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Fighting coronavirus

What the world can learn from Kerala about how to fight covid-19

The inside story of how one Indian state is flattening the curve through epic levels of contact tracing and social assistance.
April 13, 2020
A government health worker in Kerala checks a boy’s temperature.
A government health worker in Kerala checks a boy’s temperature.Getty Images

The sun had already set on March 7 when Nooh Pullichalil Bava received the call. “I have bad news,” his boss warned. On February 29, a family of three had arrived in the Indian state of Kerala from Italy, where they lived. The trio skipped a voluntary screening for covid-19 at the airport and took a taxi 125 miles (200 kilometers) to their home in the town of Ranni. When they started developing symptoms soon afterward, they didn’t alert the hospital. Now, a whole week after taking off from Venice, all three—a middle-­aged man and woman and their adult son—had tested positive for the virus, and so had two of their elderly relatives.

PB Nooh, as he is known, is the civil servant in charge of the district of Pathanamthitta, where Ranni is located; his boss is the state health secretary. He’d been expecting a call like this for days. Kerala has a long history of migration and a constant flow of international travelers, and the new coronavirus was spreading everywhere. The first Indian to test positive for covid-19 was a medical student who had arrived in Kerala from Wuhan, China, at the end of January. At 11:30 that same night, Nooh joined his boss and a team of government doctors on a video call to map out a strategy.

For some, this wasn’t their first time fighting a deadly epidemic. In 2018, the state had dealt with an outbreak of Nipah, a brain-damaging virus that, like the coronavirus, had originated in bats and transferred to humans. And, as with covid-19, there was no vaccine and no cure. Seventeen people had died, but the World Health Organization (WHO) called Kerala’s handling of the outbreak a “success story” since—despite technical shortfalls—the state’s health system had contained a potential disaster.

This time, though, they would need to go further and move faster.

By 3 a.m. the team had settled on a WHO-recommended plan of contact tracing, isolation, and surveillance. It had been used to limit the spread of Nipah, and on the medical student in January. The plan relied on consulting patients, mapping their movements to see who they’d interacted with, and isolating anyone in the chain with symptoms.

There was, however, one obstacle. The family “weren’t forthcoming,” says Nooh. They were in isolation at the district hospital but didn’t want to declare the full extent of their movements. It was as though they were embarrassed.

At this point, 31 people had tested positive for covid-19 across the country. It was a small number, but the virus was fast-moving—on average, one person was thought to infect two to three others.

This spelled bad news for India. Many of its 1.4 billion residents live in large families and don’t have running water, making it difficult to sanitize things and maintain social distancing. Even countries with advanced health-care systems were being overwhelmed, and India had just 0.5 hospital beds for every 1,000 people—a long way behind Italy, with 3.2 beds per 1,000, and China, with 4.3. In addition, there were only 30,000 to 40,000 ventilators nationwide, while testing kits, personal protective equipment for health-care workers, and oxygen flow masks were also in short supply. It was clear to Nooh and his colleagues: the only way to control transmission was to break the chain.

Detective work

Nooh, who is 40, with a thick head of hair that he combs dutifully to one side, is a soft-­spoken man who lives with his wife, a medical student, close to his office. In 2018, when a flood swept through the district and left more than two dozen people dead and 20,000 houses damaged, he had led relief efforts, and got no more than two or three hours of sleep at night. Admirers started a Facebook fan page called Nooh Bro’s Ark. 

The experience taught him not just how to manage people in a crisis, but also how to read them. He gauged, correctly, that this family from Ranni would be intractable. So rather than rely on them, he turned to old-style detective work and technology to piece together where they’d been and who they’d come in contact with.

District Collector PB Nooh
PB Nooh, a civil servant in Kerala, saw quickly that the only way to control transmission was to break the chain.

He brought in 50 police officers, paramedics, and volunteers, and split them into teams. Then he sent them out to retrace the family’s movements over that crucial week. They’d given his district officers scraps—an address here, a name there—but Nooh’s task force expanded it dramatically, using GPS data mined from the family’s mobile phones and surveillance footage taken from the airport, streets, and stores.

In a matter of hours they had learned a lot more about the family’s movements than they’d been told—and what they found alarmed them. In the seven days since arriving in Kerala, the family had gone from one densely crowded place to another. They’d visited a bank, a post office, a bakery, a jewelry store, and some hotels. They even went to the police for help with paperwork.

State support

That evening, Kerala’s health minister, KK Shailaja, arrived from the state capital. A former science teacher, she’d already gained a reputation for her prompt and efficient handling of the unfolding crisis: the media had nicknamed her the “Coronavirus Slayer.”

While the rest of India, along with countries such as the UK and the US, wouldn’t take stringent steps to limit movement for another two months, Shailaja had ordered Kerala’s four international airports to start screening passengers in January. All those with symptoms were taken to a government facility, where they were tested and isolated; their samples were flown to the National Institute of Virology 700 miles away. By February, she had a 24-member state response team coordinating with the police and public officials across Kerala.

