The state had been battling Covid-19 for more than a month before Maharashtra reported its first case on March 10. As of Saturday, it had 40 cases, while Maharashtra had 53. A deep dive on how it swung into action
On March 7, two people with fever paid a visit to Dr Shambhu, a physician at Ranni Government Hospital in Kerala’s Pathanamthitta district. It had been more than a month since Kerala reported the first three cases of Covid-19 — students who had arrived from China — so he followed procedure, and asked if they had been to any foreign country recently. They hadn’t, but said they had come into contact with a family in their neighbourhood that had just returned from Italy, where the disease was spreading rapidly.
Dr Shambhu realised that sitting before him were the first cases of secondary transmission of Covid-19 in the state. He quickly shifted them to the isolation ward and informed the health department and district administration. A medical team reached the Italy returnees’ home in an ambulance and, despite their initial refusal to cooperate, took their family members — who included their aged parents — to the hospital. The family initially refused to admit that they were sick. But when they tested positive they admitted that they had refused to furnish their travel history to authorities, had dodged screening at the airport, and had been visiting relatives instead of staying at home.
The state soon launched a massive search across the two districts the family had been to, identified more than 3,000 who had come into contact with the family, and began monitoring them. To avert a community spread, the health ministry also released a route map of the places the family had been to since returning to India. Meanwhile, CM Pinarayi Vijayan and Minister of Health and Family Welfare KK Shailaja asked everyone to stay alert.
Ahead of time
Kerala’s ‘secret’, it turns out, was being prepared for the outbreak well before it began. Dr M Narayanan, president of the Indian Academy of Paediatrics, Kerala, says, “The outbreaks in Kerala and Italy took place at almost the same time. But now, when the death toll in Italy, which has free and quality healthcare, has crossed 4,000, Kerala has not had a single death, despite having fewer resources and facilities. We have been able to identify and isolate suspected carriers, including asymptomatic ones, to avert a community-level spread.”
In what minister Shailaja called ‘a self-designed protocol’ — something she learned from the state’s battle with the 2018 Nipah outbreak, which claimed 17 lives — a surveillance mechanism was put in place in mid-January. It was part of a larger plan that involved co-ordination between the state’s infrastructure, bureaucracy and people. Quarantine facilities and control rooms were set up in all 14 districts to keep tabs on those arriving from abroad.
On February 3, as soon as the first three cases were reported, the government announced a state health emergency. As many as 18 expert groups at the rapid response control room split tasks into areas such as quarantine, isolation, monitoring, contact tracing, media surveillance, field teams, etc. When a person arrived with symptoms, health officials sprang into action at once, tracing the journey of the patient, finding his or her primary and secondary contacts, and shifting them to quarantine to avert a community outbreak. When a person tested positive for Covid-19, a map of their journey was published so that people could easily identify those who were most at risk of contracting the disease.
Dr Amjith Rajeevan, an assistant surgeon at a primary health centre in Pathanamthitta district, who also heads the media surveillance team that looks for possible links to any Covid-19 suspect that may have been overlooked, says, “When the first three cases were reported, we had the advantage of knowing they had been home-quarantined. But when a family of three dodged screening upon arrival from Italy and tested positive after visiting various places, we had the task of averting a community outbreak. The first meeting of the rapid response team was called at 7.30 am, which was attended by officials from the Chief Minister’s Office and Health Ministry, doctors, healthcare workers, public representatives and surveillance training committees. It was decided to track down the travel history of the patients and fill in the missing links. For this, we needed the help of field workers, women’s selfhelp groups and support groups, who talked to people and sourced CCTV footage. More people were quarantined, and this helped control the spread.”
Those who were quarantined in their homes were monitored using GPS to ensure they remained indoors. To support the virology institute in Alappuzha, opened after the Nipah episode, four more testing facilities were opened in various districts. At meetings convened twice a day, the ground situation was assessed and necessary arrangements were made; district-wise data and statistics on required health facilities, medical assistance and food were compiled and presented. This is followed by a daily press conference — sometimes twice daily — at which the chief minister, the health minister or both turned people’s panic into vigilance by sharing information about new developments, assuring people of a positive outcome and appreciating their efforts. While health helplines and round-the-clock emergency services worked tirelessly to quarantine suspected carriers, schools were shut down, weddings and other events with large gatherings were postponed, and cinemas shuttered.
What is the Kerala model?
As of Saturday morning, Maharashtra had 53 Covid-19 cases, Uttar Pradesh 24, Rajasthan 17, Haryana 17, Delhi 26 and Karnataka 15. Kerala, which has been battling the outbreak for longer than any other state, had 40 cases, 44,390 people under observation, and zero casualties. Why has Kerala’s battle against Covid-19 been more successful — at least so far — than those of other states? “Compared to other Indian states, Kerala has a lot of advantages,” says Dr Amjith, who has been in charge of coordinating the state’s control rooms during past crises.
