Beyond the Hype: Understanding how Kerala is Handling COVID-19

By V Santhakumar

There are a number of journalistic articles and popular messages on social media on the way Kerala has handled the COVID-19 crisis. My impression is that there is not enough focus on understanding the nuances of Kerala’s response and drawing lessons for Kerala and other states. I foresee serious challenges in Kerala due to the possible persistence of COVID-19 infections. Several writings have already dealt with the socio-political reasons which make the Kerala government more pro-active,¹and also the better status of its healthcare system in comparison with those of other Indian states,² so I will not touch upon these two issues in this article.

To understand the response of and challenges faced by the Kerala government, we look at the current crisis by dividing it into three phases – the situation before and during the lockdown, and the possible scenario after the lockdown.

Situation before the lockdown
The fact that the Kerala government became alert and pro-active to meet the COVID-19 emergency before most other Indian states, has been recognised. The experience of handling the Nipah virus last year may have sounded an alarm to the state’s administration. So, when the infection started spreading in Wuhan (China), Kerala could foresee the arrival of the virus into the state soon, since there are hundreds of people from the state studying (especially, medicine) in Wuhan and other cities of China. The government was careful in identifying those who had travelled back from China. Not surprisingly, the first few cases of the COVID-19 infection in India were in Kerala (towards the end of January) and all of these patients were those who had travelled from China.

The Kerala Government adhered to, by and large, the following strategies during this phase:

1. Identifying those who had travelled to Kerala from the infected places.
2. Encouraging them to follow self-quarantining at home.
3. Creating additional quarantine centres, fully subsidized by the state.
4. Testing all those who showed symptoms of the infection.
5. Hospitalizing all those who were infected. They were given excellent medical care in government hospitals, and hence, there were only a few critical cases and no death during this phase.

There were no major restrictions on the movement of people or on economic activities. The screening of people who came from other parts of the world, especially Europe and the Middle East, started only by March 1. The infection had started spreading in these countries by then. Hence, some people who reached Kerala from these regions before March 1, and were carrying the virus, could enter the country/state without being screened at the airports. The second wave of infections in the state started from these people. The first such case was in the district of Pathanamthitta. A family of three who came from Italy interacted with a number of relatives and other acquaintances before they started showing the symptoms and came to the notice of the governmental machinery.

The district administration responded promptly after this. All the infected patients are admitted to public hospitals, which are prepared exclusively for them, where they received concerted attention by medical professionals, fully prepared. They received good care as there was no dearth of hospital facilities due to the small number of patients and the diversion of a major part of the state’s healthcare system for this purpose. The travel itinerary of all these patients was prepared and published. There were efforts to identify all those people who had interacted, even for a short period, with these patients and to put them in home-quarantine. Those with noticeable symptoms were hospitalized. Field-level public health workers and the officials of the district administration constantly monitored and interacted with those who were under home quarantine; supported them with basic necessities (like food and medicine) if needed; and, brought them to hospitals if there were noticeable symptoms. The rate of testing also increased to cover all these suspected cases. A few of them were found to be positive. But the infection rate (the number of people who got the infection through contact with a COVID-19 patient) was not high. Only close relatives and acquaintances were infected.

There was a similar case in the Kasaragod district in the North-Kerala One person had travelled from the Middle East. The difference, in this case, was that before this person was identified, quarantined and hospitalized, many others had interacted with this person.

By that time, passengers travelling to Kerala from the Middle East and Europe were being quarantined (and most of them followed instructions). Some of them also developed symptoms (that led to the testing and hospitalization) and became COVID-19 positive and underwent treatment. There were a few others who got infections from these people who came from outside. However, barring a few cases, the spread of infections was limited to the primary contacts or close relatives or acquaintances. Even until this point, there were no major restrictions on the movement of people, except in Kasaragod. It is around this time that the Government of India declared a national lockdown.

During the lockdown
A complete lockdown was not the choice of the Kerala government, and the Chief Minister had observed, just a few days earlier, that their approach would be to allow social life as much as possible. The national lockdown was favourable in the sense that the state government could intensify the restrictions on the movement of people, and even though COVID-infections started spreading in other Indian states and, somewhat rapidly, in the Middle East, because the entry of people from outside the state and the country was banned, it reduced the number of infections, or the number of people needed to be quarantined, etc. (though the sustainability of this benefit is questionable, and we discuss this in a following section) within the state.

