KK Shailaja, Kerala’s Health Minister, has a daily video conference with her staff. The staff who are fighting the COVID-19 pandemic across the state share their day’s experiences, even the lighter moments and the jokes they cracked. The department has also arranged video meetings for staff working in isolation wards with celebrities for half-an-hour every day. Shailaja Teacher, as the whole state calls her, takes part in those meetings too.
Both the meetings are stressbusters, the Minister says. The 63-year-old politician has won praise from beyond the country’s borders for her commendable handling of the pandemic which the whole world is fighting.
In a detailed interview with TNM, she talks about how investment in the public health sector is crucial, how meticulous planning helped, and why not even a single case should be missed out.
How do you assess the state’s fight against COVID-19 so far?
It has not been easy at all. It was a herculean task to check on all the people who were arriving in the state from outside, put them in quarantine… This might sound simple, but the arrangements were not easy. Eighteen expert groups were assigned each task such as contact tracing, isolation, logistics collection, mental health of patients, transport, finance, etc. There is even a group that teaches people the protocol for burying a body if someone dies from COVID-19.
The state began preparing a protocol when cases were reported in Wuhan. How did the state prepare before it was even declared a pandemic by the World Health Organisation (WHO)?
I first read about the virus spreading on the Wuhan University premises. I read that the virus is SARS (Severe Acute Respiratory Symptom) and there was MERS (Middle East Respiratory Symptoms) from the same virus family and they later named it COVID-19. Whatever the name, the virus was dangerous and its infectivity was high. The first thought that came to my mind was the Kerala students studying in Wuhan. I soon called Health Secretary Rajan Khobragade.
Rajan told me we have to be on alert and immediately start preparations, convene a Rapid Response Team and start a control room. We started the control room on January 24. We sent a message to all District Medical Officers that a virus has been reported and chances are that it would come to Kerala catching a flight (she chuckles).
On January 27, the flight from Wuhan arrived. Many of the passengers were not symptomatic and so they were sent to home quarantine with instructions to inform us if they develop any symptoms. One student was symptomatic and she was shifted to the Thrissur General Hospital. Her result came on January 30 and she tested positive. Her parents were also quarantined at the hospital.
On February 2, came the second case of the Wuhan student from Alappuzha and on February 3, the one from Kasaragod. The three students were in hospitals when they tested positive and hence they didn’t transmit the virus to anyone.
We didn’t stop surveillance at the airports. Health workers continued testing passengers with thermometers. Some people even asked why we should continue the checks, saying we were creating panic, that we were overdoing it and people would make fun of it. Even the opposition said in the Assembly that we should look at what the US is doing. My reply was that we can’t let the people of the state die, we will not follow anyone but learn lessons from all. We had a standard protocol that we have set for the state, though we follow the WHO guidelines as well.
Our knowledge and experience told us that it was not time to step back, and we didn’t. Later COVID-19 was declared a pandemic whereas we had started precautions way back foreseeing that it would turn out to be a pandemic.
Are we planning to revise the existing strategy or reverse it?
The strategy needs to be revised frequently, it can’t be reversed.
In the beginning itself we had set Plan A, Plan B and Plan C. In Plan A, we identified a medical college, district or general hospital, of which a major portion would be allotted for COVID-19 treatment. That is how we got more than 300 beds in medical colleges. In Plan B, we included Taluk hospitals and non-functioning private hospitals. In Plan C, the idea is to convert most private and government institutions into COVID-19 hospitals.
If a community spread happened, we had even planned to convert auditoriums and schools into COVID-19 hospitals. There we would lack human resources. Then we collected a list of the human resources we had, those in the private sector and freshers from medical colleges. We charted out who would be deployed in each phase. A meeting was held with all the stakeholders. It was decided to manage with the capacity of the government team if possible or bring in human resources from the private sector if needed. At the same time, we didn’t overlook other diseases like non-communicable ones. We could face the pandemic only with this kind of meticulous planning.
What is the revised strategy?
The initial strategy was strict quarantine for 28 days. Now that the patient load is reducing, patients who have recovered need to be on 14 more days of quarantine after they are discharged. The wave has reduced. Hence the revised strategy would involve a relaxation in the quarantine rules for low-risk cases; we haven’t finalised this though. But what would be the strategy in the next phase if the curve really flattens – this will be discussed and decided.
Even international media has been praising Kerala for flattening the curve. What is our assessment?
Yes, we have flattened the curve with strict screening, quarantine, isolation and treatment. But we can’t say that we have broken the chain fully, because positive cases are still there. We have broken the chain to a great extent – the number of new cases have kept reducing implying that the viral load has become less.
