“Two people have died. Please come and pack the bodies,” a nurse tells the cleaning staff who are on a break. Within a few minutes, cleaning assistants Asokan M. and Dileep Kumar and a few others begin to prepare the bodies. It is August 3 and two elderly men have succumbed to COVID-19 at the Government Medical College Hospital in Manjeri. The relatives of the dead request the staff to dress the bodies in new clothes one last time. The hospital staff, witness to four-five deaths every day on average since April, are used to the routine. They clean the bodies and pack them in specially designated body bags.
The Manjeri Medical College is the biggest referral hospital for COVID-19 in Malappuram, the most densely populated district in Kerala (1,265 persons per square kilometre). It has 344 beds dedicated to COVID-19 cases and 203 beds dedicated to non-COVID-19 cases. The second wave may be on the wane in most places in India, but here things are hectic . The hospital staff are under great pressure. No one here contests the fact that the Medical College Hospital, which admits only C-category patients (those whose recovery is impossible without proper medical intervention), is not adequately equipped to treat the many patients coming from a district of 48 lakh people. Malappuram is currently the worst-hit district in the State, reporting the maximum number of daily new cases (3,645 new cases on August 5). While many are wondering why Kerala, which seemed to have a grip of the pandemic at one point, seems to be floundering now, Malappuram is often cited as a case in point.
Chinks in Kerala’s armour
Until a while ago, Kerala seemed like it had an exceptional pandemic story to narrate to the world, but today, the chinks in its armour are beginning to show. The State has seen a steady rise in cases since the second week of July. Over the past eight days, Kerala has recorded 20,000-22,000 new cases daily. Between July 29 and August 4, it recorded nearly 1.45 lakh new cases and 754 deaths and accounted for 43% of the nation’s active case pool.
Following the first wave, Kerala’s epidemic curve plateaued out but never hit the baseline as rallies were held before the Assembly elections and people gathered in large numbers everywhere. In January-February this year, it reported 1,500-3,000 cases daily, accounting for 45%-50% of India’s active case load.
Then the Delta variant struck. By the second week of April, when the second wave was ferociously sweeping across the nation, cases began to go up in Kerala . By mid-May, the State was in the grip of a crisis , reporting over 42,000-44,000 cases daily. When a total 15-day lockdown was imposed, the case graph again hit a plateau and 10,000-15,000 new cases were reported daily. This, however, was in stark contrast to other States where new cases and hospitalisations began to slide rapidly.
Public health experts in the State say that the second wave began a month later in Kerala than the rest of the country. Kerala’s strategy, they say, has been to spread out the curve, keep a tight hold on disease transmission, and restrict activities, so that the virus doesn’t go on a rampage and overwhelm the health system. The strategy worked well because even at the peak of the second wave, intensive care unit (ICU) occupancy in the State was just 67%.
However, Kerala is now being forced to take a re-look at its containment strategies and the socio-economic aspects of the pandemic, which are threatening to overshadow its successes. It is also being compelled to re-examine the quality of care delivered. While it encouraged home care and isolation for patients who had mild COVID-19, it is doubtful whether the health workers were properly trained to diligently follow up with the patients because the ill began to reach hospitals at a later stage of the disease — after hypoxia had set in — and many could not be saved.
High pressure, few precautions
One COVID-19 patient reached the Manjeri Medical College every 10-15 minutes on August 2. Most of them were in the age group of 50-70 years. All of them had been referred to the Medical College by other COVID-19 hospitals in the district through the COVID-19 war room. Although there are 5,093 beds earmarked for COVID-19 treatment across the district in seven government hospitals, 69 private hospitals, 12 second line treatment centres, and 10 first line treatment centres, the 547 beds at Manjeri Medical College remain crucial in the fight against COVID-19.
“The signs are ominous, yet people are oblivious to the dangers of COVID-19,” says Hari Prasad, an ambulance driver who has brought an 85-year-old woman from the Government Taluk Hospital, Tirurangadi, 30 km away from Manjeri. Two volunteers of a community youth organisation come forward to help the woman get on a stretcher. As the stretcher is taken, she gasps for breath in spite of having an oxygen mask on her face. The volunteers wear no protective gear other than two masks. Many people walk busily through the hospital veranda taking little precaution against COVID-19. Two casualty wards — one for COVID-19 patients and the other for non-COVID-19 patients — function side by side. Security guards on duty seem to be able to do little to restrict the movement of patients and those accompanying them. One security guard looks worried. Five of his co-workers have been infected; they all contracted the virus on the same day. Of the 43 security staff, 10 have been isolated after testing positive for COVID-19.
