After early success, Kerala stumbles in containing the COVID-19 pandemic

After effectively handling COVID-19 for about five months since the pandemic was first reported in India and winning praise from the international community, Kerala’s pandemic curve is now defying all predictions. The state, which successfully handled India’s first cases of the pandemic, is now on the list of top ten states with maximum caseloads, generating concern among health experts and political leadership.

The cumulative caseload as of October 22 evening was 369,323 – and the death toll crossed the 1,000-mark, at 1,255.

While Union Health Minister Harsh Vardhan, in his recent online address accused Kerala of paying the price of gross negligence during the Onam festival season in September by unlocking restrictions and promoting inter-state travel for trade and tourism, Kerala’s Left Democratic Front (LDF) government maintains that the stringent measures it had evolved since February this year to control the pandemic have achieved significant results, mainly in keeping the mortality rate below the national average.

According to Harsh Vardhan, Kerala had reported hardly 499 cases and two deaths in the period between January 30 and May 3 this year. Now the daily new cases have doubled, he said. According to him, the Kerala situation is a good lesson for other state governments, which turn negligent about public health during festival seasons.

Echoing similar sentiments, a section of health experts are also urging the state government to step up action in the face of the worsening situation by evolving new strategies and involving more professionals in the policy formation process.

The Kerala branch of the Indian Medical Association (IMA) has said that the government is formulating policies by depending solely on its bureaucracy and without considering the medical experts and professionals in the state. Without the involvement of doctors and health experts in the process of policy formulation, it would take too much time to overcome COVID-19, they said.

“As per the Union Health Ministry statistics, Kerala stands third among the states in terms of active cases. It is just behind Maharashtra and Karnataka. Test positivity rate has shot up to 13.01 in Kerala while the national average stands at around 8.3. In the case of monthly mortality moving growth rate (MGR), the state has reached 130% in October, and the national average is hardly 40 percent,” S.S. Lal, a Kerala resident and head of the public health wing at the Global Institute of Public Health, told Mongabay-India. “We only made suggestions when the situation in the state turned to worse. Our sole aim was to improve the system and minimise the damage, but now it seems that the government fails to learn from its mistakes and targets those who criticise its policies and programmes. In the face of a pandemic, it’s an unhealthy model. The government must be ready to face the reality and redraft its strategies with an inclusive approach and readiness to accept different expert opinions,” Lal says.

However, Chief Minister Pinarayi Vijayan, as reported in the media, has countered the criticism, saying that the state has the lowest mortality rate in the country – 0.36 percent, while the national average is 1.55 percent. He has also expressed strong reservations about the public statement of IMA that the “state’s health system has turned weak because of the lack of proper management and extreme red-tapism.”

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From less than 1 percent to over 10 percent 

As of October 23, Kerala had the second-highest number of active cases in the country with 93,393 active cases reported.

Earlier, in May, Kerala had brought down the number of new cases to zero on many days. But as the state started opening up, with migrant labourers and non-resident Indians returning, the cases have seen an increase again.

A second wave is prevailing now in the state and local transmissions are the highest so far. Kerala’s contact tracing mechanism, its strong point during the first wave, has not shown the same efficacy in the second phase and the number of untraceable cases is surging.

According to epidemiologists and public health professionals, the estimated sufficient reproduction number for COVID-19 (a way of measuring the pandemic’s transmission potential) in the state is 1.21.

Some government sources have attributed the rush of people on roads and in shops that compromised social distancing during Onam celebrations and a set of political agitations that Kerala witnessed during August and September as contributing to the present situation.

With complaints that testing has been inadequate in the state, Kerala has ramped up its testing and is testing on average over 50,000 persons a day. “Even now, testing continues to be low and many cases are unreported. Now testing is required to identify and isolate patients,” said N. M. Arun, a public-health expert and writer on health issues, based out of Palakkad.

Meanwhile, the health department has given instructions to all its district units to keep the test positivity rate (TPR) below 10 percent. According to a report carried by The Times of India, the TPR in 11 of the 14 districts in the state in October is over 10 percent. The government wants to keep the TPR less than 5 percent, which is when the infection rate can be claimed as under control. As per the report, the state’s present TPR is 14 percent, while the national TPR is eight percent.

“The pandemic situation in Kerala has changed significantly in the last three months. The Kerala society is now living along with the virus. As far as TPR is concerned, it is not much important epidemiologically. It has only clinical importance,” Raman Kutty, epidemiologist and emeritus professor at the Sree Chitra Tirunal Institute for Medical Sciences and Technology, said when contacted by Mongabay-India.

While experts suggest increased testing to reduce TPR, almost all of the district administrations are not very keen on increasing the testing numbers. Sources in the health department say that they used to bring down the TPR and thus keep the number of cases low by increasing testing in places where COVID-19 cases are comparatively low, but that situation has changed now and testing of those who need to be tested is happening across the state.

