Last week, when 105-year-old Asma Beevi from Kollam was discharged from a Covid-19 treatment centre, she became the oldest person in Kerala to recover from the disease that has claimed thousands of elderly lives across the world. The happy occasion, however, was also marked by anxiety in the state that reported India’s first coronavirus case six months ago.
From January 30, when Kerala’s Health Minister K. K. Shailaja confirmed that a medical student who had returned from China’s Wuhan had tested positive, until the end of May, the state had managed to keep its case tally at manageable levels, reporting around 10,000 cases in all. But in just two weeks after that, the tally doubled to 20,000, and currently stands at close to 30,000.
While the death rate is still low, the disease has been rapidly spreading in several parts of the state, especially in the coastal regions. There has also been a significant rise in cases of local transmission with no epidemiological links.
The state’s health department estimates that at least 75,000 more people may get infected over the next two months, putting severe pressure on the hospital system. While Kerala is better placed than most other states in terms of its public health system, policymakers are worried that it could buckle under the expected surge of cases.
Pramod Kumar, public health activist and former senior advisor with United Nations Development Programme, said that the numbers in Kerala began surging after people began arriving from outside once the lockdown restrictions were lifted.
“The state failed to ensure institutional quarantine to all of them despite its claims about better infrastructure and high preparedness. Home quarantine has created a situation of community spreading, especially in areas with high density of population. In Kerala, what exists is not a virus challenge but a medical challenge,” he said.
There are other causes for worry as well: a hard lockdown instituted in some parts of the state have impeded livelihoods and pushed many families, especially in coastal regions, into poverty; the fall in foreign remittances and hit to tourism and other economic activity is pushing Kerala towards an economic crisis; the government’s decision to hand over tasks such as contact tracing to the police has raised fears of growing authoritarianism; health workers who have been tirelessly doing their jobs since January are mentally and physically worn out; and the state is bracing for possible floods again this year.
A senior health department official, who spoke to HuffPost India on condition on anonymity, said that in the initial months, Kerala focused more on containment than on evolving surveillance strategies, which may have backfired now.
“A decentralised surveillance mechanism and testing facilities are needed in the coming days to contain the emerging threat. We also require solid mitigation plans with larger public involvement and the private sector also must be encouraged to participate. The pressure necessitated by the recent surge in cases may have prevented the state from evolving strong long-term mitigation plans,’’ said this person.
Health minister Shailaja told HuffPost India that the government has a clear grasp of the emerging threat, and is trying to balance the question of lives and livelihoods.
“The government has never claimed it achieved ultimate victory over the virus threat. It’s true that there has been a surge in COVID-19 spread in the state since May 4. But a complete lockdown is not practical. We have to protect lives in a way that would not affect livelihood concerns. Many Keralites have returned from abroad and other states in the last two months and we have taken all possible steps to detect virus carriers among them and to ensure them further treatment. Surveillance steps are already on to avert maximum instances of community transmission,’’ she said.
Shailaja also warned that the state’s economy was in bad shape and a huge spike in cases would lead to a collapse of the healthcare system.
“Individual-level vigilance and cooperation with the government is a necessity. At present, over 22,000 tests are happening at 84 laboratories across the state. Nine more labs would be started in the government sector soon. The state currently has 8,704 beds to treat COVID-19 patients. Over 30,500 beds will be ready within a few days. We have now involved private hospitals in the fight and the tariff fixed for them is the lowest in the country. Critics often forget the fact that the state still has the lowest mortality rate in the country: 0.32,’’ she said.
Kumar, however, said that private hospitals have played a negligible role in the fight so far.
“Government hospitals with a lot of inadequacies are handling the whole challenge, though the government has permitted private hospitals to engage with the challenge. People are preferring only government hospitals and the hospitals have to focus on other infectious diseases occurring during monsoons. Only by boosting the morale of health workers and improving the public health system can the government move ahead,’’ he said.
While Kerala has ramped up testing from the early days, experts say it is still not doing enough of these. As the number of cases increase, it is also struggling to make up for a shortfall in kits.
‘Not a law and order problem’
While the government has been trying to prevent transmission of cases from one region to another through increased police surveillance and local lockdowns, some of its decisions have come under criticism.
