Long time back in the 1970’s, in an article on Kerala in one of the national weekly magazines, it was mentioned that the difference between the children in Kerala and the rest of India was that the children here carry notebooks. In the backdrop of Kerala has handled Covid-19, perhaps one wonders if those notebooks formed the cutting edge.
The first case of Covid -19, in Kerala was a medical student from Wuhan who tested positive on January 30, 2020 and this also happened to be the first case in India. Different states in India took various stances, but Kerala showed the way in having admirable practices. It is said Rome wasn’t built in a day, so are good practices which take decades to build and I wish to take you on a journey how it all mattered. If left to itself the exponential would have resulted in about 21,000 predicted Covid cases by 3 months, but what Kerala has achieved till now is remarkable.
A brief history of healthcare in Kerala
The very strengths of the state have been the social sectors. Education and healthcare always held primary importance for all administrators’ in Kerala. The state had the strong system of Ayurveda handed across generations, and since long people has the custom of going to caregivers in times of sickness rather than self treatment.
The royal families of Travancore and Malabar took initiatives in education and healthcare and later on this was also the top priorities of the elected governments. It must be surprising to note that a royal proclamation in 1879 made vaccination mandatory for public servants, prisoners and students. The health system focused on the universality of care as the reach extended to the entire population through the primary and community health centres.
It is remarkable that the state with one of the lowest per capita incomes in the country built up a successful health system- seeing the light of day care of a high female literacy, land reforms and an efficient public distribution system. Many Christian mission hospitals too were built in the remote areas and they instilled many a young girl to take up a nursing career.
Since the formation of the state of Kerala large budgetary allocation for health and education was commendable. This led to a vast expansion of the government health facilities, increased the number of beds in modern medicine from 13,000 in 1960-61 to 36,000 in 1986. Another experiment that worked was the active role of local self governments in peripheral heathcare, which came handy in times of crisis. The peripheral health centers(PHCs) and the their referring sub-centers being under local self governance helped in responding better to the local health needs which included issues like facilities to improve water and sanitation safety. The involvement of the community has been a striking feature in Kerala’s success in times of crisis, as was seen during the floods in 2018.
The Nipah experience
The Nipah outbreak of 2018 was the forbearer the way the state responded to the Covid challenge. The Nipah virus created a panic with a high fatality rate of 88.9% and (17 dead, including a healthcare professional) before the outbreak was controlled. A super-spreader virus – the simple measures of barrier nursing, universal infection control practices and quarantine would save lives was the startling revelation. This led to the training in the use of personal protection equipment, hand washing protocols and safety of healthcare personnel. The Nipah task force at institutional and district levels included the outbreak response, contact surveillance and data management. This formed the baseline for further outbreaks and successfully contained the second Nipah wave in 2019.
The Covid-19 Outbreak, Kerala shows the way
Transparency has been the key in Kerala’s fight with the pandemic. The daily press conferences by the chief minister Mr.Pinarayi Vijayan and the efficient heath minister Ms Shylaja are an ode to this. The ministry of heath had already a draft plan ready by January, 26th, 2020, Kerala being one of the leading areas of the world having a containment strategy in place so early. Airport based surveillance in the four international airports was launched by January 23th, 2020.
So by the time the first three cases of Covid were reported between January 30th and February 3rd, 2020, – the state had already declared the outbreak as a state disaster. With 5% of the state’s population abroad, it had a challenging mission to handle them on their return.
A State response team (SRT) under the chairmanship of the Heath minister, Ms Shylaja included top officials from all concerned departments (epidemiology, community medicine, infectious diseases, paediatrics, food safety and drug control). An additional another 18 level sate team co-ordinated the various activities including surveillance, call centres, manpower management and training and infrastructure reallocation. The clear guidelines for the States Covid plan was in place including the clinical guidelines in treating cases and suspects, also updated regularly. This is science and utilization of decentralized social capital at its very best.
The state government moved at lightning pace, right from appointing the about 286 doctors in the public service commission list, to perhaps the first state in India to announce a Rs. 20,000 economic revival package, the public confidence and connect with the government never failed. The management of human resources was of war room levels on all scales. There was also the initiative for mid day meals for children at anganwadis to be delivered at their homes. Massive community kitchens sprawled all over to serve the needy and the migrant population.
DISHA, the state government’s 24 hour helpline, was always at hand to clear all doubts of the public and also provided the much needed mental health support to stressed families in quarantine.
The Nipah experience of surveillance, contact tracing and quarantine were practiced in this scenario at epic levels- it was basically a re-run of previous epidemic on a herculean scale. A three member family from Italy who had skipped the airport voluntary screening, set the ball rolling for a classic case of contact tracing in the Pathanamthitta district ,leading to isolation of almost 300 individuals, which earned the District Collector of Pathanamthitta Mr. P B Nooh, a Facebook admirer’s fan page called Nooh Bro’s Ark!
The good public health practices of surveillance, screening, treating, isolation and contact tracing formed the pillars of the battle in Kerala. This supported by early testing, isolation of infected persons, tracing contacts , shutting down large religious gatherings and schools, shutting down interstate borders and restricting international traffic , all helped in controlling the spread as of now. “Break the chain” was the slogan given by the state government to stop the super spreader virus by encouraging the simple idea hand washing, sanitizing and wearing masks.
As Kerala looks towards maintaining the flattening curve , the number of cases as on May, 4,2020 , total cases 499 ,zero cases for the last 2 days, 462 have recovered in al , only 4 deaths till date (contrast Maharashtra- 14,000+ cases and 580+ deaths), it’s too early to rejoice. The opening up of state borders and international flights may upset the curve, but as the WHO director general has said, when humanity is in face of an extraordinary enemy, we need to have extraordinary responses. Well begun is half done they say, probably that’s where Kerala stands today in midst of the pandemic.