Kerala’s Exemplary Record in Covid-19 Management
OVER the past two weeks, the Covid-19 situation in Kerala has become a topic of national discussion. This unusual media attention on Kerala was inspired by a large-scale social media campaign launched by supporters of the Bharatiya Janata Party (BJP). Their argument was that Kerala was a “failed model” in managing Covid-19. As evidence, they cited the rising number of daily infections and high test-positivity rates (TPR) in Kerala. A communal angle was also inserted into the discussion; the rise in infections was due to the waiver of restrictions for three days during Bakrid celebrations.
Unfortunately, science and reason have been casualties in this politically motivated campaign. Not a single respected public health professional has lent their support to this campaign. In fact, many experts – like Dr Gagandeep Kang and Dr Rijo M. John – have come forward and defended Kerala’s record despite the backlash that awaited them. In this article, I try to set the record straight on Kerala’s strategy to address the pandemic and document the baselessness of the accusations against it.
Kerala is highly vulnerable with respect to Covid-19; it is prone to prior morbidities and the spread of new infections. First, it has a high proportion of elderly in the population due to its past advances in raising life expectancy. In 2015, 13.1 per cent of Kerala’s population was above the age of 60, while the corresponding share was 8.3 per cent in India. Secondly, Kerala has the densest population in India. Its population density in 2011 was 859 people per km2, which was thrice the national average. Thirdly, Kerala’s topography and settlement patterns are marked by a seamless merger of the urban and the rural. Communities freely intermingle with each other across the spatial structure. Fourthly, Kerala has a highly mobile population with high levels of in-migration and out-migration.
At the same time, Kerala is also well-equipped to deal with pandemics. Its public health infrastructure – in terms of the quality of public health services and the number of hospital beds, doctors, nurses and care staff – is the best in India. Kerala’s health system is extensively decentralised, which has deepened community participation in health. Kerala is a pioneer state in the integration of mental health into public health institutions. These apart, Kerala has had experience in dealing with epidemics, as during the Nipah virus outbreak in 2018. Such experience imparted important lessons on preparedness, strategy and emergency response.
The first Covid-19 case in India was reported from Kerala on January 30, 2020. From then on, the state’s public health system responded most effectively to the different phases of infection spread.
Kerala’s strategy was focussed on preventing infections and inducing behavioural changes to slow down the spread of infections. Thus, over the past year, Kerala substantially raised its capacity to test its population. From about 500 tests per day in the first week of April 2020, the number of tests per day was raised to about 35,000 tests in August 2020, about 65,000 tests in October 2020, about 90,000 tests in February 2021, about 150,000 tests in May 2021 and about 190,000 tests in July 2021. By end-July 2021, if the number of tests per million population was 7.7 lakhs in Kerala, the Indian average was just 3.3 lakhs.
Kerala did not randomly increase the number of tests. It followed an augmented testing strategy, which targeted those regions and sections that were more vulnerable and susceptible to infections. District surveillance officers were tasked with testing more persons above the age of 60, with influenza-like illnesses, with severe acute respiratory infections, with morbidity, with pregnancy and without vaccination. All known contacts of Covid-positive cases, all patients in out-patient departments of hospitals, all new non-Covid admissions and all those who were in regular contact with the masses were targeted in testing. More tests were conducted in large clusters and containment zones, in workplaces, in regions where Delta and Delta+ variants were detected and in those panchayats with a TPR of more than 15. Such a strategy helped the state government to better identify new pockets of infection and new sections of the population prone to infection.
Identification was followed by rigorous contact tracing; it helped the state to isolate more of the infected persons. With the active assistance of local self-governments, two types of quarantine facilities were developed: home quarantine and institutional quarantine. Those who did not show serious symptoms were quarantined at home. Those who showed severe symptoms and those who did not have the facilities for home quarantine were directed to institutional quarantine. Government offices, guest houses, university hostels and private sector facilities were sourced in large amounts to ensure institutional quarantine for all the needy sections. Where possible, bath-attached single rooms were provided for each person.
Kerala also effectively instituted reverse quarantine measures. If home and institutional quarantine protected the society from the infected individuals, reverse quarantine protected the vulnerable individuals from the society. Local health workers made a list of everyone who were elderly or vulnerable to infection and mortality, such as those with diabetes, hypertension, cancer, cardio-vascular diseases, kidney diseases and lung diseases. Such individuals were separated from other family members with a risk of exposure and dissuaded from attending public gatherings or mingling with people. Separate living spaces were arranged for them if the necessary facilities were unavailable at home.
