On January 30, India detected its first coronavirus patient, a student who had returned to Kerala from Wuhan, China, the epicentre of the pandemic. The Kerala government was prepared.

The state’s public health authorities, led by the health minister KK Shailaja, promptly put in place the protocol that they had used to successfully contain the Nipah outbreak in 2018. Strict quarantine rules, extensive surveillance and contact tracing measures, public testing and treatment facilities, and the distribution of rations to the needy ensured that the spread of the disease was contained quickly.

In the early months in particular, stringent quarantine rules saw even asymptomatic patients being taken to first-line treatment centres instead of being home quarantined. A few quarantined patients were denied permission to see their demised relatives one last time. As a result, new cases declined to a trickle by May. In fact, not a single new infection was recorded on May 1 and May 6.

The Kerala model, as the state’s response to the pandemic came to be called, earned wide praise internationally.

Nearly eight months on, Kerala is recording a spike in infections, adding over 7,000 new cases on September 27. The spike began after interstate travel restrictions were relaxed in May. The state recorded 238 new infections in March and 256 in April. Of these, 153 and 77 people, respectively, had returned from abroad. After the interstate borders were opened, Kerala saw 772 new cases in May, 3,173 in June, 19,171 in July, 51,772 in August, and 1,04,717 so far in September. The number of foreign returnees was 280 in May, 1,860 in June, 3,329 in July, 1,883 in August. Of the infections reported in September, around 93 percent have no travel history, indicating wide community spread.

It would seem, thus, that the strict measures taken by the Kerala government to contain the pandemic only delayed the inevitable.

So, did Kerala overreact in responding to the pandemic, more so since its handling of the health emergency contributed to panic, scaremongering, stigma, and even violence around coronavirus? Opinion is divided.

“Yes,” said Dr PK Sasidharan, former dean of the Government Medical College Hospital in Kozhikode. “I wouldn’t blame the government though. It’s just that the strategy they followed was incorrect. The intentions were genuine, but with no experience handling a situation like this, the decisions were wrong and the insights into public health were poor.”

The “first wrong step”, he added, was the decision to handle coronavirus like Nipah. “Coronavirus is more contagious than Nipah and has milder symptoms. Nipah was restricted to one geographical location, but the novel coronavirus spreads faster and will eventually affect everyone.”

In all, over 1.75 lakh people have contracted coronavirus in Kerala so far and at least 677 have died from it.

“The actual figures are far higher,” said a health inspector in North Kerala who asked not to be named because he wasn’t authorised to speak to the media. “Many deaths are not being recorded as coronavirus deaths. The situation is grave and not as projected.”

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The Kerala government’s “overreaction” to the pandemic, as critics have described it, has come at significant financial cost, compelling the state to seek additional funds from New Delhi. Self-government institutions have been struggling to establish first-line treatment centres to accommodate even asymptomatic patients.

“Treating asymptomatic patients in first-line centres is not just an unscientific approach but a waste of resources as well,” remarked Sasidharan. “Elaborate arrangements and expensive medicines are provided for their intensive care.”

Though Kerala issued guidelines for home quarantining asymptomatic patients in August, many people, for fear of infecting family members and being stigmatised, demand hospitalisation, which is not denied.

The health inspector agreed with Sasidharan. “In the first phase, the government even provided new clothes for patients after burning the ones they wore. Many asymptomatic patients are taken to facilities run by the government. It is a huge financial burden. They could conveniently be home quarantined,” he said. “There is another flip side. People take it all lightly believing that even if they get affected, the government will take care of them.”

Dr KP Aravindan, a former professor of pathology who once led the Kerala Sasthra Sahithya Parishad, a grassroots movement to promote science, concurred that there had been “overreactions”.

“I feel that for asymptomatic cases, home isolation is a successful and less-burdening strategy for the government,” he pointed out. “If the numbers keep on rising, I think the government might compulsorily mandate home care for asymptomatic patients.”

He added, “The number of cases might not be correct as tests can be misleading. But considering the lower mortality rate, I think all is well as of now.”

Insistence on institutional quarantine has also caused some tragic incidents. A 19-year-old girl was raped by an ambulance driver on the way to a treatment centre where she was to be quarantined after testing positive for coronavirus. The authorities have since mandated the presence of two health workers in an ambulance and special care for women patients.

