney), The Guardian, 14-May-2020, www.theguardian.com; Kurian].

One of the sternest challenges, very early on, came from the district of Pathanamthitta. A family returning from Italy tested positive, but refused to disclose their movements upon return to Kerala. The civil servant in charge of the district, PB Nooh, and his team, worked round this obstacle by accessing the family’s GPS phone data, allowing them to trace all of their contacts (almost 300 people!). Nooh’s staff then tested the contacts for infection, thus shutting down the risk of the virus being exponentially transmitted to others in the community, ie, “breaking the chain” (Faleiro).

The coronavirus certainly didn’t miss Kerala, one-fifth of all Indian cases of the disease have occurred in the state. Under Shailaja, Kerala hit the ground running, before the end of January, screenings of arrivals at all four of the state’s international airports was introduced. The government imposed a lockdown even before the national lockdown was called…schools, malls, cinemas, public gatherings, were closed down, and the lockdown was stricter and longer than the national one (Kurian). Face masks were distributed to slum dwellers. Planning was precise and focused, a state stimulus package of Rs20,000 crore was directed towards the economic and medical crises.The medical task force was mobilised (doctors on leave were recalled, others asked to delay their leave). Those suffering hardship included migrant workers from other states were provided with free lunches by the state.

Communication with citizens informing them about all aspects of the crisis was clear and consistent (“Break the Chain” campaign which emphasises public and personal hygiene). Accordingly, community participation, both voluntary and active, was forthcoming. Some Keralites made accommodation available (including vacant homes in some instances) to those in need when requested to by the government [‘The Kerala Way of Tackling a Pandemic’, Times of India, 20-Mar-2020, www.timesofindia.com].

The Kerala government’s campaign against the virus has been aided by the polity’s decentralised nature of it’s structures. The coordination achieved allows the local councils to follow through on a lot of the public health measures needed to be implemented in the crisis (Biswas). The result of all this detailed planning and effort by Kerala – 587 confirmed cases and only four deaths and apparently no significant community transmissions (17-Apr-2020).

The state of Kerala and Shailaja ‘Teacher’ (so known because her occupation before entering politics was that of science teacher) are not resting on their laurels, being very mindful of the chance of a second wave of COVID-19 due to impending factors—Prime Minister Modi’s anticipated ending of the national lockdown, which will trigger a mass return of Kerala’s migrant workers based in the Gulf, and the approach of the tropical wet season in Kerala (June) [‘Kerala Lays Down Specific Plans To Tackle Monsoon Amid COVID-19 Pandemic’, NDTV, 15-May-2020, www.ndtv.com]. Minister Shaijala has been making preparations for such an event, many of the state’s teachers have been retrained as nurses to cope with a new upsurge in virus hotspots (Spinney).

EndNote: No time for Kerala complacency but a most worthy blueprint on offer 
The threat of new clusters emerging in Kerala remains very real, especially coming from outside, with a spike as recent as this past Friday—imported from neighbouring Tamil Nadu and Maharashtra as well as from overseas—reminding Shailaja and Co that the battle’s still far from won. Nonetheless, for elsewhere in India and beyond, there are lessons from Kerala‘s formidable achievement to be had from the state’s “nimble-footed, community-oriented, cautiously-aggressive approach” to the outbreak [Kurian; ‘Kerala reports 11 new Covid-19 cases’, (Ramesh Babu), Hindustan Times,16-May-2020, www.hindustantimes.com].

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✺ the Kerala government is Marxist in ideology but pragmatic in practice, it’s policies are moderately social-democratic, with a highly-privatised public health system (Kurian)