Coronavirus: what lessons can be learned from Kerala?

Chris Lovejoy asks: what lessons can be learned from Kerala's handling of the coronavirus pandemic?


Despite the constant grim media news, one state has avoided the pandemic: Kerala, India


Over 10% of the globe’s population lives in India. Considering internal travel restrictions didn’t exist in India (or in the USA or the EU) before the lockdowns, an epidemic easily could have spread across the country. Yet, for the 1.3 billion people in India, the different COVID outcomes appear to be primarily a consequence of delegating health care to local governments (although other influential factors include wealth differentials, a variety of cultures, religions and the political systems within local governments). 


The BBC reported India had 266,598 confirmed virus cases on 10th June and, Mumbai had 51,000 cases, yet one Indian state claims to have avoided the pandemic. If this claim is correct, could another COVID pandemic and a surge in infections after the lockdown ends be avoided?


One Indian state, Kerala, has had only 524 cases of COVID-19 and four deaths. The state has a population of about 35 million and a GDP per capita of only £2,200, which suggests an effective disease containment policy is possible in a democracy that isn’t wealthy. By contrast, the UK (double the population with a GDP per capita of £33,100) reported more than 40,000 deaths, while the US (10 times the population with a GDP per capita of £51,100) reported more than 100,000 deaths, as well as rapid transmissions of the virus in their counties, resulting in strict lockdowns being enforced.


Such an amazing outcome requires an explanation. The Guardian, fortunately, has provided a detailed explanation of how this was achieved in Kerala.


Laura Spinney wrote the health minister, KK Shailaja, had phoned one of her medically trained deputies on 20th January. She had read online about a dangerous new virus spreading in China. “Will it come to us?” she asked. “Definitely, Madam,” he replied.


And she began her preparations.


Three days after reading about the new virus in China, and before Kerala had its first case of COVID-19, Shailaja held a meeting of her rapid response team. The next day, 24th January, the team set up a control room and instructed the medical officers in Kerala’s 14 districts to do the same at their level. The state adopted the World Health Organization’s protocol of test, trace, isolate and support. (N.B. tracing people requires finding every person contacted by an infected person in order to stop the spread of the virus.)


On 27th January, one week after her first phone call, the first cases were identified when passengers filed off the Chinese flight from Wuhan and had their temperatures checked. Three were found to be running a fever and were isolated in a nearby hospital. The remaining passengers were placed in home quarantine – sent there with information pamphlets about COVID-19 that had already been printed in the local language, Malayalam. The hospitalised patients tested positive for COVID-19, but the disease had been contained. “The first part was a victory,” says Shailaja. “But the virus continued to spread beyond China and soon it was everywhere.”


In late February, encountering one of Shailaja’s surveillance teams at the airport, a Malayali family returning from Venice were evasive about their travel history and went home without submitting to the now-standard controls. By the time medical personnel detected a case of COVID-19 and traced it back to them, their contacts were in the hundreds. Contact tracers tracked them all down, with the help of advertisements and social media, and they were placed in quarantine. Six developed COVID-19. 


Another cluster had been contained, but by now large numbers of overseas workers were heading home to Kerala from infected Gulf states, some of them carrying the virus. By 23rd March, all flights into the state’s four international airports were stopped. Two days later, India entered a nationwide lockdown.


At the height of the virus in Kerala, 170,000 people were quarantined and placed under strict surveillance by visiting health workers, with those who lacked an inside bathroom housed in improvised isolation units at the state government’s expense.


That number has shrunk to 21,000.


“We have also been accommodating and feeding 150,000 migrant workers from neighbouring states who were trapped here by the lockdown,” she says. “We fed them properly – three meals a day for six weeks.” Those workers are now being sent home on charter trains.


Shailaja was a celebrity in India before COVID-19 due to her proactive response to an outbreak of an even deadlier viral disease, Nipah, in 2018. She visited the village at the centre of the outbreak. The villagers were terrified and ready to flee because they did not understand how the disease was spreading. “I rushed there with my doctors, we organised a meeting in the panchayat [village council] office and I explained that there was no need to leave because the virus could only spread through direct contact,” she says. “If you kept at least a metre from a coughing person, it couldn’t travel. When we explained that, they became calm – and stayed.”


Nipah prepared Shailaja for COVID-19, she says, because it taught her that a highly contagious disease for which there is no treatment or vaccine should be taken seriously. 


Every village has a primary health centre and there were hospitals at each level of its administration, as well as 10 medical colleges. This occurred in other states, too, says MP Cariappa, a public health expert based in Pune, Maharashtra, but nowhere else was so much invested in their primary health system. Kerala enjoys the highest life expectancy and the lowest infant mortality of any state in India; it is also the most literate state. “With widespread access to education, there is a definite understanding of health being important to the wellbeing of people,” says Cariappa.


Although emergency measures such as the lockdown are the preserve of the national government, each Indian state sets its own health policy. In 2016, Kerala undertook a modernisation programme. One pre-pandemic innovation was to create clinics and a registry for respiratory disease – a big problem in India. “That meant we could spot conversion to COVID-19 and look out for community transmission,” Shailaja says. “It helped us very much” and – according to Shailaja – no community transmission subsequently occurred during the COVID epidemic.


Each district was asked to dedicate two hospitals to COVID-19, while each medical college set aside 500 beds. Separate entrances and exits were designated. Diagnostic tests were in short supply, especially after the disease reached wealthier western countries, so they were reserved for patients with symptoms and their close contacts, as well as for random sampling of asymptomatic people and those in the most exposed groups: health workers, police and volunteers.


Shailaja says a test in Kerala produced a result within 48 hours. “In the Gulf, as in the US and UK – all technologically fit countries – they are having to wait seven days,” she asks, “what is happening there?” 