These measures were backed up with campaigns to ensure Covid-19 appropriate behaviour. These campaigns were named “Break the Chain” in 2020 and “Crush the Curve” in 2021. The aim was to popularise face masks, sanitisation and physical distancing on an everyday basis.
All the above measures – in which local self-governments played a leading role – helped Kerala slow down the spread of infections. Sero-epidemiological surveys of the Indian Council for Medical Research (ICMR) provide us with the evidence. In May 2020, the percentage of persons with antibodies was 0.73 per cent in India and 0.33 per cent in Kerala. In August 2020, these shares were 0.8 per cent in Kerala and 6.6 per cent in India. In December 2020, these shares were 11.6 per cent in Kerala and 21 per cent in India. In May 2021, these shares were 42.7 per cent in Kerala and 67.6 per cent in India. In other words, more than half of Kerala’s population was protected from Covid-19 infections even in May 2021.
We can also test the efficiency of testing by comparing the number of persons with antibodies in sero surveys with the number of persons who tested positive in Covid-19 tests. In December 2020, Kerala was identifying one out of six actual cases, while India was identifying one out of 28 actual cases. In May 2021, Kerala was still identifying one out of six actual cases, while India was identifying one out of 33 actual cases.
Slowing down infections not only saves vulnerable persons from infections and mortality, but also provides space and time for the government to improve health infrastructure.
Kerala provided high-quality health care to all Covid-19 patients. A new Covid hospital was set up in Kasargode. Covid Care Centres (CCC) were established in all the districts. Covid First Line Treatment Centres (CFLTC) were established in each district for the treatment of patients with minor symptoms. Covid Second Line Treatment Centres (CSLTC) were established in each district for the treatment of patients with moderate symptoms. Domiciliary Care Centres (DCC) were set up to treat asymptomatic patients. More intensive care unit (ICU) beds and ventilators were added. Daily oxygen availability was almost doubled from 129.1 MTon on March 30, 2020 to 249.2 MT on July 30, 2021. More doctors and nurses were recruited to meet the needs of higher patient load (for a detailed report, see Kerala Development Report 2021, Kerala State Planning Board, Thiruvananthapuram).
There is no better evidence for the success of such a strategy than in the lower mortality rates in the state. As per the figures available till July 30, 2021, Kerala’s case fatality rate (CFR) was 0.5 per cent, while India’s CFR was 1.34 per cent. There was not a single death in Kerala due to the shortage of oxygen.
Indeed, the estimation of number of deaths during the pandemic is a controversial subject. Many state governments have been accused of suppressing the actual number of Covid-19 deaths. Here again, most independent reports place Kerala above other states both in the transparency of reportage and keeping mortality rates low. Here, I use data on “excess deaths” from Kerala’s Civil Registration System (CRS). Of course, all excess deaths are not Covid-19 deaths. Nevertheless, CRS data help us to arrive at broad and indirect estimates of the extent of undercounting of deaths.
Let us consider the April-December period of 2020 – the first wave. The official number of Covid-19 deaths in 2020 was 3,073. Between 2015 and 2019, Kerala registered an average of 190,499 deaths during these months. In 2019 and 2020, it registered 199,962 and 192,050 deaths respectively during these months. Thus, in 2020, the number of registered deaths was higher by 1,551 based on the 2015-19 average as the baseline but lower by 7,912 based on the 2019 figure as the baseline. The reason, obviously, was a decline in the number of deaths due to non-Covid reasons in 2020. The extent of undercounting (i.e., what multiple of the official deaths are the excess deaths) was negative if we set 2019 as the baseline and +0.5 if we set the 2015-19 average as the baseline.
Let us consider the January-June period of 2021 – the second wave. The official number of Covid-19 deaths during these months was 10,287. Between 2015 and 2019, Kerala registered an average of 119,292 deaths during these months. In 2021, it registered 141,736 deaths during these months. Using the 2015-19 average as the baseline, the number of excess deaths between January and June 2021 was 22,444. In other words, the extent of undercounting was 2.2.
