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Kerala should explore a scientific and practical way out of the COVID crisis

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While agreeing that Kerala’s COVID-19 control strategy has performed better than most other states, at least until recently, Dr Abdul Ghafur, Coordinator, Chennai Declaration on AMR and Apollo Adjunct Professor, Consultant in Infectious Diseases, Apollo Cancer Institute, makes that case for a change in strategy as the current strategy the state follows is having a crippling effect on economy. He, therefore, advocates a strategy that can help save lives and livelihood

Kerala has the highest number of daily COVID-19 cases than any other state in the country. The test positivity rate (TPR) is consistently over 10, while the national average is well below 2. Kerala contributes to more than 50 per cent of the COVID-19 cases in India now. Kerala economy is still in a lockdown mode, while the rest of the country has opened up.

At the beginning of the pandemic, the state had one of the lowest COVID-19 tallies in the country. So, what exactly is the reason behind the drastic change, from the lowest to the highest number? What are the implications of this situation? Should we change the strategy? If so, how can we make that change scientifically and practically?

Is Kerala a victim of its early success? The fantastic success of the Kerala COVID-19 control model at the beginning of the pandemic attracted global attention. The Government and the public of the state rightly deserved this acclaim. However, being a Keralite and an individual who knows the ground reality of the state, after discussion with several individuals from all walks of life, I had suggested a strategy change at the beginning of the pandemic itself. At the same time, I was not surprised, though disappointed, when the suggestion was sidelined. Why should Kerala change the horse when the state was winning the race? The COVID-19 control was very effective at that time, and, understandably, the recommendation for a drastic change in the strategy was not palatable to most. But, on the other hand, the state carried out an excellent contact tracing approach that did help to keep the number very low for a significant period. Thus, the state succeeded in delaying the peak of the first wave and the onset of the second wave.

The CFR (Case Fatality Rate) is still significantly lower than in most other states. Kerala didn’t have to witness any dramatic scenes of oxygen deficiency and heaps of dead souls, unlike several other states. Despite a large number of cases, the health care system is still not overwhelmed. Kerala has performed better than most other states in indicators such as excess mortality rate- a crude indicator of the transparency in COVID-19 death reporting. That said, Kerala, like most other states, has underreported the COVID-19 deaths. The extent of this sweeping under the carpet phenomenon could be lower than most other states.

Where did Kerala go wrong?

What was my reason to recommend a change in strategy at the onset of the pandemic? COVID-19 is a marathon and not a sprint. Whatever approach we follow should be sustainable over a prolonged period. The Kerala model was not sustainable. Kerala COVID-19 strategy failed to recognise the dynamics of the COVID-19 pandemic. The hangover of the fantastic success of the Nipah control lured the state into an unrealistic COVID-19 control strategy. Nipah is a sprint that high-impact short-term measures can control. On the contrary, COVID-19 is a marathon that needs a strategy that can be maintained over a prolonged period, without burnout. This burnout is the root cause of the scenario Kerala is witnessing today.

As predicted, prolonged hard work resulted in the system getting burned out over time, with severe lapses in the COVID-19 control measures at the ground level. This resulted in a large and relentless second peak, with a steady increase in the overall death rate and a crippling effect on the economy. The prolonged lockdown is not a viable strategy for a state with a very fragile economy largely dependent on foreign remittance. The delayed second wave now doesn’t show any signs of a declining trend, while the rest of the country is doing business as usual.

The economic impact

The prolonged second wave and the lockdown pushed the state’s economy into a precarious scenario, affecting the big and small business sectors alike. The ordinary citizen of the state, probably for the first time in decades, tasted the impact of an empty pocket. The tourism industry has faced a devastating blow that will need a long time to recover. The state, under pressure from the business community, eased the lockdown just before the Bakri Id festival. This relaxation was done with a good intention but without the backup of a scientific strategy. The move attracted severe criticism from the Supreme Court. The ordinary small-scale shop owners of the state have now threatened a boycott of the lockdown restrictions and a decision to keep the shops open. This is an unfortunate scenario and will result in further worsening of the already precarious COVID-19 situation.

We need a solution and a way forward. The answer should be scientific, practical, incorporating the existing strengths and correcting the weakness and based on the past experiences of success and failures.