On the other hand, the national lockdown posed several challenges and the pressure on the state government multiplied as daily-wage workers, who lost their sources of income needed to be supported. A large number of these were migrants who were facing a number of challenges – many among them wanted to go back to their homes in other states but that was impossible because all transport, including trains and busses, had been suspended; they had no income to survive on; the living conditions in their cramped labour colonies are not conducive for social distancing and other precautions which are needed to prevent the spread of COVID-19; their contractors were reluctant to meet their cost of living or pay wages during this period when work was stalled; and, so on.

There are also others like older people, people with disabilities or those requiring regular medicines and medical care, who were affected due to the closure of shops and restrictions on mobility. The government of Kerala tried its best to provide the required support to all these people. A set of basic commodities was supplied to almost all households. Advance payments were given to those who are on the payroll of social security pensions from the government. Migrant workers were supplied with basic food materials and those who were living in cramped labour camps were relocated to shelters where social distancing and other precaution were possible. Community kitchens were started at the local government level to feed those who could not buy and make food due to the lack of money or other reasons. There were many other support measures, including the supply of medicines to non-COVID patients. Overall, the humanitarian support that is provided by the government of Kerala is much more comprehensive than that in a number of other Indian states.

The other major challenge was the crippling of the economy. One impact of this was on the people who work in the informal sector and these include not only workers but also small traders and many others. Tourism and hotel industry, which is an important domestic economic activity, almost came to a standstill. There are a number of other such activities including fishing. However, the most important impact is on the revenues of the government. The tax revenue has decreased substantially. The ban on alcohol sale during the crisis has also dried a major source of income for the state government. On the other hand, the cost of managing the crisis has gone up tremendously during the lockdown. This is due to the need to provide the required support to all people who cannot earn their basic livelihood during the lockdown. The state government cannot borrow more money due to the already high debt and the restrictions by the central government. It is forced to take away a part of the salaries of the government employees (including those who are doing sincere and hard work during the COVID-crisis) to partially mitigate the situation. It is also depending on the donations from people. Though the willingness to support the government during such a crisis is laudable, the financial vulnerability of the state government is not a desirable indication.

Possible scenario after the lockdown
Though the number of new cases has not increased, the trend is not disappearing. However, the state cannot continue with the lockdown. Moreover, it has to receive the lakhs of Keralites who are currently in other Indian states and countries once the lockdown is withdrawn or even before that through special arrangements (like those to bring in migrant workers from the Middle East). It would be very difficult socially and economically to disallow inbound travel from elsewhere in India and the world for the next six months. Stopping the movement of people from or to Kerala would be very costly to the state, considering the dependence of its economy on global markets and the mobility of people. COVID-19 infections have become severe in other parts of the country and world currently. It may not be very easy to quarantine all people who are travelling to Kerala after the lockdown.  In essence, allowing in-bound travel would mean that the state has to be prepared for the continuation of COVID-19 infections (and possible community spread).

For these reasons, the state may need to eventually follow a different approach. What are the aspects of such an approach?

1. Giving utmost importance to personal hygiene. There have to be more awareness campaigns regarding the dos and don’ts during this time. There can also be a lot more testing of suspected cases. The number of testing kits available has to go up drastically. Procedures for quicker testing have to be used widely. People need to quarantine themselves even if they suspect having contacted COVID-19 patients. It is important to isolate older people from those who are suspected to have the infection. This should not be difficult since we already take such extra care if someone in the family has any contagious disease, like chickenpox. This is to ensure that if one gets the infection, the chances of it spreading to others in the family and community are minimized.
2. There have to be public quarantine centres with adequate facilities and basic food. This is necessary since many people in the state may not have adequate space within their home to quarantine themselves without transmitting the disease to close relatives. Primary health centres and other such facilities can be used for this purpose as long as the infection level is not very high.
3. We should visualize a scenario where many more people are infected with COVID-19. As long as such infections are at a reasonably low level, we may allow hospitalization of all such patients. However, this situation may change. Then, the approach should be to encourage all patients who are at a lower risk to stay at home or quarantine centres with basic medical support. There can be a set of guidelines on the basic medicines and practices to be used by such patients, and we need to develop such guidelines with the hope that these can be followed within homes or quarantine facilities.
4. The attention of the public healthcare system should focus on the 10-20 percent of patients who can become chronically ill due to the COVID-19 infection. Almost all secondary and tertiary care public and private hospitals should be prepared to meet such a situation. There have to be efforts to acquire a lot more ventilators, oxygen support systems, and enhance the preparedness of the medical staff.
5. A major change in this approach is to allow normal economic, social and personal activities. It is not presumed that such activities can go on smoothly when many people are infected or under treatment. However, we need to find ways of allowing these activities to the extent that is possible and by treating chronically infected patients, quarantining those who are infected and limiting the spread through personal hygiene. Thinking that the spread can be contained substantially through the continuation of a complete lockdown may not be realistic.
6. Currently, we are using much more economic resources (in terms of opportunity cost) for containing the disease. This could become detrimental if we cannot contain the disease, which seems to be the emerging situation. If the probable future is one where we have to encounter this virus infection, society needs a much more robust financial capacity to do so. This requires allowing economic activities on the one hand and using a greater part of the resources generated through that process to treat those patients who are chronically ill due to the COVID-19 infection, on the other.
7. There are possibilities of using available medicines and there has to be a global collaboration to develop appropriate protocols for this purpose. We may hope that the efforts to develop vaccines against COVID-19 would be successful soon. However, we may have to accept a future where this virus is going to be around causing infection to sections of people once in a while, prompting the society to provide the best possible care and to contain the infection. Then, COVID-19 may become like one of the viruses or infectious diseases like H1N1, Ebola and others.

