“Not testing alone. Not contact tracing alone. Not quarantine alone. Not physical distancing alone. Do it all. Find, isolate, test and treat every case, to break the chains of transmission…. Do not let this fire burn.”

If this recent statement of World Health Organisation (WHO) Director General Tedros Adhanom Ghebreyesus offers the best prescription for dealing with COVID-19 as of now, a State in India that has attracted everyone’s admiration with its quick and effective response to the spread of coronavirus is Kerala.

Right from early February, when three students of Wuhan University in China, then the centre of the outbreak, returned to their homes in the State and were promptly identified, tested and found to be the first known positive cases for coronavirus infection in India, Kerala increased its preparedness, readiness and response to the threat of the pandemic.

It effectively utilised the most valuable resources at its disposal: time, the advance notice it got after the first trickle of people living abroad began to return in the wake of the pandemic threat; the well-known strengths of its refurbished healthcare system; and the out-of-the-blue yet hands-on experience it had gained in the past few years while handling two outbreaks of the deadly Nipah virus (“Managing Nipah”, Frontline, June 22, 2018).

With early detection and prompt containment efforts focussing on review of each case, tracing everyone who had contact with the infected person, putting them on observation, setting up emergency quarantine and hospital facilities, taking steps to ensure that people who returned from overseas, including tourists who showed symptoms of the disease and their contacts, stayed under quarantine at home, hospitals or hotels, Kerala has offered a vigilant, well-informed response to the spread of COVID-19 and its consequences in the State.

These steps, based on WHO guidelines, may appear commonplace as every other State also soon followed them, but Kerala has demonstrated a remarkable difference once again at the time of a crisis in the way its government went about implementing them, stirring up the official machinery and ensuring the participation of every section of society.

Special isolation facilities and treatment protocols based on the Ebola model that were established following the Nipah outbreak were readied almost as a reflex reaction. A back-to-the-basics approach for infection control was put in place soon after the first positive case was identified. The government made it clear through detailed daily media briefings by Chief Minister Pinarayi Vijayan and Health Minister K.K. Shailaja that the tasks involved, especially in contact tracing, creating awareness about the need for quarantining and in training healthcare and hospital personnel, were more difficult this time and sought the cooperation of the people in surveillance and containment efforts.

The entire State would wait for these daily briefings, remarkable for the competent government response to the emerging crisis, the confidence and clarity with which each day’s events were analysed and the convincing manner in which sensitive government decisions were explained and their rationale conveyed to the people at regular intervals. Equally popular were the social media accounts of the Chief Minister, which proved to be a remarkable compilation of updates on government steps to tackle this dangerous pandemic, the enormity of the tasks involved and advice and appeals to the people.

As a result, within the shortest possible time perhaps, the whole of Kerala was made aware and vigilant about the nature of the virus and its spread, the fact that its infectious period, transmissibility, clinical severity and extent of community spread were yet to be fully understood and about the difficult tasks involved if the State was to survive such a contagion.

The State dealt with the first stage of the crisis, successfully containing a spread of the disease by quarantining the students from Wuhan who had tested positive and providing them hospital care until they recovered fully. But soon, a family of three with a travel history to Italy arrived at the Kochi airport, disregarded official guidelines to report to the authorities about any visit to coronavirus-affected countries, and chose to roam about in their native village and surrounding areas of Pathanamthitta district.

They later tested positive for the virus, after a relative reported sick at a local hospital and told the authorities of their arrival. The government had to force them to stay under quarantine. To its horror, Kerala realised then that it had seen the first small chain of transmission of the virus within its territory, even as the biggest annual religious festival in the State—a congregation of over 30 lakh women devotees spread over 10 days at the Attukal Bhagavathy temple—was taking place in the State capital.

But in its wisdom, the government let the event run its course with all its attendant risks, issuing merely health advisories on the dangers involved for the participants and cautioning those with symptoms from taking part in the festival. This was perhaps the only flaw in the measures taken by the State ever since the first positive cases were identified.

On March 19, as the number of COVID-19 cases in India crossed 198, in Kerala, 25 people had tested positive for the virus (after the first phase involving the three students from Wuhan who later recovered) and 31,173 persons were under surveillance. Among them, 237 were in isolation in hospitals and the rest were on home quarantine. The State saw an increase in suspected cases, especially after a steady flow of people began from various affected countries. On a single day, on March 19, for example, as many as 6,103 people (7,861 the previous day) were additionally put under surveillance.

The State was surely learning that many of the steps the government had announced may only be successful in the early stages of the outbreak, that the logistics of continuing the containment efforts further would be challenging, and that individual responses to government directives will be a key factor in preventing the situation from turning bad.

There were several reports of people violating home quarantine norms and trying to hide their travel history from the authorities. In a prominent instance, the functioning of the prestigious Sree Chitra Tirunal Institute for Medical Sciences and Technology in Thiruvananthapuram was badly affected when one of its doctors who had recently visited Spain came back on March 1 and attended duty for over 10 days. After this, on disclosure of his travel history, he tested positive for the virus. Several senior doctors and an unknown number of other hospital staff had reportedly interacted with the said doctor and were hence forced to go on home quarantine in order to avoid risk to patients, a large majority of them needing critical care.