In the changed situation, the health department has given direction to all the district administrations to assess the infrastructure facilities available in the coming months to deal with the possible surge in COVID-19 cases. Other than the severely ill COVID-19 positive patients, those who need maternal care and dialysis care require special facilities.

“At present, Kerala’s public healthcare system is in a mess, and 80 percent of the intensive-care units have now got filled. The situation has turned worse because of the governmental approach placing bureaucracy above public health experts,” IMA president Abraham Varghese said in a press statement.

Delayed diagnosis

Experts are also citing delayed diagnosis as a cause of COVID-19 related deaths in the state. Data available from the state health department itself prove about one-fifth of COVID-19 patients who died in Kerala had succumbed within a day after their admission to the hospital. This has generated the allegation that people are often tested too late and the delays have facilitated the spreading up of the virus.

Among those who tested positive for COVID-19, Kerala is focusing more on the elderly and people with comorbidities. However, obese people are also turning into a crucial segment to deal with. According to the health department, around two-thirds of COVID deaths had either diabetes or hypertension, or both. Nearly one-third had other comorbidities.

“A major issue in Kerala is delayed diagnosis. Late admission to hospitals increases the risk. Then there would be a poor response to treatment, especially in the case of aged people. Chances of recovery are very less in the case of those who arrive late and get soon into ventilators,” pointed out Fathahudeen, head of the department of pulmonary and critical care medicine at Government Medical College in Ernakulam when contacted by Mongabay-India. He is also a nodal officer and leader in the treatment of COVID-19 for the district.

According to Mysore Sanjeev, convener of the non-governmental organisation Project JeevanRaksha, the government must make institutional isolation compulsory for male COVID-19 positive patients aged above 50 years with comorbidities.

“Pregnant and lactating women also must be provided with the same facility. There must be larger campaigns prompting people for early testing. The most vulnerable segments must be kept under round the clock monitoring of medical experts to eliminate the risk of delayed medical intervention,” he said when contacted by Mongabay-India.

“An alarming situation is prevalent across the state, especially in highly populated districts like Malappuram, Kozhikode and Thiruvananthapuram. There must be rampant testing in order to identify maximum infected persons and to isolate them. A worrying phenomenon is that more cases are now being found among those in reverse quarantine. If we allow it to continue, the state will lose the only advantage it has so far, the low death rate,” said Dr. Gopikumar P., secretary of Kerala chapter of IMA, in a statement.

In the face of mounting criticism and renewed threats, the state government has imposed prohibitory orders invoking Section 144 of CrPC across Kerala. Under it, a ban on assembly of more than five persons will be in place till the end of October. A number of senior government officers have been given the power of executive magistrates to help contain the pandemic by avoiding mass gatherings. However, hitherto there have been no restrictions on the mobility of people and functioning of commercial centres and offices.

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The high density of population

Kerala has a high population density, with over 750 people per square kilometre, compared to the national average of 460, making it harder to contain the disease.

Despite having crossed 1,000 deaths, the rate of deaths due to COVID-19 is at 0.4 percent, is among the lowest in the country.

“There are limitations for any health care system anywhere in the world. Our doctors, nurses, paramedical staff, health workers and experts are working tirelessly with extreme dedication for the past eight months to minimise the impact of the pandemic. Only because of our vigilance, the patient load is not getting exceeded above our system capacity. Now we require the cooperation of people. They must desist from mass gatherings and forming of crowds. A major lack of civic sense is visible and that is why people roam around without bothering much about the after-effects,” Kerala Health Minister K.K. Shailaja said when contacted by the Mongabay-India.

“The much-trumpeted Kerala model in fighting the pandemic has failed miserably. Now the government is not meeting any of its responsibilities. Lack of coordination and the refusal to utilise expert opinions mainly from Keralites working in global health organisations have created the prevailing alarming situation,” Kerala’s Opposition Leader Ramesh Chennithala said when contacted by Mongabay-India.

While listing out the flaws in COVID-19 containment, he alleged that the state government was keeping the number of tests per day as low despite the huge spike in caseload. He also accused the government of a lack of transparency on data related to containment efforts.

When contacted, the nodal officer of the state health department for communicable diseases, Amar Fettle, said the state’s success in fighting the pandemic depends largely on the way the general public cooperating with the authorities.

“People must have to behave responsibly and avoid huge gatherings. There must be a willful effort on the part of people in keeping the protocols without lapses. In many places, people require a behavioural vaccine than a pharmaceutical vaccine. Better behaviour is the cure,” Fettle said.

Shailaja said the state was trying its best to keep the elderly safe from the infection as they are a vulnerable group. “The health department is under severe stress right from the end of January when the first pandemic case of India was reported in Thrissur. Those who are levelling baseless allegations against the department must be aware of the difficult situation in which we are functioning. We have basic minimum resources, and staff deficiency is high, but we are committed to fighting the pandemic till the end,” the Minister said.

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Banner image: Samples getting collected at a primary health centre in Thiruvananthapuram. Photo by Deepaprasad T.K.