• 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.

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.
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.

A person suspected to be infected by COVID-19 enrolls himself at an isolation camp in Kannur, Kerala. Photo by S K Mohan.A person suspected to have COVID-19 enrolls himself at an isolation camp in Kannur, Kerala. Photo by S K Mohan.

An effective medical network built over decades

Kerala’s efforts are strengthened by an effective medical network. On March 4, a BBC talk show on COVID-19 had showered praise on Kerala for its effective and efficient handling of the cases reported in the state so far. According to eminent virologist Shahid Jameel, chief executive of DBT Wellcome India Alliance, what makes Kerala different is its health infrastructure. “Apart from hospitals, the state has a wide network of primary health centres which function as the first level of contact with the population. The state also has the capability to diagnose and track viruses and other infections,” he said in the BBC panel discussion on COVID-19 crisis.

The first phase of COVID-19 in the state started early February when the country’s first three confirmed COVID-19 cases were medical students that returned to Kerala from Wuhan in China (where the virus first emerged). All of them were cured in isolation wards.

The students were prompted to follow a rigid protocol, which included a 28-day quarantine to contain the spread of the infection. Quarantine is a treatment in isolation for suspected cases of COVID-19 depending on the seriousness. Those with serious symptoms are isolated at medical college hospitals with isolation wards, while those with minor symptoms are quarantined at home under regular observation of health officials and doctors.

The first phase ended at the beginning of March when new cases started being reported. More suspected cases of travellers from Italy (Indian and foreign nationals) were reported in the first week of March, the start of the second phase. The health department officials managed to trace all those who reached the state from countries with high cases of COVID-19 (particularly China, Iran and Italy) in this phase and isolated them, even if they had minor symptoms. According to the World Health Organisation, the most common symptoms of COVID-19 are fever, tiredness, and dry cough. Some patients may have aches and pains, nasal congestion, runny nose, sore throat or diarrhea. These symptoms are usually mild and begin gradually. Some people become infected but don’t develop any symptoms and don’t feel unwell. Most people (about 80%) recover from the disease without needing special treatment. Those who came in contact with the suspected patients were home quarantined.

A healthcare worker at the reception of an isolation ward at a government hospital in Kannur, Kerala. Photo by S K Mohan.
A healthcare worker at the reception of an isolation ward at a government hospital in Kannur, Kerala. Photo by S K Mohan.

When the Nipah outbreak was detected in Kerala in 2018, the health department had issued alerts for people diagnosed with pneumonia-like symptoms. Based on expert opinion that the virus was being spread through fruits eaten by bats, the government has advised people to reduce fruit consumption. Then the infection control measures were initiated which included isolating patients, using surgical masks and decontaminating surfaces.

“We are fighting COVID-19 in the same way we handled Nipah. That time we were poorly equipped and lack of previous exposure remained a major handicap. Now we are well-equipped with better experiences,’’ said Shailaja. “The Nipah virus outbreak has taught us that isolation is one of the most effective methods to control the spread of infection. We were also able to convince the people about the need to treat and isolate symptomatic patients. Strong public vigil has helped us to trace and deboard an Italian tourist infected with COVID-19 who escaped from isolation and monitoring to return to his home by a flight from Kochi international airport,” she said.

“What is worth applauding is the transparency and probity the Kerala government has shown in the case of fighting the virus threats. Chief Minister Pinarayi Vijayan and Minister Shailaja are conducting press conferences on a daily basis to keep people aware of the gravity of the issue and the steps taken by the government. It’s a Kerala model that began during the floods of 2018 and nowhere else you can see such an attempt which is highly educational. Apart from a roundup of the day, each press meet provides plenty of practical information to the ordinary people about the pandemic that sweeps the world,” Kozhikode-based public health expert Suresh Kumar told Mongabay-India.

Read more: Nipah infection in Kerala – Don’t blame the bats alone; improve public health

“Break the chain”

As of March 20, 2020, Kerala has 28 confirmed cases of people (Indian and foreign nationals) with COVID-19. A total of 10,994 people are under observation across the state and among them 289 are in isolation wards in different government hospitals. A total of 2,147 blood samples have been collected for testing and among them 1,514 turned out to be negative, according to data sourced from the health secretary on March 17, 2020.

Women members of self help and neighbourhood groups are assisting staff of primary health centres in tracking those who arrived from abroad, following reporting of cases on March 9 when a family from Kerala that returned from Italy was confirmed with COVID-19. In each of the 14 districts of Kerala, special cells have been formed to prepare route maps of each infected person. The map tracks every point from where the patient landed in India or came in contact with an infected person up to the moment when he or she was admitted to the hospital. The information comprising the place and time is then circulated through newspapers and social media with the request to all those who came in contact with the person in those places to be vigilant and access preventive care.

While the union government stipulated period of quarantine for those who have tested postive for COVID-19 is 14 days, Kerala is quarantining COVID-19 positive cases for about 28 days. In the isolation wards, the admitted patients are receiving their choice of meals, access to wi-fi and counselling sessions, according to the health secretary. Another step taken by the government is opening of multiple call centres to keep check on the mental health of those who are home quarantined. As of now 14 such call centres are opened at district headquarters.

The youth volunteer at the Break The Chain campaign organised by the Kerala health department to encourage hand sanitising and prevent the spread of the virus. Photo by S K Mohan.
A youth volunteer at the Break The Chain campaign organised by the Kerala health department to encourage hand sanitising for preventing the spread of the virus. Photo by S K Mohan.

“I spent 25 days in isolation and there were occasions when I felt depressed. A counsellor called me and comforted me regularly. I got better care and my favourite food including chicken biryani,”Kerala’s first coronavirus patient, who was discharged after completion of the treatment, told Mongabay-India.

To avoid possible breaking of quarantine, the government is using GPS tracking (tracking phones) and has tackled some cases where patients in quarantine have escaped. In another significant step, government has forced internet service providers to increase connectivity (network capacity and bandwidth) by 30-40% in the state to meet the surge in demand as people are placed in quarantine or forced to work from home. Women self help groups, prison inmates, youth organisations and social collectives have been prompted to prepare sanitisers for bulk buying and distribution among the needy.

Strict police action against those who spread fake news, home-delivery of mid-day meals to kids that used to attend anganwadi centres that closed in response to the pandemic and medical check-ups at 24 spots bordering Tamil Nadu and Karnataka for people entering the state by rail and road are the other major steps undertaken by Kerala. On March 15, the health department launched a “break the chain” campaign to encourage hand sanitising among people to prevent the spread of the virus.

Banner image: A state transport employee wearing a mark on duty in Kerala. Photo by S K Mohan.

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