Doctors in the casualty wards face tremendous pressure as patients, mostly from the lower middle class, stream in. “We have 56 doctors at the hospital apart from doctors from the medical college. The delay in the arrival of the house surgeons of the 2016 MBBS batch has begun to affect us,” says Sheena Lal, Deputy Superintendent. Lal is in charge of the hospital as Superintendent K.V. Nandakumar is in quarantine after testing positive along with the resident medical officer. Lal is, however, confident that the pressure on doctors handling the casualty and COVID-19 wards and ICUs will ease with the arrival of the house surgeons in a couple of weeks.
The high patient load compels junior resident doctor Mohammed Shareef to take the risk of alternating between the two casualty wards. He admits that the pressure is so high that precautions often go for a toss in the COVID-19 zone. Shareef says the hospital is facing space constraints and staff shortage. But the hospital has more than tripled the number of ventilators and vastly enhanced its oxygen capacity since it reported its first COVID-19 case on March 16, 2020. The number of non-invasive ventilators (NIVs) has gone up from 21 to 73, including 10 portable and four neonatal ventilators. There is centralised oxygen supply in all the wards following the setting up of a liquid oxygen plant. An oxygen generator is also ready at the hospital. “This was done in recent months,” says Lal. Signs of a third wave are clear and present, she says.
A poorly performing district
Malappuram breathed easy during the first wave of the pandemic as many patients did not require NIV support. But during the second wave, it fell miserably short of NIVs. Manjeri Medical College witnessed 15 deaths on a single day, May 27, during the peak of the second wave. Nearly 10 were on account of oxygen failure. This happened despite Chief Minister Pinarayi Vijayan’s assurance that Kerala had adequate oxygen supply. The government joined hands with philanthropists and enhanced the facilities. Although the hospitals in the district have 162 ventilators today, several of them are not working.
According to the Kerala Government Medical Officers’ Association (KGMOA), the district lacks sufficient health staff and infrastructure. Population-wise, Malappuram is five times the size of Wayanad and four times the size of Pathanamthitta. When the State has an average of one hospital bed for 879 people, the bed ratio in Malappuram is 1:1,643. Malappuram’s lone Government Medical College with 547 beds is spread across 23 acres, while the Government Medical College in Alappuzha, a district with only half of Malappuram’s population, is spread across 145 acres and has more than 1,100 beds. A KGMOA study before the COVID-19 outbreak found that Malappuram was responsible for one-fifth of the State’s infant mortality and one-fourth of maternal mortality. Government hospital facility for delivery is available only for 16.64% of pregnant women in Malappuram. Prior to COVID-19, the district had stood behind others in immunisation and topped in dengue deaths, lifestyle diseases and road accidents.
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The strain posed on the health staff in Malappuram district is much higher than what their counterparts in other districts face. If a junior public health nurse serves 5,000 people in other parts of Kerala, she serves 15,000 people in Malappuram. If there is a public health centre (PHC) for every 39,000 people elsewhere in the State, in Malappuram there is one PHC for every 53,500 people. If there is a community health centre for every 1.4 lakh people elsewhere in Kerala, in Malappuram there is one for every 2.4 lakh people.
Because the General Hospital was upgraded to a Medical College eight years ago, Malappuram lost super-specialty wings such as cardiology, nephrology, urology, and neurology. It also lost the General Hospital and the Woman and Children Hospital.
A week ago, a Central team led by P. Raveendran from the Ministry of Health and Family Welfare visited the district. Blaming the district officials for the shortcomings, Raveendran’s team suggested tighter measures for Malappuram to address the pandemic. District Medical Officer Sakeena K. says that despite the constraints, they were able to restrict COVID-19 deaths to well below 1%. The number of COVID-19 deaths reported in Malappuram is 1,638. “This number against a population of 48 lakh is only 0.03%. In fact, that tells us how hard the medical team in the district fought COVID-19,” Sakeena says.
Measures taken by Sakeena and her team, such as traveller surveillance, contact tracing, telemedicine facilities, the triage system at the block level, and prevention of cluster formations won the State’s approval in the initial phase of the pandemic. Now the team is setting up 326 additional oxygen beds at seven government hospitals in the district and strengthening the paediatric wards in anticipation of a third wave.
Vaccination on the rise
In spite of the initial reluctance of the people towards COVID-19 vaccines, the district is now witnessing a heavy rush for inoculation. According to health officials, it was the second wave that changed the people’s mindset towards vaccines. While 39% of the population have taken at least one dose of a vaccine, 16% have been given two doses.
However, the district with 106 civic bodies, including 12 municipalities, finds it tough to plan any massive vaccination campaign because the vaccines allocated for Malappuram are distributed through 116 health centres.
Health staff attend to a patient in a COVID-19 ICU ward at Manjeri.