The biggest strength of the state is its very efficient healthcare system. We have a uniformly distributed network of good quality Government and private hospitals developed over the last several decades. A dedicated workforce and an educated public are added components complementing the strength of the excellent hospital network. The system can absorb the impact of a large number of COVID-19 cases.

This strong network has compensated for the large number of COVID-19 cases that ensued due to the unsustainable COVID-19 control strategy. The lower Case Fatality Rate (CFR) results from this pre-existing strength and is unlikely to be significantly contributed by any specific COVID-19 control strategy by the state.

Though the CFR is low, the high case count creates a steady increase in the overall COVID-19-related death tally and the mortality per million population. The state should continue the excellent quality care in the Government and private COVID-19 hospitals. Additional financial and workforce support to these hospitals will maintain the low case fatality and overall death rates.

Opening up the economy

Now, let us analyse how we can open up the economy to alleviate the impact of the prolonged second wave. We need to open up the economy fast, without repeating the error that happened during the Bakri Id and attracting another reprimand from the Supreme Court. So, the strategy that we devise must be scientific and practical.

First, the state must stop listening to the so-called external experts. They keep on singing praises on the COVID-19 control measures of the state and attempting to justify the situation with complex mathematical calculations that the ordinary public has no understanding or interest in. The so-called expert mathematical modellers and statisticians sitting in their posh offices do not understand the socio-economic structure of the state. Many of these experts have a solid connection to organisations with conflicts of interest in the state’s health policy. Justifying the COVID-19 situation is a way of getting into the good books of the state. The state then will be forced to return the favour to the organisations these experts are affiliated to. These organisations will then try to influence the state’s health policy.

The state must listen to the people on the ground. They are the beneficiaries of the good policies and scapegoats of the flawed strategies. The so-called experts, including myself, receive the monthly salary irrespective of whether the economy is open or locked down. It is the ordinary people who suffer.

Exempt vaccinated and antibody-positive individuals from lockdown restrictions

The vaccinated individuals do receive significant protection from infection and severe disease than the unvaccinated. Those individuals who had clinical or sub-clinical infection, develop an antibody against the virus. The antibody level remains detectable for a significant period. Most COVID-19 recovered individuals remain antibody positive for eight months or more after the infection. The level of immunity provided by natural infection is not very dissimilar from the immunity received by vaccination.

A recent ICMR sero survey reported that 67 per cent of Indians are antibody positive. The seropositivity rate in Kerala was 44 per cent. If we combine the vaccinated and the antibody-positive individuals, at least 50 per cent of the Kerala population will be seropositive.

With the support of ICMR, we should identify reliable antibody testing kits and authorise the laboratories in the state to perform the testing. We should enforce the lowest possible uniform fee structure for such an antibody test report. The public can pay for the antibody testing. We can assign six months’ validity to a positive antibody test report. Individuals carrying a positive antibody report should repeat the test after six months unless they receive two doses of vaccine interim. We should exempt the antibody-positive individuals, or the vaccinated from COVID-19 lockdown measures. These individuals can run business establishments even in areas with high test positivity rates.

It is perfectly acceptable to allow such customers to visit malls and markets. They can utilise public transport in all regions. At least half of the members in every household or establishment will be antibody positive.

Those individuals who are neither vaccinated nor antibody positive and wish to be exempted from the lockdown restriction can be asked to carry out antigen or PCR testing every two weeks or even weekly. The antigen/PCR testing should be at the expense of the Government. The law enforcement agencies and volunteers can ensure compliance with the implementation of the strategy. The strategy will help the business establishments to remain functioning on all days full time. No court of law will criticise this science-based strategy.

Fast track vaccination

The Centre should provide a preferential supply of the vaccine to Kerala state. The high number of COVID-19 cases is dangerous not only to the state, but also to the whole country. The increased community transmission will help the virus develop hazardous variants. Unless we bring down the number of COVID-19 cases fast, the variants that emerge from the state can spread across the country. So, a preferential vaccination strategy is in the best interest of the state and the nation.

The State Government must try to convince the Central Government of the criticality of the situation and make a request for the preferential supply. The Centre should not show any inhibition in honouring the request. The leaders of all political parties should stand together on this issue. Let the state and Centre work in a harmonious way in controlling the COVID-19 situation in the state.

Let us forget our political differences and academic egos. Let us think about our people. Let us save lives and livelihood.

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