Kerala: In a vulnerable position

The big concern for the State is whether, despite the government’s best efforts, the sharp rise in the number of COVID-19 patients would cross the threshold capacity of the health system to accommodate them.

After keeping COVID-19 transmission at a low and safe level for five to six months, Kerala is now dealing with a rapid increase in the number of cases, with the health authorities even considering the possibility of a surge in the number of patients overwhelming the health facilities.

The State is reporting one of the highest per day increase in COVID-19 cases in India, with the total confirmed cases crossing three lakhs and active cases going over a lakh on October 13. As on that day, the recovery rate was 67.64 per cent and there were 1,046 deaths until then.

On October 10, with 11,755 positive cases, Kerala recorded the highest per day rise in the number of cases in the country, surpassing Maharashtra (11,416) and Karnataka (10,517), considered to be the worst-affected States.

Chief Minister Pinarayi Vijayan said the most challenging period for the State in terms of handling the pandemic would be October and November. He said: “We should be able to strengthen preventive measures more effectively during this period. Only then can we contain the number of deaths from rising. The situation is that over 10,000 cases are being reported daily. The number of tests has been increased. But the test positivity rate is over 10 per cent. This indicates that the number of cases will rise further. In the neighbouring States, the epidemic is continuing unabated. Recent estimates show that in Karnataka, there are over 6.66 lakh cases, and in Tamil Nadu over 6.33 lakh cases. In both the States, the number of deaths is reaching the 10,000 mark. The population density in Karnataka is 319; in Tamil Nadu, it is 555. We have to remember that in Kerala it is 859.”

The relief, however, is that Kerala could keep the death rate low until now. It was around 0.35 per cent in October. However, while four to 12 deaths were reported in early September, it was between 20 and 29 in the first 13 days of October. Health Department authorities say it could go up further in the coming weeks.

Several factors make Kerala especially vulnerable to the COVID-19 pandemic: it has one of the highest proportion of elderly and people with lifestyle diseases, a high density of population, and a rural-urban continuity that gives an urban character to its villages. Moreover, studies have shown that the infectivity of the strain of virus spreading in Kerala is high, which makes it spread faster, even though it need not necessarily mean that fatality too will be high. But the test positivity rate is higher than the national average of 8.3, with the highest rate of 18.16 being reported on October 13.

The Chief Minister reiterates at every press conference that even though the number of cases has gone up, the fatality rate is low because Kerala could strategically delay a pandemic peak and strengthen its health system in the meanwhile. Pinarayi Vijayan said: “In May, the death rate was 0.77 per cent. In August, it was 0.45 per cent; in September it went down to 0.37 per cent. The case fatality rate on October 8 was only 0.22 per cent. The neighbouring States have recorded 10 times the number of deaths than in Kerala. It is when we compare thus that we understand the importance of the efforts that have been made in Kerala.”

IMA’s warning

The Kerala unit of the Indian Medical Association (IMA) has, however, warned that the State is now facing an “extremely serious situation” and points out that there is a “frightening inadequacy” of ICU and ventilator facilities in Kerala’s treatment centres.

IMA State president Dr Abraham Varghese and State secretary Dr P. Gopikuar said in a press statement on October 5 that 80 per cent of the ICU-ventilator beds had already been occupied and government hospitals had more or less excluded treatment to non-COVID patients. They warned that there was only one doctor, two nurses and two attenders for every 50 patients and said that the IMA had been regularly demanding the increase in the number of tests being conducted.

“When 50,000 tests are conducted the test positivity rate is 14.5 per cent. Even now if we conduct one lakh tests there is likely to be over 20,000 positive cases. Without taking efforts to isolate such people, we are now letting them transmit the disease,” the statement said, cautioning that the “decisions ought to be taken by health experts and not politicians or officials”.

The IMA has demanded that the government treat the situation like a “health emergency”, immediately increase tertiary care, ICU and ventilator facilities, and make real-time data about the availability of ICU and ventilator beds available to the public through government websites.

The IMA’s criticism came in the context of an agitation announced by doctors, and it even alleged that politicians and bureaucrats were leaving out health experts from COVID-19 management and decision-making. The Chief Minister, in turn, accused those who criticised the government’s good work as “self-styled experts” and “vested interests” who were trying to “mislead the public about the Health Department that had been managing the pandemic fully on the basis of scientific advice and necessary caution”.

Pinarayi Vijayan also indicated that the irresponsible way in which people in general went about celebrating Onam and the opposition parties organised political demonstrations all over Kerala (on the gold smuggling case and related issues) are factors that led to the loosening of the vigil and increasing the caseload all on a sudden in the State.

In such a context, there is no doubt that the big concern for the State is whether, despite the government’s best efforts, the sharp rise in the number of COVID-19 patients would cross the threshold capacity of the health system to accommodate them.

With 70 to over a 100 health workers testing positive every day, Kerala is already facing a scarcity of key medical professionals. Even though there have been efforts to increase ICU and ventilator facilities, a severe shortage of people specially trained in such units is likely to become an important factor in the coming days, experts have warned.

According to one estimate, there are over 5,000 beds in government hospitals, nearly 35,000 beds in the first-line treatment centres established in various locations and over a 1,000 ICU beds in the State. Private hospitals have in addition been asked to set aside at least 10 per cent of the beds for COVID care. With the surge in numbers, unlike in the initial months, not all COVID-positive patients are admitted in the treatment facilities; only those with symptoms, who are seriously ill, the elderly and those with comorbidities are admitted. According to the “Quarantine Summary” released by the government, as on October 12, 28,309 patients were hospitalised and 2,53,104 were under home quarantine. A large number of patients are being advised to stay at home and quarantine themselves and seek admission only when necessary.

The health system has been advised to be vigilant about any sudden increase in patient load that could challenge ICU/ventilator care facilities in every district, even as efforts are on to increase testing by opening “testing kiosks” in a variety of public places. By mid-October, Kerala opened its tourism centres, except the beaches, to visitors, mainly domestic tourists. Meanwhile, it has asked district magistrates and gazetted officers specially designated as “sectoral magistrates” to monitor the ground situation regularly and ensure that COVID safety norms are followed everywhere. They have also been advised to use the provisions of Section 144 of Criminal Procedure Code, 1973, to prevent gathering of more than five people anywhere, except, still in a restricted way, for weddings, funerals and some other specified purposes.