In the seven days since arriving in Kerala, the family had gone from
one densely crowded place to another.

This was unusual—but Kerala often goes a different route from the rest of India. The small coastal state at the country’s southern tip is steeped in communist ideas and governed by a coalition of communist and left-wing parties.

In recent years, as some states have followed the populist lead of India’s Hindu nationalist prime minister, Narendra Modi, Kerala has maintained its focus on social welfare. Its health-care system is ranked the best in India, with world-class nurses who are headhunted for hospitals in Europe and America; the state’s life expectancy figures are among the highest in the country.

The minister’s arrival in the district reassured Nooh. He wasn’t on his own; the machinery of the entire state was at his disposal. “The seriousness of the government was amazing,” he says. Each team on his task force was increased from six people to 15.

KK Shailaja
Kerala’s health minister, KK Shailaja, a former science teacher, quickly gained a reputation for her handling of the unfolding crisis: the media nicknamed her the “Coronavirus Slayer.”

By March 9, around 48 hours after the family tested positive, Nooh’s teams had a map and a flow chart listing each place they had been, when, and for how long. The information was circulated on social media, and people were asked to dial a hotline if it was possible that they had interacted with the family. Nooh’s office was flooded with calls: the family had met with almost 300 people since arriving in town.

Now the teams had to track down these people, gauge their symptoms, and either send them to the district hospital for testing or order them to self-isolate at home. The number of people self-isolating quickly rose to more than 1,200. Still, Nooh knew that people who agreed to self-isolate wouldn’t necessarily do it. So he set up a call center in his office, bringing in more than 60 medical students and staff from the district’s health department, whose job was to call everyone isolating, every day.

The callers ran patients through a questionnaire meant to assess their physical and mental health, but also to catch lies. If anyone was caught sneaking out, “we had the police, the revenue department, and village councils ready to act,” Nooh says. But the carrot was as important as the stick: his office also delivered groceries to those in need.

The district was placed on high alert. Nooh wore a mask, scattered bottles of hand sanitizer around the office, and reverted “to the old model of namaste” rather than shaking hands. This was now ground zero for the covid-19 crisis in India.

Leadership on display

On March 11, the who declared the covid-19 outbreak a pandemic. The next day, India reported its first death. Even so, Modi—perhaps concerned by the impact on the already lackluster economy—refused to issue public advisories and didn’t address the media. His biggest concern seemed to be a plan to redesign the heart of the Indian capital, including parliament, at a cost  equal to $2.6 billion.

In Kerala, a different style of leadership was on display. With 15 cases now confirmed across the state, Pinarayi Vijayan, the chief minister, ordered a lockdown, shutting schools, banning large gatherings, and advising against visiting places of worship. He held daily media briefings, got internet service providers to boost capacity to meet the demands of those now working from home, stepped up production of hand sanitizer and face masks, had food delivered to schoolchildren reliant on free meals, and set up a mental health help line. His actions assuaged the public’s fears and built trust. 

“There was so much confidence in the state government,” says Latha George Pottenkulam, a clothing designer in the port city of Kochi, “that there was no resistance to modifying one’s behavior by staying in.”

There were other reasons why Kerala was better equipped to deal with the crisis than most places. It is small and densely populated, but relatively well-off. It has a 94% literacy rate, the highest in India, and a vibrant local media. Elsewhere in the country, people were taking WhatsApp rumors at face value—for example, spreading messages claiming that exposure to sunlight could protect against the virus. But in Kerala, most people realized the seriousness of the situation.

Manju Sara Rajan, the editor of an online design magazine in the district of Kottayam, told me she felt safer living in Kerala than anywhere else in India. “We have been considering the possibilities for far longer,” she said. Everyone around her knew the number to call if they developed symptoms, and they weren’t acting heedlessly by rushing to the hospital at the first sign of a dry cough.

By March 23, the number of confirmed cases in Nooh’s district had risen from five to nine, but the containment efforts were judged successful.

That didn’t mean Kerala was coming through unscathed. It is one of India’s smallest states but has almost the same population as California: the district of Pathanamthitta has more than a million
residents alone. Services were under severe pressure, and local doctors were stretched.

Nazlin A. Salam, a 36-year-old GP at the district general hospital, found herself working 12-hour days. She christened her turquoise blue Nissan Micra the “Covid Car”—nobody else in her family would go near it—and sanitized it every night. After returning from work she would bathe before approaching her children, and refused to kiss them in case she unwittingly transmitted the virus.

Her patients were stable, she said, but there were only three ventilators at the covid-19 isolation ward and another two for general use, in a hospital with a potential intake of 400 people. To keep numbers down, the district administration would have to continue contact tracing and testing. By March 28 it had more than 134,000 people under surveillance, with 620 in government care and the rest isolating at home.Every day, Nooh arrived at his office at 8:30 a.m. and didn’t leave until 9:30 p.m. Even when he was in bed, calls and messages about the situation streamed in.

