While public health experts and opinion makers praise Kerala’s achievements in the public health sector, the Indian state is battling a series of public health challenges apart from the recent COVID-19 outbreak.Kerala has survived two successive devastating floods which created enormous health related challenges and still remains vigilant against deadly Nipah Virus attack, Kyasanur Forest Disease ( KFD) and bird flu (avian influenza).Apart from well-equipped government hospitals with dedicated medical experts, the state has a wide network of primary health centres which function as the first level of contact with the population. The state is now acquiring a permanent mechanism to diagnose and track viruses and other infections. Balaji Viswanathan, chief executive officer of a Bengaluru-based start-up, was holidaying with his family at the Alappuzha beach in Kerala in the first week of March when his son met with an accident early in the morning and he had to be rushed to a nearby government hospital. “In thirty seconds, the reception at the hospital has processed the entry without seeking any identity proof,” he wrote on his Facebook post. “In another 30 seconds, the doctor in charge of the emergency wing had examined the child and found it was not life-threatening. In another two minutes, the blood was contained and first aid was done. In another five minutes, a senior doctor made the first assessment and asked for an X-ray. As it was early hours, I had to wake up the lab technician, but the X-ray was ready in another two minutes,” narrated Viswanathan about his experiment with Kerala’s public health system in his social media post. “We returned to the holiday home to just get some food and then went back to the hospital for the ortho. We waited for about five minutes to seek the assessment of the ortho. In the next five minutes, another duty doctor came in and had the bandage replaced and a prescription given. Amazingly our holiday continued without any delay,” continued the post which attempted to explain how Kerala is turning a role model of public health in the face of the global outbreak of the coronavirus. Kerala has been earning praise in the media and among citizens for its effective and efficient handling of COVID-19 in the southern Indian state. The novel coronavirus disease (COVID-19) has been characterised by the World Health Organization as a pandemic. The causative virus SARS-CoV-2 has infected more than 209,839 confirmed cases, as of March 19, 2020, ever since it was first reported from Wuhan in China late last year (2019). In Kerala, 28 (Indian and foreign nationals) have been confirmed as cases of COVID-19, as reported by the union Ministry of Health and Family Welfare on March 20, 9 a.m. Kerala Govt's Special Package | #COVID19 20,000 Cr financial package to fight the pandemic. ✅ Loans worth 2000 Cr through Kudumbashree ✅ 2000 Cr for employment guarantee programme ✅ 2 months welfare pensions in advance ✅ 500 Cr health package — CMO Kerala (@CMOKerala) March 19, 2020 On Thursday, March 19, the Kerala Chief Minister Pinarayi Vijayan announced a relief package worth Rs. 20,000 crore (Rs. 200 billion) for the state affected by COVID-19. The fund has been set apart for consumer loans which would be made available through women’s neighbourhood collective Kudumbashree. The fund would also be made available, to be disbursed as wages, under the rural job employment guarantee schemes in April and May and social security pensions for two months, normally given in April, will be given in March itself. The chief minister also announced financial assistance for Below Poverty Line (BPL) and Antyodaya families. Other procedures to prevent hoarding and artificial scarcity of essential goods, subsidised lunch outlets, relaxation on water and electricity bill payments and financial assistance to public transport drivers were part of the relief announcement. “As a state with large number of expatriates contributing significantly to the economy and a global tourism hub visited by people from different countries, the virus has landed Kerala already in a huge financial crisis. Trade and commerce have been hit badly. But we will not dilute our continuing fight against health sector challenges. We wish to be identified globally as a success story of the public sector in healthcare,’’ the Chief Minister told Mongabay-India prior to the relief announcement. Waging a multi-pronged public health battle Kerala, the state with the highest literacy rate and living standards in India, is battling a series of public health challenges apart from COVID-19. Cases of Kyasanur Forest Disease (KFD) and bird flu (avian influenza) have been reported in recent times from Wayanad and Kozhikode districts in the northern region. KFD, which claimed two lives in Kerala last year (2019), has already caused the death of a Wayanad resident this year. Meanwhile, bird flu fears have led to large scale culling of birds – a worldwide practice against bird flu involving culling of domestic birds either infected or at the risk of being infected – in the northern districts, in an attempt to contain the disease. Infected birds shed flu virus in their saliva, nasal secretions, and feces (droppings). Humans in turn become infected when they have contact with contaminated excretions or surfaces. Most cases of bird flu infection in humans have resulted from contact with infected poultry or contaminated surfaces. Read more: [Interview] Taking One Health approach to tackle zoonoses crucial for India The bird flu cases in north Kerala are making poultry farmers of Alapuzha district in the south a worried lot as Kuttanad in the district was badly hit by H5N1 in 2014-15 and H5N8 in 2016-17 (H5N1 and H5N8 are two variations of bird flu). More than ten lakh ducks were culled in Alapuzha and neighbouring Kottayam district following each outbreak. Mass culling of ducks over the years had caused severe financial losses to the farmers there. Social workers in Kerala spread awareness about COVID-19 and provide masks and cloth for protection. Photo by S K Mohan. “Actually we are waging a multi-pronged battle in the health sector to keep people safe. The Nipah outbreak that claimed 17 lives in Kozhikode in 2018 was the biggest challenge so far. Though it resurfaced last year, we were able to contain it effectively through preventive measures and rapid awareness initiatives. In fact, the Nipah outbreak has helped us learn many lessons in the fight against viruses and that experience is now making us well prepared to face the COVID-19 challenge,” said Kerala’s Health Minister K. K. Shailaja in an interaction with Mongabay-India. A school teacher turned politician, Shailaja has already won wide global appreciation for her dedicated and effective interventions armed with scientific knowledge and reasoning, in containing the Nipah virus in Kerala. Apart from identifying and quarantining COVID-19 carriers, Kerala government has also initiated awareness drives in 14 districts of Kerala not just among the local people but also among migrant workers and visitors from outside the state. Also, it is keeping a close vigil on misinformation and unscientific information on COVID-19 and other epidemics. The Kerala Health Department and Home Department have special wings to prevent the spread of misinformation and fake news. The social media wings of the police and health department are conducting counter campaigns against fake news using scientific data and a strong public vigil on fake news is encouraged. Recently, a naturopath in the state who claimed that he would heal coronavirus infection was arrested and the government is keeping a close watch on all who make dubious medical claims, even on social media, regarding COVID-19. “We are ensuring dedicated and targeted teamwork through broader unity. The commitment of our staff is exemplary. We are also ensuring cooperation of political parties including those in the opposition, public health activists, leading healthcare institutions, researchers, scientists and social organisations. After all, Kerala has a rich legacy of making major gains in the health sector through effective coordination and public participation,” said Shailaja. Kerala’s health secretary Rajan N. Khobragade said the COVID-19 is only the latest among the public health challenges Kerala has battled valiantly in the last few years. “We survived two climate change-induced, massive, devastating floods which created an enormous health-related crisis in the last two years. KFD and bird flu are revisiting us along with Nipah. Though anthrax has not yet emerged as a major challenge to the state, leptospirosis and rabies are still creating hurdles. We are fighting all these with public participation and involvement. Highest transparency is what we are ensuring in all our interventions,” he said.