In another incident, a patient who was admitted to the Thiruvananthapuram Medical College with injuries sustained in a road accident was provided treatment. Only later did he disclose that he was on home quarantine at Kollam but had violated directions to go on a bike ride when he met with the accident, forcing 16 doctors and nine hospital staff to go on quarantine themselves, affecting hospital work at a critical juncture when resources were stretched to the limit.

However, such instances were the exceptions and do not take the sheen away from the outstanding way the government went about containing COVID-19 and preparing the State for the uncertain period that lay ahead.

A reading of the prominent government initiatives during the month after the first three positive cases were identified would perhaps be instructive.

Kerala was perhaps the first State to announce the immediate closure of schools, including tuition centres and madrasas, cinemas and other establishments until the end of March; promote the importance of physical distancing and personal hygiene; gauge the need for quickly setting up more (but still not enough) testing facilities; deliver mid-day meals to schoolchildren at their homes until schools reopened; introduce quarantine facilities in all prisons in the State; utilise the services of prisoners to help meet the acute shortage of face masks; encourage large-scale production of sanitisers locally; involve local body members in surveillance and monitoring of those in quarantine; utilise community organisations to set up makeshift sanitiser kiosks at street corners; take steps to improve the quality and availability of broadband Internet to help those working from home; provide a dedicated app, “GoK Direct”, to tackle fake news and false social media campaigns with up-to-the-minute information on government decisions and travel guidelines; launch an interactive web portal to provide all currently available scientific and general information about COVID-19 to the public and health-care personnel; rope in religious and community leaders to curtail large gatherings during prayers, rituals and festivals in places of worship; launch door-to-door monitoring of those kept under home quarantine; provide training to those who come in regular contact with the public, such as ambulance drivers and auto and taxi drivers; undertake the hard task of tracking individual contact patterns and preparing flow charts of the time and places of visit of all those who tested positive for coronavirus and give them wide publicity as a warning to those who could be at risk of infection; launch a popular and effective “Break the Chain” campaign, involving, among others, Ministers and cine artistes on television and social media and elsewhere, to create awareness about physical distancing and frequent hand washing; and take extra care to ensure that people who tested positive were not stigmatised but blame was put squarely on irresponsible behaviour.

Kerala also declared an economic stimulus package to address the hardship in society that has followed the coronavirus outbreak, the first State to do so. On March 19, the Chief Minister announced a Rs.20,000-crore economic package for the purpose, of which Rs.500 crore was exclusively for the health sector (besides other assistance), Rs.2,000 crore to provide loans through Kudumbashree, the vast network of women’s self-help groups, and Rs.1,000 crore to provide jobs through rural employment guarantee programmes.

The government also announced free ration for a month for all families irrespective of the category to which they belonged and made arrangements for paying welfare pensions to all eligible sections two months in advance.

On March 19, in a commendable gesture, the Congress-led Opposition coalition too joined hands with the Left Democratic Front (LDF) government in the fight against COVID-19. At a joint video conference with ward-level members of all the local bodies in the State, Chief Minister Pinarayi Vijayan and Opposition Leader Ramesh Chennithala urged them to sink political differences and unite to work proactively at the local level against the spread of the disease, as the State faced the prospect of community phase transmission of the virus in the coming weeks.

Referring to the experience of many other countries that suggested the possibility of wide transmission in the community, the Opposition Leader too supported the government’s call to local administrations for an extremely vigilant approach to ensure that people followed government guidelines and restrictions.

But as Kerala braces for the next stage with severe strain on the health system as it struggles to keep its grip on the key areas of surveillance, contact tracing, testing and patient care with the involvement of local communities, it is becoming clear that the State is leaning heavily on past social investments to ensure such small steps mattered in the management of the pandemic.

Kerala’s quick mobilisation contrasts sharply with the experience of many other States and is a demonstration that epidemic preparedness does not start on the eve of an outbreak and that the investments in universal education, effective decentralisation of powers and resources, and women’s empowerment, among others, have silently come into play to its advantage in the war against coronavirus.

From the late 1990s, with decentralisation becoming a reality in Kerala, as 25 to 30 per cent of the Plan funds became available for local bodies and planning and resource mobilisation began at the local level, facilities in many grassroots-level hospitals in the State improved dramatically.

In the past decade, Kerala also invested heavily to reorient its chain of nearly 900 rural primary health centres, to train grassroots-level health workers to monitor the health status of rural households, to provide quality treatment services including speciality care facilities at the taluk, district and general hospitals in addition to the medical college hospitals, and to create a patient-friendly environment in all government hospitals (“Reinventing healthcare”, Frontline, September 29, 2017).

The wisdom of Kerala’s planners to keep the network of government hospitals as a counterweight against the private sector has come to the aid of the State at this critical juncture too, when it is preparing for what seems to be a long battle to try and contain the viral pandemic that has left entire nations terrified.