Every year after the Union Budget, newspapers carry articles critiquing the abysmal allocation for the health sector. As the COVID-19 threat looms, doctors, healthcare professionals and state institutions have been regularly issuing guidelines on the precautions to be taken. However, the ubiquitous fault lines of India’s public healthcare infrastructure are being laid bare as we combat our latest adversary. In his book, Everybody Loves a Good Drought , veteran journalist P. Sainath poignantly details what it looks like to be a poor family that relies on government hospitals. He remarks how the 1994 plague in India got unprecedented media attention because unlike several other diseases, it couldn’t be restricted to rural areas and urban slums. The disease-causing bacteria had the audacity to enter elite spaces; in Sainath’s words, “Worse still, they (the bacteria) can board aircraft and fly club class to New York. Too many of the beautiful people felt threatened.” COVID-19, although a lot less dangerous than the plague, was brought to India by infected passengers flying in from affected nations. This argument is not to suggest that either of these diseases are to be taken lightly, but rather to shed light on how India responds differently to health requirements based on the social and class locations of those affected. The advent of COVID-19 has led to a peculiar scenario wherein those who can otherwise afford private healthcare are now relying on government facilities to be quarantined and tested. It took a pandemic like COVID-19 for some to realise what most of India has been dealing with for decades. A case in point is the Agra woman who was falsely reported to have fled quarantine. In reality, she reportedly resisted the option of being isolated at a public health facility because “the sight of the unhygienic toilets made her retch”. This is an apt representation of the consequences of meagre health spending and lack of motivation from state institutions to strengthen public healthcare infrastructure. With a system that cannot even ensure fully functional toilets in public health centres, the COVID-19 challenge towers over our health administration.
Preparing for an outbreak
Given India’s record on public health, Kerala has been receiving praise for the way it is tackling the emergency. Be it the presence of health infrastructure prerequisites or its experience in handling the Nipah virus, the Kerala government’s preparedness for COVID-19 was relatively stronger than other States. Discussions on how to address it started as early as mid-January. When various countries started confirming cases, Kerala was the first State to draft measures for its containment. The measures became more stringent when the State reported its first case on January 30. Since then, the government has become more vigilant and taken proactive measures to trace people who have had primary and secondary contact with those who tested positive. The situation became grave after a family that flew down from Italy tested positive for the virus. After vigorous tracing, we found that 719 people had come in contact with the first case. The government then tightened the norms for people returning from other countries. It started taking strict action against all those who were not revealing their travel history. All those who were in primary and secondary contact were tested and kept in isolation or home quarantined. The next step was to cancel big religious ceremonies. The government then gave a list of people under observation. More recently, the government started checking people at different entry points to the State. Healthcare workers are stationed at all check posts on roads to check travellers for the virus before they enter the city. A similar exercise is conducted for those taking trains. If we are to learn from China and South Korea, the most efficient way to tackle the situation is to aggressively trace and test potential cases of COVID-19. Experts have said that the only reason South Korea was able to handle the crisis without imposing any lockdown was because of rampant testing. However, in order to follow these best practices, even Kerala, with superior mechanisms for healthcare, faces the challenge of limited resources and labs for testing. In such a situation, it is important to judiciously use available facilities and localise efforts. All of this can be achieved only through clear political will, strong public healthcare services and commitment on the part of people. It is important for citizens to closely follow measures prescribed by the government. An important step towards this is to ensure that people don’t go for testing without solid grounds. If they do, the public health facilities will be overwhelmed. To ensure that people have access to the dos and don’ts for self-isolation, monitoring symptoms and reporting to health facilities at the right time, the Kerala government has launched a mobile application called GoK Direct. The Disha helpline has also been used for awareness generation. The ‘Break the Chain’ campaign advocates ideas of basic cleanliness and hygiene. This attempt to bring about a behavioural change is gaining traction across the State and is also being picked up by the national media. Such precautionary measures and social distancing by citizens will buy some time and lighten the burden on government functionaries. This buffer period should be leveraged by the State government to strengthen testing facilities so that we reach a point where a maximum number of symptomatic individuals can be tested. In this context, based on the State government’s request, the Indian Council of Medical Research has sanctioned 10 testing centres in Kerala. The government is also planning to facilitate the setting up of more testing centres with the help of the private sector for meeting the required capacity.
Lessons from and for Kerala
That Kerala came up with a set of guidelines before the COVID-19 outbreak was possible because of its history of unswerving governmental support for public health. The administration has been serving as a catalyst for the development of health services. This is reflected in the expansion of health infrastructure — for example, setting up the National Institute of Virology’s unit in Alappuzha soon after the Nipah incident. The epidemiological status of the State is currently characterised by the burden of both non-communicable diseases and increased incidence of communicable diseases in recent times. The monitoring system created by the government in public health infrastructure has been highly successful. It has helped healthcare officials to detect and combat diseases quickly. The healthcare system in Kerala is decentralised to achieve the potential gains of improvement in service delivery and access. Consequently, in the context of COVID-19, the State has been successful in tracing individual cases and implementing measures like the ‘Break the Chain’ campaign successfully. Efforts are being made to provide infrastructure and quality services through the ‘Aardram Mission’, which focuses on developing primary health centres into family health centres. The government has been successful in putting the public health sector back on the rails.