COVID-19 and Kerala | When high performance in containment efforts places a state at a disadvantage

(Representative image: Reuters)

Kerala has been a paradox of sorts. The state, despite performing remarkably well on several counts related to COVID-19 containment, is struggling to lower the number of new infections. It’s been three months since the seven-day average for the number of new infections a day hasn’t fallen below 10,000.

The state accounts for the second-largest number of cumulative COVID-19 infections, in spite of a 12th rank in terms of population. Kerala now has the highest number of active cases in India, despite being in some form of lockdown for close to two-and-a-half months. For a passive observer, this seems like a success story going awry.

Here comes the real challenge, if we leave aside the politics of health.

Kerala has the best public health system in the whole of India, with consistently the highest scores in Niti Aayog’s health index. The state performs very well, in comparison with most other states in India, in terms of Infant Mortality Rate, Maternal Mortality Rate, Under-5 Mortality Rate, Hospital Beds per 1000 population and health workers per 1000 population. The primary health centres are well functional, even in the difficult-to-reach parts of the hilly districts of Idukki and Wayanad.

The state also did not see desperate scenes like what unfolded in our national capital, during the COVID-19 second wave. The access to quality assured COVID-19 care was good; and the state government did a remarkable job in capping prices and cracking down on profiteering. The ‘superstar’ status achieved by the former Kerala health minister KK Shailaja can also be partly attributed to the very efficient handling of the crisis. But when and how did everything go ‘south’?

If we look at Kerala’s COVID-19 epidemic curve, we can see that there are long plateaus after the first and second waves. In the first wave, after a peak of 11,755 cases on October 10, the average number of daily cases stayed above the 5,000 mark till mid-February. The same phenomenon is visible now, during the aftermath of the second wave.

After touching 40,000 in early May, the number of cases has stayed quite high, so much so that one-third of all the COVID-19 cases reported in India a day is now contributed by Kerala. The arguments about ‘Delta’ variant causing this phenomenon was blunted after other states showed rapid decline in the number of cases. The state government has tried every trick up its sleeve, but with no significant success visible on the COVID-19 epidemic curve. This is causing great consternation among the public and political circles.

The crippling lockdown and the subsequent restrictions have affected small businesses, the tourism sector which contributes significantly to the state economy has come to a grinding halt, and the tax revenue for the government has dwindled. The shop owners’ associations have taken a belligerent stance; and a showdown between the government and trade bodies look imminent.

Social media commentators, who now criticise the Government of Kerala, seem to have forgotten the ‘flatten the curve’ motto that we had when there was a first lockdown in the country in March 2020. The basic assumption was that the peak of the epidemic curve should be at a ‘manageable’ height, so that the disease load in the community does not overwhelm the healthcare delivery capacity. When the area under the curve is the same, a curve with a lower peak will have a broader base. In simple language, it means that when we ‘flatten the curve’, the duration of the epidemic will be longer.

In highly-contagious infections like COVID-19, outbreaks tend to die out only when a large proportion of the susceptible population has been infected or vaccinated. Therefore, in most infections which spreads through respiratory route, there is a trade-off between the peak case load in the community and the length of the outbreak. In most Indian states the infection may have spread very fast, resulting in the epidemic curve showing rapid rise and fall.

There have been several media reports on possible under-reporting of COVID-19 cases and deaths in various states. When the number of deaths reported in the civil registration system during the second wave was compared with the expected number of deaths during the same period, it was found that there were significant ‘excess’ deaths in several states. It is reasonable to assume that a vast majority of these excess deaths may have been due to COVID-19. Some calculations show the possible undercount factor may be as high as 23 in Madhya Pradesh while it may be only around 0.5 in Kerala. This shows a huge reporting bias, which may have contributed to the poor perception about the COVID-19 containment efforts in some states.

Even with a reliable registration system which more or less captured data on all the COVID-19 deaths happening within the state, Kerala has had one of the best case-fatality rates. The state ranks seventh in the total number of deaths, even after having the second-largest cumulative case load in India.

But we cannot paint a rosy picture in all aspects of COVID-19 containment efforts after the second wave. On July 14, when India did close to 2 million tests, Kerala’s contribution was around 150,000 only. A state which contributes around one-third of the total number of cases should have definitely done more.

Though ‘super spreader’ events are not happening, a large number of community and household clusters are still persisting. The micro containment zones also have its own share of problems, with lax enforcement and poor compliance by residents in some regions. The state government also needs to understand that sustainable change in human behaviour is a multidimensional process and it may not be possible through fear and police interventions. A consultative process, taking into confidence the various stakeholder groups, may be the only way forward to blunt the antagonism towards COVID-19 restrictions. At the same time, the restrictions in place should be reasonable and based on sound scientific principles.

The bottom line is that the COVID-19 situation in Kerala will persist like this for some more time. The media and the public should not panic, seeing the persistently high load of infections daily. The state government should be able to ramp up its vaccination efforts in the coming weeks, while preparing for and hoping that a third wave or a new variant of COVID-19 does not get them back to the bottom of the ladder.