“Keralites are a global community and Covid-19 infections have now been reported from all over the world, but we were prepared to face it right from when it hit China. Equipped with a peoplefriendly health delivery system, state-ofthe- art infection control facilities, expertise of public health professionals and strong backing of district administrations, Kerala could face the challenges. The state also has another great advantage — highly educated local body representatives, who are in direct contact with the people. Kerala’s high literacy rate made spreading awareness easier,” he adds.
Apart from government medical colleges, primary and community health centres, the public and private sector healthcare systems in Kerala maintain high standards. As CM Vijayan put it, “We have excellent healthcare systems, from primary health centres to super-specialty hospitals. The spirit of this system is a popular partnership. Healthcare workers from all parts of the system have joined hands to battle this crisis.” Minister Shailaja says, “Our main target is to not lose any life. Community service and public cooperation — seeking medical assistance in case of symptoms — will help us win the fight. The key to containing the virus is responsible behaviour.”
That’s exactly what Arjun (name changed to protect his identity) exhibited when he and his friends — all of them MBBS students in Wuhan, the epicentre of the outbreak — returned to India just before the city was locked down. Arjun and two of his friends are the three first Covid-19 cases in India. He says, “Our 30-member team was the first to have landed in India from Wuhan. At Kolkata airport, we underwent basic tests and signed papers, after which we were given guidelines. Once I reached my home in Alappuzha district, I informed the health department of my arrival and stayed at home. A few days later, I saw that one of my friends had tested positive, becoming the first person in India with the disease. Though I had no symptoms, I put on an N95 respirator and reported to the nearest primary health centre.”
Harbinger of hope
Harbinger of hope Any new contagious disease brings with it desperation, panic and mass hysteria. To tackle these, the Kerala government introduced trustworthy communication channels and outreach programmes. Through the mobile app GoK-Direct Kerala, which sends real-time updates and SMS alerts to subscribers in various languages, the Department of Information and Public Relations ensure transparency. To improve the lives of everyone forced to remain indoors, the government announced it would increase WiFi bandwidth. Through social media campaigns such as ‘Break the Chain’, calls for social distancing, and by acting swiftly against those spreading fake news, it combated fear and stigma. The government also ensured the supply of essential commodities and medical assistance to the public for free. Children who could no longer go to anganwadis (rural child care centres) continued to receive their much-needed mid-day meals at home. “About 3.7 lakh students in 33,115 anganwadis in the state have benefitted from the initiative,” Shailaja says.
But the masterstroke of the Pinarayi government was the Rs 20,000-crore health package he announced on March 19 to revive the economy. Of this, Rs 2,000-crore is for disbursing loans through Kudumbashree, a women’s self-help group; Rs 1,320 crore for paying two months’ welfare pension in advance; Rs 100 crore for families that do not otherwise receive any welfare pension; and Rs 100 crore for free cereals through the Public Distribution System. He also announced the opening of subsidised lunch outlets, relaxation of power and water bills, and assistance to public transport staff.
The challenges ahead
The Kerala model has been praised widely, but with one-sixth of its 3.5-crore population being expatriates, the state is not taking anything for granted. If even one person under quarantine ventures outdoors, it could spark a community-level outbreak. “Had this shutdown been done earlier, we could have avoided the current risk of community spread from patients exposed to secondary transmission,” says Dr Narayanan. Though the state machinery was been able to contain the disease at first, this responsibility is now with the public. There are people who have organised or attended mass gatherings, prayer meets and temple festivals. Many who returned from the Hajj have not practised home quarantine. The six new positive cases reported on March 20 from Kasaragod district were infected by a foreign-returnee who attended weddings, public events and football matches, forcing the whole district to shut down.
Dr Narayanan said, “After a lull, cases have spiked. The disease has reached tertiary contacts. If this explodes, I am not sure that we have enough infrastructure, hospital beds, ventilators and intensive care units to accommodate all patients and combat a massive outbreak. Even the lives of healthcare professionals are at risk. Kerala also has a huge high-risk population of senior citizens, cancer patients and others who need immunosuppressants.” Though Kerala has better medical facilities than most other states, it has only 1.1 hospital beds for every 1,000 people. While the government is converting college hostels to Covid-19 centres, it will face a shortage of ventilators and ICUs in case of a community-level spread. The only way to combat the disease, therefore, is to practice social distancing.
Published in Mumbai Mirror on March 22, 2020