Key lessons and policy prescriptions
Some of the key lessons from Kerala’s experience are the following:

1. Kerala handled the Corona flu with the seriousness of the Nipah while most countries took it as common flu. Both were wrong in their assumptions, but it worked for the state as it erred on the side of caution.
2. All social voluntarism, bureaucracy and leadership preparedness was tested by the 2018 floods.
3. The personal and involved leadership of the Chief Minister aligned policies and gave people assurance.
4. Kerala had put in place a reasonably robust system to address the COVID-19 crisis even before the lockdown. This included (1) Identifying those who travelled to Kerala from infected places; (2) Encouraging them to follow self-quarantining at home; (3) Creating additional quarantine centres fully subsidized by the state; (4) Testing all those who showed relevant symptoms; and (5) Hospitalizing (in public hospitals) all those who are infected. Though the hospitalization of all infected people may not be feasible if there are more cases after the lockdown (which cannot be ruled out) is lifted and people arrive from outside the state. Then, there has to be a strategy of hospitalizing only those who are chronically ill and quarantining all other patients – a strategy adopted in many developed countries. It may be desirable to charge a reasonable fee for the hospital treatment and to meet quarantine expenditure in government-provided care centres from those who can afford to pay. The charging mechanism can be like the one in Sri Chitra Institute of Medical Sciences, a hospital owned by the government of India.
5. As noted earlier, a viable system to handle the crisis was put in place in Kerala even before the lockdown. The lockdown has not flattened the number of daily cases in most parts of India, though the increase in daily cases has been only moderate in Kerala during the national lockdown. There is no reason to think that there will not be an increase in the number of cases after the lockdown. Kerala is one state which has developed the experience and can provide lessons to other states to handle the crisis even without a stringent lockdown.
6. The government of Kerala has so far followed a maximalist approach by putting in all its efforts. The lockdown has also enhanced the resources to be committed to meet this challenge. This is also creating a perception that it is sufficient to contain the virus. However, there could be the persistence of COVID-19 infections even with this maximalist approach. Also, such an approach cannot be continued. There is a need for Kerala society to move towards an equilibrium with adequate and appropriate care on the part of individuals, a viable (and not maximalist) support system that is created by the government, and an expectation of the persistence of this infection for at least some more months (until the arrival of the vaccine or some such solution). There have to be changes in the perception of all actors to move towards such a desirable equilibrium.
7. The pro-active state supported by pro-social actions on the part of people at large has enabled the state to contain the virus infection so far and minimize the death rate. There has been a certain level of coordinated collective action which most other Indian states could not achieve. The plight of the poor and vulnerable sections was also taken into account during the period of the lockdown. The state of government hospitals and other aspects of public healthcare are notably good in terms of access and quality (probably even compared to the situation in certain developed countries.) However, the crisis has also brought out the vulnerability of the state government. On the one hand, it is under great compulsion to use public resources to provide reasonable quality healthcare and education to the whole population. It is also providing basic goods and minimal social security to those who cannot earn an income on their own. On the other hand, the state government faces a severe shortage of funds not only during the periods of crisis but also in normal times. It has crossed the limits of borrowing that are imposed by the Government of India. It cannot pay the salaries of its employees. It is compelled to mobilize funds as donations from public and philanthropists to tide over this and other such situations. This is not a sustainable or desirable situation.

AUTHOR
V Santhakumar, Professor, Azim Premji University, Bangalore.

Disclaimer: The views and opinions expressed in this article are those of the author/s and do not necessarily reflect the official policy or position of Azim Premji University or Foundation.