[Kerala uses tracking of patients
and supplies, a network of health care workers and coronavirus “war rooms” to
succeed where the national government has fallen short.]
Local health workers quarantined
Mr. Sajeev, a 52-year-old mechanic, at home and connected him with a doctor
over the phone. When he grew sicker, they mustered an ambulance that took him
to a public hospital with an available bed. Oxygen was plentiful. He left 12
days later and was not billed for his treatment.
“I have no clue how the system
works,” Mr. Sajeev said. “All that I did was to inform my local health worker
when I tested positive. They took over everything from that point.”
Mr. Sajeev’s experience had much to
do with where he lives: a suburb of Kochi, a city in the southern Indian state
of Kerala. Kerala officials have stepped in where India’s central government
under Prime Minister Narendra Modi has
failed, in many ways, to provide relief for victims of the world’s worst
coronavirus outbreak.
Though supplies have tightened,
Kerala’s hospitals enjoy access to oxygen, with officials having expanded
production months ago. Coordination centers, called war rooms, direct patients
and resources. Doctors there talk people at home through their illness.
Kerala’s leaders work closely with on-the-ground health care workers to watch
local cases and deliver medicine.
“Kerala stands out as an
exceptional case study when it comes to proactive pandemic response,” said Dr.
Giridhar Babu, an epidemiologist at the Public Health Foundation of India,
which is based in the northern city of Gurugram. He added that “their approach
is very humane.”
An ad hoc system of local
officials, online
networks, charities and volunteers has emerged in India to fill the gaps
left by the stumbling response of the central government and many states.
Patients around India have
died for lack of oxygen in hospitals where beds filled up quickly.
Kerala is by no means out of
trouble. Deaths are rising. Workers face long
hours and tough conditions. The situation could still worsen as
the outbreak spreads.
On paper, Kerala’s death rate, at
less than 0.4 percent, is one of India’s lowest. But even local officials
acknowledge that the
government’s data is lacking. Dr. Arun N.M., a physician who monitors the
numbers, estimates that Kerala is catching only one in five deaths.
A relatively prosperous state of 35
million, Kerala presents particular challenges. Over 6 percent of its
population works abroad, mostly in the Middle East. Extensive travel forces
local officials to carefully track people’s whereabouts when a disease breaks
out.
Kerala’s policies can be traced to
the earliest days of the outbreak, when a student returning there from Wuhan,
China, in January 2020 became India’s first recorded coronavirus case.
Officials had learned lessons from successfully tackling a 2018 outbreak of the Nipah virus, a rare
and dangerous disease.
As borders closed last year and
migrant workers came home, the state’s disaster management team swung into
action. Returning passengers were sent into home quarantine. If a person tested
positive, local officials traced their contacts. Kerala’s testing rate has been
consistently above India’s average, according to health data.
Experts say much of the credit for
the system lies with K.K. Shailaja, a 64-year-old former schoolteacher who
until this week was Kerala’s health minister. Her role in fighting the Nipah
virus inspired a character in a 2019 movie.
“She led the fight from the front,”
said Rijo M. John, a health economist from the Rajagiri College of Social
Sciences in Kochi. “Testing, tracing and tracking of contacts was very rigorous
from the beginning.”
Local officials like Ms. Shailaja
have come under intense pressure. Last year, Mr. Modi imposed one of the
world’s toughest lockdowns on the entire country, a move that slowed the virus
but drove
India into recession. This year, Mr. Modi has resisted a nationwide
lockdown, leaving local governments to take their own steps.
India’s states are also competing
against each other for oxygen, medicine and vaccines.
“There has been a tendency to
centralize decisions when things seemed under control and to deflect
responsibility towards the states when things were not,” said Gilles Verniers,
a professor of political science at Ashoka University.
To coordinate resources, Kerala
officials assembled the war rooms, one for each of the state’s 14 districts. In
the district of Ernakulam, where Sajeev V.B. lives, a team of 60 staffers
monitors oxygen supplies, hospital beds and ambulances. Thirty doctors keep
tabs on the district’s more than 52,000 Covid patients.
The war rooms collect data on
hospital beds, ventilators and other factors, said Dr. Aneesh V.G., a medical
officer in the district. When doctors, via telephone, determine that a patient
needs to be hospitalized, they notify the war room. Case numbers pop up on a
giant screen. Workers decide what kind of care each person needs and then
assign a hospital and an ambulance.
A separate group monitors oxygen
supplies, calculating the burn rate of each hospital. Pointing to a screen,
Eldho Sony, a war room coordinator, said that “we know who needs supply
urgently and where it can be mobilized from.”
Dr. Athul Joseph Manuel, one of the
doctors who designed the war room, said triage had been crucial. “In many
cities across the world, lack of medical resources was not the primary issue,”
he said. “It was the uneven distribution of cases that led to many hospitals
getting overwhelmed.”
Other places have set up similar
centers, with varying effectiveness. Health experts say Kerala’s have worked
because the state has a history of investing in education and health care. It
has more than 250 hospital beds per 100,000 people, roughly five times India’s
average, according to government and World Health Organization data. It also
has more doctors per person than most states.
Officials have also worked closely
with state health clinics and with local members of a national network of
accredited social health activists, known in India as ASHA’s. The workers make sure
that patients stick to their home quarantines and can get food and medicine.
They also preach mask-wearing, social distancing and the virtues of
vaccination. (Kerala’s share of fully vaccinated people is nearly double the
national average of 3 percent.)
The work is low-paying and
difficult. Geetha A.N., a 47-year-old social health activist who is the first
point of contact for 420 families, begins her rounds at 9 a.m. She delivers
medicine door to door and asks if any households need food. Her phone rings
nonstop, she said, as patients call for advice or for help finding a bed.
Workers like her are intended to be
volunteers, so Ms. Geetha’s pay is low and infrequent. She makes about $80 a
month but must buy her own protective gear. “In the early days, we got masks,
sanitizers and gloves,” she said. “Now, we have to buy them ourselves.”
Despite shortages elsewhere, Kerala
for now has enough medical oxygen, though supplies are tight. Alarmed last year
by a low stockpile and by reports abroad of patients dying in hospitals, local
and national officials based in Kerala ordered oxygen producers to increase
their output, which rose to 197 metric tons per day from 149 a year ago. That
prepared the state for a tripling in demand when the second wave struck.
Kerala has also won praise for how
it has tracked virus variants. Scientists are studying whether a variant first
found in India has
worsened the country’s outbreak, though they have been hindered by a lack
of data. Kerala has used gene sequencing since November to track variants,
helping to drive policy decisions, said Dr. Vinod Scaria, a scientist at the
CSIR Institute of Genomics and Integrative Biology in New Delhi.
“It’s the only state that has not
given up at any point in time,” Dr. Scaria said, adding that “they’re eager to
use evidence to drive policies.”
A political shuffle has led some
experts to wonder whether Kerala can keep its gains. This past week the
Communist Party of India, which controls the state government, excluded Ms.
Shailaja from its cabinet. The party said it wanted to give young leaders a
chance, but observers wondered whether Ms. Shailaja had grown too popular. She
didn’t respond to requests for comment.
“Even the best-performing
governments,” Professor Verniers of Ashoka University said, “are not immune
from shooting themselves in the foot due to misguided political calculations.”