Among the state’s 14 districts, Thiruvananthapuram is the worst affected, with more than 200 cases being reported per day for weeks now. The latest outbreak began in the coastal belt of Thiruvananthapuram from a fish vendor who used to cross the state border with Tamil Nadu regularly for work.
Most of the fishworker families in this belt are poor daily wage earners, and the lockdown has pushed them into abject poverty. The government initially tried to use force to control the situation instead of taking people into confidence. When people in the region refused to cooperate with the restrictions, the government sent gun-carrying commandos to conduct route marches in the villages, resulting in protests. It was only after the government convinced people that there would be no more commando marches and that basic necessities would be available in shops that health workers were allowed to enter these areas and do tests.
Sindhu Mariya Nepolean, a researcher from Poonthura, told HuffPost India that many people were reluctant to turn up for antigen tests in the beginning as the primary treatment centres and isolation wards in the coastal belt have limited facilities and hygiene.
“Instead of taking the local community in confidence and alleviating their fears by holding talks with the community leaders, the government committed a mistake by sending commandos,’’ she said.
Some experts also think that many people may be flouting restrictions due to excessive, misplaced confidence in the state’s health system.
“It is not wise to treat a public health hazard as a law and order problem. We also have to disown the campaign that the state’s health system possesses the capacity and the expertise to contain the pandemic. The public must be made aware of the gravity of the issue and only a decentralised approach can pay dividends,’’ said Dr N.M. Arun, a public health expert.
Across the state, fishing activities have been suspended for some weeks now, evoking resentment among coastal communities. Tribals, Dalits and others have suffered disproportionately from job losses and livelihood destruction.
The National Disaster Management Authority and the Coalition for Disaster Resilient Infrastructure, an international forum launched by the country, have warned Kerala that the state could face a serious economic crisis soon. In a report published in July, the agencies suggested a partial reopening of the tourism sector as one of the paths to recovery.
“Around 20% of Kerala’s population resides abroad and with the ongoing crisis, a large number of expats have been returning to Kerala. This puts Kerala in a uniquely vulnerable position due to an increased risk of the virus and a fall in foreign remittances,” said the report.
Taking into account that foreign remittances account for one-third of the state’s economy and remittances are predicted to fall by 15-20% this year, the state will face serious challenges, the report added.
The surge in cases has given the state’s opposition a chance to corner the government. Congress leader Ramesh Chennithala, Kerala’s leader of opposition, alleged that the state government has left people in the lurch, with scarce state support.
“Chief Minister Pinarayi Vijayan had claimed in March that 2.5 lakh beds would be readied to quarantine expatriates. But after the arrival of the first few chartered flights, the government has retracted from its mandate for compulsory institutional quarantine,” he said.
Chennithala also said there was a lack of clarity in the government’s directions on isolation and treatment.
Kerala had initially announced that it would conduct tests on everyone who travelled to the state to segregate those who contracted infection. It also wanted to transport them separately and keep them in isolation until they were cured. But this plan couldn’t be carried out due to the centre’s non-cooperation.
So far, more than 600,000 people have returned to Kerala from within India and abroad during the post-lockdown repatriation exercise. This led to a shortage in testing kits by May-end, after which the state decided to restrict tests only to those showing symptoms.
While the state has been trying to keep track of travellers, police sources say many people have been entering the state unannounced through the remote border roads of Thiruvananthapuram, Idukki, Wayanad, Kasargod and Kannur. Some people have also managed to hold lavish marriage ceremonies and well-attended funerals in spite of restrictions.
In the initial months of the coronavirus outbreak, the state was confident that it could handle the situation like the Nipah virus outbreak of 2018. But public health activists point out that the Nipah virus only spread over a small area and that its disease epidemiology is completely different from that of Covid-19.
In the case of Nipah, the government was able to control the spread by using ingenious technology-driven attempts at contact-tracing. Collection of spatiotemporal data helped the government, along with Kerala’s unique social capital and decentralised governance.
In the case of Covid-19, the government successfully launched many initiatives including the ‘break-the-chain’ campaign stressing social distancing and community kitchens aimed at the poor. There were also efforts to ensure counselling to reduce mental stress among affected people. But as cases surge, the focus has shifted to treating those who have tested positive.