“I think testing is very important – also quarantining and hospital surveillance – and people in those countries are not getting that.” She strongly believes “Proper planning” is essential.


Places of worship were closed under the rules of lockdown but resistance has been noticeably absent in Kerala – in part, perhaps, because its chief minister, Pinarayi Vijayan, consulted with local faith leaders about the closures. Shailaja says Kerala’s high literacy level is another factor: “People understand why they must stay at home. You can explain it to them.”


The Indian government plans to lift the lockdown on 17th May (the date has been extended twice). After that, she predicts, there will be a huge influx of Malayalis to Kerala from the heavily infected Gulf region. “It will be a great challenge, but we are preparing for it,” she says. There are plans A, B and C, with plan C – the worst-case scenario – involving the requisitioning of hotels, hostels and conference centres to provide 165,000 beds. If they need more than 5,000 ventilators, they will struggle – although more are on order – but the real limiting factor will be manpower, especially when it comes to contact tracing. “We are training up schoolteachers,” Shailaja says.


Once the second wave has passed – if, indeed, there is a second wave – these teachers will return to schools. She hopes to do the same, eventually, because her ministerial term will finish with the state elections a year from now. 


Laura Spinney's article demonstrates an effective disease containment policy is possible in a democracy that isn’t wealthy, emphasising the importance of forward planning, engaging with the community and using resources that are available.  


Julia Hollingsworth and Manveena Suri reported on the outbreak of the Nipah virus, which killed 18 people within a couple of weeks and had a fatality rate of between 40% to 75% — a great deal higher than COVID-19. They reported that the most vital issue was contact tracing and claimed: “If we trace the call correctly, we can isolate the human being from other folks and we can crack the chain and flatten the curve of the epidemic”. Oommen Kurian, a senior fellow at the Observer Exploration Basis, stated that Kerala “reacted as if it’s a really fatal disease from the start when folks were truly doubtful across the earth about the deadliness of the virus.”


Their report contrasted the differences between Kerala and the worst affected area in India, Maharashtra. This state includes Mumbai, one of the world’s biggest cities with huge slums in it, slums which are extremely difficult to control during an epidemic. Kerala has the oldest populace in India (13% of Kerala’s population are aged 60+ while 9.1% of in Maharashtra’s population are 60+), meaning they have a higher vulnerable demographic than anywhere else. Kurian considered Maharashtra did not act as promptly as Kerala and “was reactive”, rather than proactive because it hadn’t recently dealt with a viral outbreak. Kurian believes Maharashtra cannot benefit from tracing after more than 23,000 cases had been confirmed (as each infected person is very likely to have been in contact with a large number of people) and stated: “The thing about making contact with tracing is that it is really easy to get overwhelmed if you go above a threshold”.


In the 2011 census, Kurian observed 94% of Kerala’s population were literate when the national average was 73% (and this made it easier for the state to communicate with its citizens). Kurian also said Kerala experienced a per capita GDP in 2017-2018 of 184,000 Indian rupees, compared to the national average of 114,958 rupees. While the Central Bank of India stated Indian citizens employed around the world sent $69 billion to India and 19% of these remittances went to Kerala. 


Consequently, although significant differences exist between the two states, the critical difference was the speed, and manner, in which they responded to the crisis.


Although Kerala has flattened the curve, the crisis might easily return. “We are bracing ourselves for the third wave,” Isaac, Kerala’s state’s finance minister, tweeted. Kerala’s chief minister, Pinarayi Vijayan, believes that until people undergoing treatment have fully recovered and their quarantine periods are completed “we can’t let our guard down a single little bit.”


Yet the risks are huge as India’s lockdown is set to be lifted later this month. India also has started repatriation flights for Indians stranded abroad or have lost their jobs (and Kerala has many citizens working and residing overseas). Kurian warns this is really not the time to be complacent. “The true fight is just coming. As soon as the international tourists come again and the migrants appear back again and the area economic system commences operating once more, that is when the future wave will hit Kerala, and if they are caught napping, it will look a whole lot like Mumbai.” 


Significantly the BBC reported on 10th June a surge of infections in India (with 266,598 confirmed cases and 90,000 of them in Mumbai and, in Delhi, the authorities expect more than half a million cases by the end of July) (see The surge coincides with India's decision to relax restrictions after a stringent lockdown lasted three months. Shopping malls, places of worship and offices were allowed to reopen on 8th June and, earlier, shops, market places and transport services had been allowed to open. The BBC reported experts had said there was no other option but to lift the lockdown. It was causing a massive economic toll on the country, millions had lost their jobs and livelihoods, businesses were shutting down, and the fear of hunger drove masses of daily-wage migrant workers to flee cities - mostly on foot because public transport was halted - and many died from exhaustion and starvation. The government lifted the lockdown hoping most of India's undetected infections would not require hospitalisation. But although states used the lockdown period to ramp up health facilities, hospitals in major cities are being overwhelmed and many patients with COVID-like symptoms are being turned away.


It is very difficult to quantify the risk of being infected by the coronavirus. We don’t know if after recovering from the virus, patients can infect third parties, nor if they can gain immunity (on either a temporary or permanent basis). Nevertheless, the WHO stated on 17th July that there were about 8 million confirmed coronavirus cases and only 83,000 were in China. Therefore, for each case in China, there were about 1,000 cases outside China. This understates how infectious the coronavirus is because most cases in China couldn’t have infected people outside China, as China’s lockdown prevented most Chinese people leaving China. 


When a lockdown ends, the virus must not be allowed to return and cause the country to revert to the situation it was in before the government enforced its lockdown. To minimise the risk of another lockdown, governments must learn lessons from across the globe.


What can we learn from Kerala's success?

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