The State seems to be doing very well on the vaccination front with 42.81% having received the first dose and 17.86% both the doses. In the 45-plus age group, 83% have been administered the first dose while 43% have received both the doses. The current predicament of rising cases in the State should be weighed against the unique situation created by the circulation of the Delta variant, which has been leading to re-infections as well as breakthrough infections in fully vaccinated individuals, says a public health professional. “It is high time the State paid attention to the disaggregated data of new infections because the proportion of re-infections and breakthrough infections among new cases will help the State identify pockets where active transmission is on. The false sense of security among vaccinated individuals might keep the Delta transmission chains alive for a long time as it is now established (by the Centers for Disease Control and Prevention) that vaccinated persons have viral loads similar to that of unvaccinated persons, which helps them transmit the infection easily,” a senior public health professional says.
The State has the lowest seroprevalence rate in India. According to the Indian Council of Medical Research’s fourth round of seroprevalence study in June, only about 44% of the State’s 3.5 crore population had developed antibodies to the virus. Since mid-May, the Delta virus variant has been driving up cases, causing a prolonged epidemic.
People’s behaviour in Malappuram has always been a subject of criticism. When shops opened, crowds thronged the stores. Marriages took place and the police turned a blind eye to the numbers attending the wedding celebrations. Traffic jams were common in several of Malappuram’s towns during the lockdown. “Usually it takes 38 minutes for us to cover 46 km to reach Kozhikode Medical College from Manjeri Medical College. But there were days when it took nearly one and half hours on emergency trips during the lockdown,” says Pavin A.R., an ambulance driver.
Rakhal Gaitonde, public health expert and Professor, Sree Chitra Tirunal Institute for Medical Sciences and Technology, says, “It is ironic that while the government was clamping down on public life and movement, the business community and markets as part of its containment measures, congregations and celebrations were going on uninterrupted in private spaces, potentially sustaining disease transmission.”
Pandemic fatigue
But while this is just disease epidemiology that one cannot alter, a team from the National Centre for Disease Control has come down heavily on the State for its failure to implement home isolation and care effectively, for poor and inadequate contact tracing and containment measures, and for a low proportion of RT-PCR tests, which it says have led to the current surge in infections. Kerala’s testing levels have been consistent throughout the pandemic. Tests were increased when the second wave hit — an average of 1.5 lakh tests were done daily — but a large proportion of them were Rapid Antigen Tests. While officials refused to comment on this, health officials admit that the diligence and thoroughness with which the State used to do contact tracing, isolation and follow-up is no longer possible. The same goes for home care and follow-up too, which has been faltering. With patients coming to hospital at a later stage of the disease, mortality is going up.
“Earlier, health workers were supported by the local bodies, volunteer groups, police and teachers. One and a half years later, we are on our own. We are acutely short-staffed, overworked and tired. The same group is being roped in for all COVID-19-related activities: from testing to vaccination, apart from mmunisation and vector control,” a field worker says.
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“Pandemic fatigue has affected everyone and communities and health workers need more support and incentives from the government. Districts need to be supported with strategies that have a more local context,” says Gaitonde. Mortality reduction is another area where public health experts feel that the State can do more. There were wide fluctuations in the mortality rate, from 0.2% to 1.2%, between April and July, 2021, and also between districts.
Health Minister Veena George said in the Assembly this week that disease severity seemed to have reduced due to rising vaccination numbers. Even when cases were rising, hospitalisation and ICU occupancy seemed to remain stable, she said. The re-infection rate has come down but breakthrough infections are now being reported, she said.
On Thursday, the government announced in the Assembly that it was replacing its Test Positivity Rate (TPR)-based containment strategy, which it had been following for the past six weeks, with a micro-containment strategy wherein only specific localities – wards in rural areas and streets in urban areas – will be under lockdown, depending on the number of new infections in a locality. The TPR-based strategy had been widely criticised as unscientific and counter-productive because TPR can be easily manipulated. TPR is the proportion of positive cases from the total tests done and therefore, large-scale testing amongst people who are unlikely to be infected can artificially bring down the TPR. But the government had refused to listen to the criticism.
With the lockdown affecting the livelihood and freedom of people, it became important for the local bodies to reduce the TPR so they could maintain their political image and local popularity. A high TPR and a lockdown was projected as being a measure of their inefficiency. Thus, all local bodies were competing with each other to reduce the TPR somehow by herding in everyone to test, rather than testing appropriate groups. This had seriously affected actual disease containment.
Clearly, Kerala is facing its toughest challenge yet. If, till now, it was a struggle to save lives, a rising case graph and pandemic fatigue is forcing the government to gear up to the bigger challenge of striking a balance between saving lives and protecting livelihoods.
