The Pulse | Society | South Asia

Rampaging COVID-19 Cases Expose Flaws in Kerala’s Healthcare Model

While cases across India have declined after a devastating surge in April and May, the situation in Kerala remains serious.

Rampaging COVID-19 Cases Expose Flaws in Kerala’s Healthcare Model

People wearing masks wait to get vaccinated for COVID-19 outside a school in Kochi, Kerala state, India, Wednesday, September 1, 2021.

Credit: AP Photo/R S Iyer

With Kerala struggling to cope with a huge COVID-19 caseload and high test positivity rates (TPR), the once globally-acclaimed “Kerala model” for handling public health emergencies has come under scrutiny.

It was in Kerala in January 30, 2020 that India’s first case of COVID-19 was detected. By early May that year, it did seem that the outbreak had been contained when daily new infections in the southern Indian state fell to less than five. This was reportedly made possible by Kerala’s strategy of aggressive testing, tracing contacts of the infected, and isolating the infected and their contacts. The strategy of the Kerala government was hailed as the “Kerala model.”

Proponents of the “Kerala model” say its rudiments lie in the state’s Left Front government’s perspective of healthcare, which involves the allocation of huge resources to develop public health infrastructure, the devolution of power and funds to local bodies, and the use of community participation in overcoming the crisis. The proponents of “Kerala model” also give credit to health department officials who assiduously implemented the government strategy.

However, a year and four months later, the situation has changed through and through. Now Kerala is facing a perfect storm on the healthcare front. Almost 70 percent of the total COVID-19 positive cases reported in India by the end of August 2021 were from Kerala.

Besides, an equally dangerous contagion, Nipah, which haunted the state in 2018, has resurfaced at the northern Kerala city of Kozhikode, where it was also detected earlier. Despite claims of huge investment in infrastructure, the state doesn’t have a single laboratory boasting biosafety level 3 (BSL-3), which can test for Nipah virus infections.

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Delayed second wave?

The alarming situation has raised questions about the efficacy of the “Kerala model.”

To pre-empt “unwarranted” questions, the Left Front government has already come up with a few explanations. Its spin doctors say that unlike in other states where the second wave began and ended early, in Kerala the second wave’s outbreak was delayed and is continuing.

Chief Minister Pinarayi Vijayan has raised another point. At a recent press conference, he cited a July 2021 sero-survey by the Indian Council of Medical Research, which revealed that while 68 percent of the Indian population has COVID-19 antibodies, only around 42 percent of people in Kerala have them. This means that community spread of COVID-19 didn’t happen in Kerala to the extent it did in other states because of the strict lockdown and implementation of social distancing and other COVID-19 protocols.

Vijayan also raised the usual defense of the Left government that pandemic surveillance is better in Kerala than in other states where it floundered, leading to a high number of cases.

However, a section of epidemiologists dismiss such arguments as baseless. Dr S. S. Lal, an internationally known public health expert and President of the Kerala unit of the All-India Professionals’ Congress wonders if there is any yardstick to clearly demarcate the present surge of COVID-19 cases in Kerala as a second wave. He notes that the number of COVID-19 tests conducted by the state was low earlier and so the number of confirmed cases was low. The tests have increased since May 2021. Subsequently, there has been a spike in the number of cases confirmed as COVID-19 positive, he adds.

It is also pointed out that while almost 70 percent of the COVID-19 tests conducted in Kerala are antigen tests, which are considered less credible, the majority of tests conducted by other Indian states are Real-Time Reverse Transcription Polymerase Chain Reaction (RT-PCR) tests considered much more reliable.

On the COVID-19 deaths in Kerala, Lal points out that the data has been fudged and there has been under-reporting. An expert panel appointed by the Kerala government in August 2020 had also found that the state was under-counting deaths and the real COVID-19 deaths could be up by at least 50 percent.

Steady and gradual rise in caseload

The spread of the COVID-19 pandemic in Kerala, which began after three students returning from Wuhan in China were found infected on January 30, was steady and gradual. It did not show distinct phases. The number of daily confirmed cases in February, March, and April 2020 was usually less than 10, and on some days between 10 and 20.

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In early May, the number of daily cases dropped to around two. The Kerala government and its supporters went overboard, declaring the first wave to be over and claiming to have flattened the curve. That is the story of the presumed first wave of COVID-19 in Kerala.

However, the euphoria was short-lived.

On May 20, Kerala reported 24 COVID-19 positive cases and since then the number of cases has risen steadily. By July, the daily caseload ran into hundreds. Though the total number of confirmed cases was still not alarming, the recovery rate was less than the national average recovery rate of 50 percent. COVID-19 tests in the state were conspicuously low during the period. When Kerala conducted less than 20,000 tests daily, the other southern states of Andhra Pradesh, Tamil Nadu, and Karnataka were carrying out 45,000, 55,000, and 30,000 tests, respectively. The test positivity rates in Kerala were less than the national average of over 10 till August 2020. In September, while the national average TPR came down, Kerala’s TPR shot up and has remained high ever since.

Impact of elections

In December 2020, elections to local bodies were held in Kerala. It was an inflection point. Thousands of candidates and hundreds of thousands of political workers crisscrossed the state as part of the campaign, paying scant regard to COVID-19 protocols. Subsequently, the daily caseload went through the roof. The situation got out of control in the months that followed. Then came the elections to the Kerala State Assembly in April of this year. Once against COVID-19 protocols were ignored, pushing the state into a catastrophe from which it is yet to recover.

Currently, while India as a whole has recovered more or less from the COVID-19 catastrophe, the number of daily infections reported from Kerala remains high. Nobody speaks much about the once-vaunted “Kerala model.”

An honest review of the model reveals that the widely publicized advantages of the strategy were based on wishful thinking, and that the goals of the government’s COVID-19 containment strategy have never been sincerely implemented. Testing was low, the number of infected rose slowly over a period of more than a year, protocols were not implemented seriously and sincerely, and healthcare infrastructure was poor and crumbled under pressure.

Shortages of ICU beds, ambulances, and proper care were reported from across the state during October and November 2020. The Kerala unit of the Indian Medical Association issued a press release on lack of basic infrastructure in the healthcare sector on October 5. However, things improved on that front thereafter, following corrective steps by the authorities.

Kerala’s staggering COVID-19 caseload is the result of policy failure. Though the Left always emphasizes the uniqueness of Kerala, its COVID-19 mitigation policy has not taken into account the state’s actual uniqueness, like its huge population density, the nature of social life, and the very high mobility of its people. Implementation of social distancing norms at marriage ceremonies, examinations, and in public transport was also poor.

However, there is light at the end of the tunnel. Around 75 percent of the state’s population that is eligible for the COVID-19 vaccine has now received at least one dose. According to the Kerala government, the COVID-19 fatality rate in Kerala is a low 0.51 against the Indian average of 1.34. However, not everyone accepts this figure.