Is Kerala’s well-managed Covid-19 fight threatening to unravel?

When ET Magazine called, the doctor had just poured himself a drink to wash down the fatigue of the punishing week. “You have no idea what we are going through,” says the doctor, who oversees a Kerala government-run Covid-19 centre an hour’s drive from Kochi airport. “I cannot describe the exhaustion with words.”

Five months after it began relentlessly chasing the novel coronavirus, Kerala’s public healthcare system is so wound up that it now risks snapping as new cases surge. It comes at a time when other communicable diseases such as dengue and leptospirosis, common during the monsoon, are spreading in some regions. The state also has a high incidence of diabetes, cancer and other lifestyle diseases that often turn a Covid-19 infection into a fatal affliction.

On January 30, Kerala’s first case tested positive. It was a medical student from Wuhan in China, the epicentre of the outbreak that has affected more than 10 million people in 213 countries. A vigilant health minister, KK Shailaja, had primed the state’s public healthcare system when news of a lethal virus in China began trickling in in December and ordered passenger screening at airports.

Shailaja had the experience of dealing with the virulent Nipah outbreak in 2018. The state keeps a close watch on contagions worldwide as it receives millions of tourists every year and has a diaspora spread across the globe, increasing its chances of importing a disease.

Italy had discovered its first case around the same time as Kerala. While the virus wreaked havoc in the European nation with a case fatality rate (CFR) of 14.4% and killing about 30,000 people by early May, Kerala had just three deaths.

The state, along with the rest of the country, then went into a six-week lockdown which helped slow the spread of the germ. By May 3, when the lockdown was cautiously lifted to restart a halted economy, the number of active cases had climbed to a peak of 262 (on April 7) and tapered off to 95. No new cases were reported. During the period, the whole administrative machinery, including the police, was focused on one mammoth task — taming the virus.

The picture has changed dramatically two months later, with the virus hitching a ride with migrant Malayalis returning home from other states and abroad. More than a million Malayalis live and work in the Gulf countries and about 300 of them have reportedly died abroad in the pandemic. Total Covid cases in Kerala jumped nearly nine times from 499 on May 3 to 4,465 on July 3. The death toll has risen to 25 and another 10 are said to be on ventilator support.

It is a complex administrative operation to monitor 1,77,011people, 1,74,117 of them in home quarantine. While the police make sure they are not breaking isolation rules, health workers keep a look out for symptoms. Simultaneously, surveys are being carried out to check for transmission. Over a hundred people are being added every day to this list of persons to be watched.


Additionally, 1,140 psychiatrists, counsellors and social workers are tracking the psychological health of infected persons, elderly people living alone and children. They have made more than 5.7 lakh calls to quarantined persons and nearly 12.7 lakh calls overall so far. About 3,500 people have reported anxiety and depression and another 1,765 have reported issues related to Covid-19 stigmatisation, according to government data.

Vigilance fatigue is setting in slowly as overworked doctors, nurses, police personnel and administrators deal with exhaustion, worried family members and, above all, the fear of infection.

Two popular doctors — a paediatrician and a physician — testing positive in Edappal in Malappuram spread panic, with one estimate suggesting that 20,000 people might have come in contact with them. The government has yet to release the findings of a rapidtest study for community spread in containment zones, but media reports quoting unnamed sources have suggested that surveys using rapid tests indicate the spread is “higher than anticipated”.

“The only way to prevent it is to regulate the flow of new arrivals in the state,” says Mohammed Asheel, executive director of Kerala Social Security Mission and the person in charge of coordinating the state’s response to the pandemic.


Contact could not be traced for about 1% of positive cases. Asheel says that indicates silent circulation of the virus but it was not yet treated as “community spread” because clusters have to emerge to satisfy WHO’s definition of such a classification. To compare, he points out that Covid-19 positive people with untraceable contact in India are over 40%.

Statistically, while there has been a spike in cases post-lockdown, the management has been more effective in the state. The chairperson of the expert committee on Covid-19 management, B Ekbal, says that effective screening and isolation of imported cases have helped in containing the spread. “The proportion of contact positives (those residing in the state who have contracted the disease) is in single digit. It was about 33% before May 3,” Ekbal said. It was 9.4% between May 4 and July 3.

Kerala’s Covid-19 strategy has two key elements; keeping the CFR below 2 and the rate of spread at 1 or below (which means one person infects one other or less). The whole of February, both were zero, perhaps a first in the world. The CFR on July 3 stood at 0.5% compared with India’s 2.9%. The strategy of “trace, quarantine, test, isolate and treat” paid off. But maintaining it is a challenge as it requires people and constant vigil.

“Fatigue is developing,” says Ekbal, adding hospitals have started “layering” or dividing the staff into two teams. One works for a week and rests the next while the other team takes over. This is not ideal as the virus’ gestation period is considered to be up to a fortnight. So far, 4,06,200 people, excluding travellers from other states, have arrived in Kerala. While 4,465 cases in the second phase turned out to be positive, only 419 of them were infected through contact.

The rest arrived with the infection. Regulating the flow of arrivals has become a contentious issue. Initially Chief Minister Pinarayi Vijayan had said that only those who were tested at their origin station will be allowed entry into the state. A hue and cry followed and the state relented. “It’s become an emotional issue. People say that families are separated and parents and children have not been able to unite. Many of our staff have also not seen their children in months,” says Asheel.

Phase four of Vande Bharat Mission began on July 1. The Ministry of External Affairs has listed 497 flights from across the world, of which 177 or 35% would land in Kerala. The new flood of visitors will challenge Kerala’s feted public healthcare system. It would have to draw deep from its depleting reservoir of public will to fight this phase out.