“That was an atrocious act committed by a sick man. It was unfortunate. There had not been a security lapse until then,” remarked a health official who asked not to be identified. “It could have been avoided had the patient not been transferred so discreetly.”

Sasidharan also complained about the constant revision of the Covid protocol, calling it inappropriate. “Quarantine rules were proper earlier, especially during the initial inflow of NRIs. All virus carriers could be identified and quarantined. Then the quarantine period was reducded from 28 days to 14 and now to seven.”

The health inspector concurred. “This doesn’t cover the incubation period properly and could actually facilitate community spread of the disease. People neglect symptoms or do not get tested at the right time as stipulated. And now every case has no source.”

This, he said, was partly an outcome of the “ridiculous situation” where “instead of epidemic control experts like public health officials, police have been given the power to initiate action against people who refuse to comply with the rules”.

“It’s absurd to have the police who are already burdened with responsibilities to work on the healthcare front. The protocol rules need to be revised and corrected for proper compliance,” the inspector said.

Sasidharan added, “Decentralised patient care should be decided by a panel of general practitioners who have adequate insight into public health issues and epidemiologists with a vision for a progressive society. With well-equipped primary care centres, a good team of health workers, intelligent planning on testing and isolating only the symptomatic and vulnerable ones who require critical care, the plan will be effective.”

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On the other side, there are health experts who contend that the Kerala government adopted the right approach after coronavirus arrived. That it managed to even delay the peak of infections was a big success.

“History will keep only one record: how many survived,” said Dr Mohammed Asheel, citing the example of the Spanish Flu which killed nearly five crore people over four years in the first quarter of the last century.

Asheel is the executive director of the Kerala Social Security Mission, which is leading the fight against the pandemic. He continued, “We set up over 300 virology labs as well as quality infrastructure and health facilities. We could control imported cases with all these systems in place. Italy, with its all excellent facilities, let it peak and the cases spiralled out of control and many patients died. Delaying the infection peak has its own advantages. We get time to study the virus and then devise strategies to combat it.”

Aravindan agreed, “Almost six lakh people arrived in Kerala from the Gulf and we managed to control transmission. All current cases are connected to arrivals from other states after travel restrictions were relaxed and our deaths are also lower. It’s a huge success indeed.”

Moreover, he added, echoing Asheel, “The delayed peak will help conduct more research and continue interactions with the global research community to identify more viral traits. Until we find the vaccine, this will go on. It could be prolonged but it will be worth the wait.”

Dr Rajeev Jayadevan, the president of the Indian Medical Association’s Kochi chapter, even supported institutional treatment for asymptomatic patients.

Pointing out that the novel coronavirus isn’t harmless compared to flu viruses, he said, “This virus, unlike others, can suppress the symptoms and that’s why I recommend that even asymptomatic patients should not be left untreated. In many cases, the bewildering condition of happy hypoxia has been noted. The patient might not have noticeable symptoms, but their lungs would be deteriorating, reducing the amount of oxygen they can absorb. Those with serious lung, blood and cardiac conditions fall in high-risk categories.”

In the long run, though, decisions must be made depending on the available resources and the patient load, he added. “The world over, home treatment with proper monitoring is being followed. When numbers go higher, we too will have to go for optimisation of available resources. The virus does not spread according to a rulebook and predictions are irrational.”

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Is Kerala equipped to deal with the ongoing spike in infections?

The government has maintained that it has provided more than adequate facilities and resources to deal with any situation. But with the cases suging, even the chief minister, Pinarayi Vijayan, has expressed worry. And Shailaja has expressed concern about the shortage of ventilators which could result in more deaths if the cases keep spiking. There is reportedly a scarcity of oxygen cylinders in the state’s public hospitals as well.

As of September 27, there were 380 Covid patients in ICUs across Kerala and at least 92 on ventilator support.

“As of now, we are good,” said Sulphi Noohu, the state secretary of the Indian Medical Association. “But at some places the cases are rising exponentially which is a cause for worry. Government and private hospitals in Thiruvananthapuram, Ernakulam, Kozhikode, Thrissur have adequate infrastructure and facilities to handle rising cases. But in Pathanamthitta, Alappuzha and Idukki, where the infrastructure and the number of hospitals are minimal since the people mostly depend on neighbouring districts for their healthcare needs, rising cases of infection might pose a grave problem.”

Vandana Mohandas is an independent journalist in Kerala.

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