Only one or two new cases are reported now, but at the same time those under treatment are still recovering. We still cannot miss a single case. So we will continue to be on alert until the last positive case becomes negative and until no new positive cases are reported for a few consecutive weeks.
What are the drawbacks and advantages of the existing strategy?
There are no drawbacks to point out, if we find a better strategy then we can say there were drawbacks. Our strategy was developed with the essence of all the best strategies and so far we haven’t found anything better than this. About why we didn’t test asymptomatic people – because it was impossible. Because if they were infected in the past three or four days the result would be negative. This would give the person a false sense of security and they would likely not follow health advisories. They could turn out to be positive later and by that time would have mingled with a lot of people. Hence, the strategy was to place them on strict quarantine and to test if symptoms develop, and also test those who have pneumonia symptoms on the periphery.
Initially it wasn’t possible to test all the people who came from outside as the number of testing kits we had were not sufficient, especially RNA extraction kits. We had to contact other countries to get the kits as they were manufactured only in a few places in India. We handled the stock wisely, without using all the kits available to test people who were less likely to be infected. Or else we would have run out of kits when high-risk people needed to be tested. Also we would have run out of Personal Protection Kits.
How much are we prepared to deal with the influx of non-resident Malayalis when the air traffic restrictions are lifted?
It’s tough to know, though we are prepared. It would be unscientific to quarantine them all at one place. So most likely we will decide to quarantine them at home wherever it’s possible. But those who don’t follow the advisory might be brought to a common quarantine room. We have already identified rooms at institutions.
Were you expecting more help from the Centre?
Yes, we expected more financial help from the Centre. Now it’s like we are running on borrowed money. This will ruin us after the current scenario passes, we’ll be left with no money to deal with anything else.
Has this pandemic shown how crucial it is to invest in the public health care system?
Investing in the public health sector is very crucial. The one thing I’ve repeated ever since I became the Health Minister is to increase the Centre’s investment in the health sector. Currently, the country’s investment in the healthcare system is only around 1% of the Gross Domestic Product and what Kerala receives is a small percentage of that. The state is unable to make popular intervention into the health care sector with that meagre share. Because our concept is to strengthen both the mental and physical health of the people for which a huge investment is needed.
But investment alone is not enough, because even countries that have invested hugely in the health care system have failed to deal with the pandemic: for example, the Scandinavian countries of Norway and Sweden. I used to regularly cite these countries as models because their investment in the health sector is around 30%. What is more important is people-centric planning. That is how Kerala became a model.
The state’s people-centred approach began in 1957. It’s not important how much resources we have with us, but how we use it.
Kerala’s priority was poverty alleviation, health and education, individual development and housing. When the government headed by EMS Namboodiripad came to power in 1957 an ordinance was brought to prevent evicting people from the land they lived on.
This was followed by making education available for all. Prior to that, education was the privilege of the rich. The government decided to start schools in all districts by paying teachers on its own.
The same government created the base for public intervention in the health sector by building hospitals for the poor. Primary health centres (PHCs) were set up in all panchayats where one acre of land was available. By the time the Left Democratic Front government came to power in 2016 there were PHCs in all panchayats. However, what I also learnt was that post the ‘70s we ignored primary health care instead we focused on the curative part.
But in most of our PHCs there was only one doctor and no standardisation of operation. We decided to standardise this to convert PHCs into Family Health Centres. But we had no model. Then I visited primary hospitals in the UK and thought that some of those facilities could be adapted in our PHCs. We also checked family health care centres in Cuba. After a slew of discussions with experts, we decided how our family health care centres should be.
Hence the PHCs were converted into buildings, with a garden, a comfortable room for doctors, comfortable seating for patients, hand sanitisers, separate rooms to check those who have fever, and Swas clinics for those with allergy issues.
In the second level, we strengthened Taluk hospitals, made them more spacious, bought more equipment while high tech buildings are under construction in district hospitals. That is how we have 200-250 beds that can be set aside at a district hospital during a pandemic like COVID-19.
Our concept was that the poor shouldn’t feel sad about not being able to afford specialised facilities. We converted the hospitals with more or less the same buildings as private hospitals and we maintain the premises tidily. This would give a patient the feeling that they have come to a big hospital. The poor should also benefit from the achievements in the science and technology sector.
You battled Nipah twice and now the pandemic… how is the Health department mentally dealing with this fight?
We get things done through teamwork, sharing the burden as well as the happiness. I view my officials as family. I scold those who fail in their duty and appreciate those who work hard. The appreciation makes the staff more sincere, they feel free to call me at any time.