Pooling data for 2020 and 2021 together, the extent of undercounting in Kerala was 2.2. This was the lowest extent of undercounting reported for any Indian state in 2020 or 2021, going by the reports put together by The Hindu and Scroll. Considering the average for 2018 and 2019 as the baseline, the extent of undercounting was 23.8 in Madhya Pradesh, 17.9 in Andhra Pradesh, 11.1 in West Bengal, 7.3 in Haryana, 6.4 in Tamil Nadu and 4.3 in Karnataka. In short, Kerala had the most transparent system of death reportage among all states.
THE RECORD ON
While the rate of rise in infections can be slowed down to gain time to upgrade health infrastructure, it cannot be infinitely postponed. Every society must reach a herd immunity level of 70 to 80 per cent to ultimately tide over the pandemic. A society could do that in two ways: one, by allowing infections to freely spread; and two, by slowing down the spread and fully vaccinating as many in the population. Kerala chose the latter path. The price to pay was hard work, but the gain to be harvested was the reduction of death rates and the societal pain induced by widespread deaths.
India’s vaccine strategy has been botched up due to poor planning for vaccines by the Government of India. India is facing an acute policy-induced vaccine shortage from April 2021, which has constrained Kerala’s efforts too. The state has not received the requested number of doses. Yet, official data show that Kerala has an exemplary record in vaccinating its population.
As on July 30, 2021, Kerala had covered 52 per cent of its eligible population with one dose, and 22 per cent of its eligible population with both the doses. The coverage of healthcare workers and frontline workers was 100 per cent with the first dose and 82-83 per cent with both the doses. Among those above 45 years, 78 per cent had received the first dose and 41 per cent had received both the doses. Among those between 18 and 44 years, 24 per cent had received the first dose. Kerala also has an impressive record in achieving negative wastage of vaccines; it squeezes out an 11th vial from a pack of 10 vials. As on July 30, 2021, Kerala’s vaccine wastage was -6.1 per cent for Covishield and -0.6 per cent for Covaxin.
Given the high share of uninfected population, and the recent emergence of the Delta variant, the rise in infections in Kerala in July 2021 is not surprising. In fact, the second wave had begun in most Indian states in early-March itself. In Kerala, however, the second wave began only a month later: in April. It would be bizarre to argue, then, that Kerala started the second wave; it needs time to flatten the curve. It would be equally bizarre to argue that the new rise in infections in July, which was piggybacking on the second wave, was due to the waivers provided for Bakrid. These waivers were provided for just three days, from July 18-20. But the rise in cases had begun from June 29 itself.
Higher number of cases in Kerala are also due to higher levels of testing and the adoption of augmented testing. As a result, TPR levels too continue to be high. If more vaccines were available, this problem could have been ameliorated. That was the expectation too. However, given the shortage of vaccines, it appears that Kerala may have to endure a longer period to achieve herd immunity.
Yet, the present situation in Kerala is not a “crisis”. Crisis sets in when the rising number of cases strains the state’s health infrastructure. But the expansion of health infrastructure over the past year has ensured that adequate amounts of hospital beds, ICU beds, ventilators and oxygen are available. As on July 30, 2021, the percentage of ICU beds occupied was only 63.2 per cent and the percentage of ventilators occupied was only 27.4 per cent. The average daily oxygen usage as on July 31, 2021 was 111.6 MT, but total oxygen availability on the day was 249.2 MT. In addition, the total oxygen stock in manufacturing units and refilling plants was 703.7 MT. About 1.93 lakh doses of Remdesivir injections were in stock on July 31, 2021.
Thus, Kerala’s health infrastructure is not yet in strain. The government is in control of the situation. Kerala’s case in July 2021 stands in sharp contrast with the case of states like Uttar Pradesh in March-April 2021. There were lakhs of avoidable deaths in these states. The shocking pictures of dead bodies floating around in the Ganges were evidence that state governments there had miserably failed in managing the pandemic. Clearly, the politically motivated campaign against Kerala has only one aim: force a downgrade of Kerala’s status in the public eye so that the misery and agony experienced by people in states like Uttar Pradesh can be normalised.
But Kerala’s enlightened people have historically seen through such conspiracies. They stand solidly behind the government of Kerala and feel justifiably proud of what their collective effort has demonstrated to the whole country, and even the world.