NEW DELHI - Before many countries had fully grasped the devastation that COVID-19 would bring, health authorities in India’s southern state of Kerala were closely monitoring a 20-year-old student who returned from Wuhan, China on January 25.

Days later, as soon she reported some uneasiness in her throat, she was shifted to an isolation ward in a hospital and her family members were placed in quarantine. Tests showed she had COVID 19 — she became India’s first case of the dreaded infection.

The state moved fast because by mid-January it had already put in place a strategy to isolate people who showed symptoms in hospitals, trace their contacts and put them in home quarantine.

Three months on, Kerala is being hailed for not just flattening the curve of the deadly infection even as it spikes in many parts of the country but for having an extremely low mortality rate. Only three of 400 reported cases have died so far – less than one percent, significantly less than the rest of India or in many parts of the world. About two-thirds of the patients, including a 93-year-old man and his 88-year-old wife have been cured – the country’s best recovery rate.

Indians wearing surgical masks walk out of the government general hospital where a student who had been in Wuhan is kept in isolation in Thrissur, Kerala state, Jan. 30, 2020.

Health experts attribute the state’s success to two factors — what they call a “formidable” primary health care system and the experience it gleaned in the last two years when it handled another deadly virus outbreak.

Ruled by a coalition of communist and left-wing parties, Kerala spends the most in India on health and has the highest literacy rate in the country.

“We have doctors, nurses and paramedics in every village,” said K.N. Harilal, a member of the Kerala State Planning Board. "So, we have a strong army of health care workers to fight epidemics.”

The brain damaging Nipah virus, for which also there is no cure, surfaced in the state in 2018 and 2019 but was tamped down with the same strategy of tight surveillance and contact tracing. As a result, terms like quarantine and isolation became household words in Kerala even before the pandemic.

“You can’t imagine the terror we went through at that time, and fear is a very good trainer,” said Rajeev Sadanandan, the state’s former health secretary who was on the frontlines of tackling the Nipah virus. “So, when coronavirus came, the state was ready for it.”

However, tackling coronavirus was a more herculean task for the state of 34 million. It has a high population density. Hundreds of students enrolled in Chinese universities, including those in Wuhan, and tens of thousands working in Middle Eastern countries headed back amid the coronavirus scare, some bringing the virus with them. All had to be kept under surveillance.

Municipal workers in protective gear carry the body of a woman who died of the coronavirus disease (COVID-19), to a crematorium in Ahmedabad, India, April 17, 2020.

In some cases, these migrant workers returned home after two or three years. “They had already been in quarantine from their families for so long. So, a lot of awareness building campaigns had to be done to educate people to resist the temptation of mingling closely with family members and spreading the infection,” said Harilal.

Inevitably there have been bumps. Like the rest of India, Kerala had a shortage of testing kits. And there were instances of people who evaded or broke the quarantine protocol after returning from overseas.

One three-member family that hit local headlines managed to slip through screening at airports when they failed to report that they had travelled to Italy and subsequently went on to visit crowded places like markets, a hotel and a bank. It set in motion frantic efforts to track their primary and secondary contacts. Twelve teams that included medical workers, police and volunteers worked for days to prepare the travel path of the family, using GPS data from their phones, eventually tracing more than 4,000 people who then had to be placed under observation and quarantine.

Indian workers walk with garbage after cleaning an isolation ward at a hospital for observing people suspected to have a new coronavirus infection in Kochi, Kerala state, Feb.4, 2020.

Officials give much of the credit to local level health workers. “Every health worker knows how to take charge of their population, how to trace the contacts, how to teach them about home quarantine. ‘I won’t slip up, this won’t get out on my watch,’ that pride is there in the system,” said Sadanandan.

He points to his own experience when he went into home quarantine on returning to Kerala from Delhi – the state was one of the few that asked not just overseas but also domestic travelers to stay at home. “I would get daily calls inquiring ‘are you getting a cough, do you have fever, are you feeling stressed?’ I was given numbers to contact in case I needed them,” he recalled. “I could make out that they were under tremendous pressure with so many people to contact, but the calls always came.”

In several cases, local communities pitched in by cooking food for those who were in quarantine or those stuck far away from their homes.

Policy makers admit that there are still many battles ahead. Most of all there is the risk of a fresh round of infections when an influx of residents from overseas and other states arrives after India’s stringent countrywide lockdown is lifted.

“Hundreds of thousands would have to be quarantined, tested and, if positive, treated, ensuring there is no secondary spread,” the state’s finance minister, Thomas Isaac wrote in the Indian Express newspaper. “We do not want to lower our guard and rest on the laurels.” He pointed out that a lockdown was not enough to tackle coronavirus — preparedness was the key.

But even if Kerala does finally overcome the challenge of coronavirus better than the rest of the country, many ordinary people share the same worries that are sweeping India — lost livelihoods that may not return anytime soon. The concerns are even higher for this tiny coastal state, whose picturesque backwaters and tea estates on rolling green hillsides make tourism a key sector and where many families depend on remittances sent by overseas workers.

Anoop Murali, who left his small family farm five years ago for the city to ferry tourists around in a rental car, has returned to his village. He does not know when or if visitors will come back. “I simply don’t know what to do. There is no work at all, maybe we have to go back to farming. That’s all we talk about these days,” he said bleakly.