Why Kerala’s COVID Response is a Success Story

By Dr. Lisha Ruparel

How has Kerala managed to lead the country in its COVID response?

Coronavirus first made its entry into India through the Land of Gods. A COVID-positive patient landed in Thissur from Wuhan on 30th January 2020. Kerala is extensively connected to the world in a way a few other Indian states are. It has an expatriate population of 2.5 million people and four international airports servicing over 17 million passengers every year. Hence it was not unusual that initially the state was leading the COVID incidence rate in India. How did the state manage to reverse this?

The Silver Lining of Nipah outbreak

When rest of Indian states was struggling with health surveillance to locate COVID infections, Kerala did not seem to be new to this concept. One of the reasons could be its lesson from the previous outbreak. Less than 2 years ago, in May 2018, the state experienced the Nipah virus outbreak. Though it claimed 17 lives including that of a healthcare worker, Kerala managed to contain the spread beyond its borders. This ensured foundation of a strong surveillance mechanism and an introduction to contact tracing. For the COVID-19 outbreak, it ramped up this lesson, beginning right from Thrissur.

Hands-on Governmental Leadership

While India panicked to put together strategies and teams, Kerala was into the implementation phase, says Dr. Chandy, Director of Believers Church Medical College and Hospital in Thiruvalla. "Isolation centres were identified by the collector of each district, prepared and kept ready since March. Each district had a COVID hospital ready with adequate manpower and requisite equipment. The proactive measures and hands-on leadership by the Kerala government is praise-worthy.” The state machinery effectively put to use communication strategies and social mobilisation even as it set up mechanisms to identify, isolate, test and treating the infected. The collector of each district held regular meetings with the medical fraternity for updates regarding treatment protocols,” he says.

“The Government has been continuously preparing to anticipate the next step to be taken and not be caught unaware. The citizens returning from foreign countries were asked to provide information regarding their family members— if anyone was suffering from any comorbidity or there were small children at home. We did this before anyone came to Kerala from outside its borders, community workers enquired if the house had a room with attached toilet for room-quarantine. Only those who did not have such facilities were sent to institutional quarantine,” explains Dr.Mohammed Asheel, Executive Director of Kerala Social Security Mission.

Infact, Kerala was the first state in India to screen patients arriving from foreign countries.  "80 percent COVID cases are due to those that returned from other countries and only about 20% of the cases are locally transmitted," he reveals. Till date, it is the only state that mandates 28 days of home quarantine, as against 14 days in rest of the nation, for those returning from COVID-struck countries and states that red or high risk zones.

Decades of Investment in Healthcare Paid Off

Kerala, for decades, has treated healthcare as a priority. It has the highest overall health index in the country and a robust primary health system. “The focus on primary healthcare has paid off very well for us during the pandemic,” says Dr. Asheel. The health gains can be attributed to several factors and is especially noticeable at a time when the entire country’s healthcare infrastructure is under strain. “The state has a decentralized approach to governance, which ensures preparation and quick response. Each ward has a Arogya committee which along with the sanitation department ensured that citizens who returned from foreign countries were under strict quarantine. The committee maintained a continuous supply and delivery of essentials to the inhabitants of these centres, giving them less reason to step out. Online social and cultural activities were started to keep the citizens busy and motivated. They also undertook activities like distributing essential supplies to the geriatric population and setting up community kitchens to feed the migrants,”  he explains.

An Educated and Well-aware Population

Not only did years of investment in healthcare pay off, its investment in education also contributed to dipping the COVID curve. Kerala literacy rate stands at 93.91 percent (2011 census) as against national literacy rate of 74 percent, making its locals educated and aware.  This was an advantage as state’s Ministry of Health regularly disseminated health promotional information through social media forums in the local language to create awareness. Dr. Chandy attests that Keralites who came in contact with a COVID-positive patient would come forward and self-isolate themselves. 

Leveraging Technology

From providing regular updates and information to tracking quarantined individuals., Kerala employed technology to rescue it from the infection effectively. "Technology was used to analyse data on international passengers from different airlines and the Bureau of Immigration for capacity building. Simulation models were used to predict the number of cases and to prepare the resources to be needed to treat the infected, location data for contact tracing and surveillance of patients in isolation, information from hospitals on the availability of beds and ventilators,” says Dr. Sanjiv Singh of Amrita Institute of Medical Science.

Arming Hospitals for the COVID War

Hospitals too were made ready for the epidemic. They stockpiled their supply of personal protective equipment. "We used the time to prepare three negative pressure operation theatres and the strength of intensive care unit was also increased. Due to the early success in flattening the curve, inter-district travel was allowed thereby allowing the patients to seek treatment for other diseases. Thereby patients seeking treatment for diseases like cancer, cardiac patients and patients undergoing dialysis were not affected,” explains Dr. Singh.

Furthermore, for every patient seeking treatment at hospitals for any medical condition, an in-depth, detailed medical history including their travel history as well as of relatives was recorded. "Suspected patients were isolated and screened. Thorough initial screening prevented the spread of infection in the healthcare facilities which could function at normal capacity to treat other patients,” says Dr. Chandy.

Health Promotion Initiatives

On 15 March, the government introduced a three-prong approach initiative called 'Break the Chain’ to tackle the virus spread. The campaign educated on importance of public and personal hygiene. Water taps at public places were installed to facilitate access to hand-washing. The initiative also emphasised on the use of masks and social distancing.

An measure adopted by Thanneermukkom gram panchayat in Alappuzha to enforce social distancing stands out for it’s out-of-box approach. The authorities mandated the residents to carry an umbrella when they step out in the public. Two opened umbrellas, not touching each other would ensure minimum distance of 1 meter from one another thereby maintaining the requisite distance to prevent the spread of infection.

Dr. Singh aptly sums up the mantra for its success: The secret sauce of Kerala’s response has been planning for the worst and expecting the best.