For most of March, India’s prime minister still hadn’t announced a plan to combat the pandemic. He had asked Indians, in a nationally televised speech, to come out on their balconies one Sunday to clap for health workers. Another day, he asked them to stay home for a few hours—a “people’s curfew”—but his messaging was so muddled that large crowds, which included police officers, took to the streets to blow conches, bang utensils, and ring bells as though they were celebrating a festival.

Then, on March 24, without warning, Modi declared that India would go into a 21-day lockdown—and it would start in less than four hours. Keralites were prepared for this national closure, since they had already been living in an informal lockdown for weeks. But they also had support: Vijayan, the state’s  chief minister, was the first in the country to announce a relief package. He declared a community kitchen scheme to feed the public, and free provisions including rice, oil, and spices. He even moved up the date of state pension payments.

The rest of India wasn’t quite as lucky. With the shutdown just hours away, people rushed out to buy food and supplies: in many areas they quickly dried up.

The lockdown didn't cover shops selling food, but many people chose to stay indoors to avoid crossing paths with law enforcement.

At the same time, hundreds of thousands of migrant workers who were now out of jobs tried to find their way home, but with state borders sealed and trucks and buses suspended, they had no option but to walk hundreds of miles to their families. By March 29 at least 22 of them had died on the way.

Meanwhile police officers, determined to be seen doing their job, chased down anyone who was outside, even trucks carrying essential supplies, couriers from Amazon Pantry, and of course the desperate migrant workers. In West Bengal, they beat a man buying milk. He died. The government later confirmed that the lockdown didn’t cover shops selling food, but many people chose to stay indoors to avoid crossing paths with law enforcement.

The supply crisis escalated so quickly that one reporter nosing around the prime minister’s home constituency in Uttar Pradesh found hungry children chewing on grass. Equipment shortages left some desperate doctors wearing raincoats and motorcycle helmets instead of coveralls and protective masks. Although the government announced a $22.5 billion stimulus package, it was tiny relative to the needs of India’s population. It wasn’t even clear how and when it would get food into people’s hands. And yet, Indians had no choice but to stay indoors.

The country had “missed the boat on testing,” said Ramanan Laxminarayan, director of the Centre for Disease Dynamics, Economics, and Policy, in a TV interview. “Containment is not an option anymore.” The lockdown would slow the spread of the virus, but, he said, there could be 300 million to 500 million cases by July:  “Eventually everyone in India will get covid.”

What was needed now was to proactively test anyone over the age of 65 who was showing symptoms, and for the public sector to start making ventilators “on a war footing.”

A few days earlier, the prime minister had proposed an emergency covid-19 fund for the eight member nations of SAARC, the South Asian Association for Regional Cooperation. In grandiose fashion, he declared that India would contribute $10 million. “We can respond best by coming together, not growing apart—collaboration, not confusion; preparation, not panic,” he said, during a video conference with regional leaders. 

Then, after flashing money at SAARC, he tweeted to solicit donations from the public for a fund he had set up to fight covid-19, but with little transparency about the fund’s legal framework and where the money might actually go.

As the virus spread across villages, towns, and cities and then lit into India’s—and Asia’s—largest slum, Dharavi, in Mumbai, the government continued to ignore calls for more testing and equipment. Then it announced that it would start broadcasting reruns of the Ramayana, a 1980s TV show based on the Hindu epic of the same name whose central message is the triumph of good over evil.

The Modi government’s failure to act left it to individual states to protect people as best they could. Only states like Kerala, with the experience and aptitude to take on a crisis of international proportions, felt able to do so.

'Everyone must contribute'

As of March 31, the Indian government had announced 1,637 cases of covid-19. In Kerala, 215 people had tested positive. And if Laxminarayan is correct, this was only the beginning.

Nooh was still contact tracing, testing, and isolating, his team chasing down every potential patient. There were now more than 162,000 people in self-isolation in his district, as well as more than 60 community kitchens, eight relief camps to house and feed migrant workers unable to return to their home states, and a two-member documentation team taking notes in the event that the situation repeats itself.

One Saturday in March, Nooh took a long drive to Konni, a town on the edge of a forest that is famous for elephants. One part of the forest is inhabited by an indigenous community of 37 families, separated from the town by a river. There was no bridge, and Nooh had heard that relief supplies hadn’t gotten there. At the water’s edge, he rolled up his sharp blue trousers and hoisted a jute sack full of provisions over his shoulder. It weighed about 35 pounds (16 kilograms). This wasn’t his job, but he wanted to send a message. “In an unprecedented situation, everyone must contribute,” he said. 

Twenty-three days earlier, Nooh had been faced with the “biggest ever challenge” of his career. Now, despite being severely overworked, he saw an opportunity. “As a society, we’ve never faced such a situation,” he said. “Let’s see what we can do.”

Sonia Faleiro is the author of Beautiful Thing: Inside the Secret World of Bombay’s Dance Bars (2010). Her new book The Good Girls will be published in January 2021.

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