Amala Poli // The state of Kerala in India, recognized in 2018 for effectively containing the deadly Nipah virus outbreak, has reported four deaths since the outbreak of the COVID-19, despite a population of 35 million people. Being the state with India’s first reported COVID-positive patient, instead of being the hardest-hit region, Kerala holds the unique position of having one of the best strategic healthcare models in the pandemic across the world. What can other state governments in the country and the rest of the world learn from Kerala’s approach? A combination of testing, contact tracing, and foresight about the impending outbreak are some of the factors that have allowed the exemplary management of the pandemic in a state with a per capita GDP between 2600 and 2900 US dollars.
In Kerala’s decentralized structure of governance, local institutions are empowered to manage health care; this self-governance has led to a closer and more effective engagement of the state’s health infrastructure in recognizing various needs of communities as well as implementation of necessary changes.  The empowerment of local self-governments to engage closely with the community and the state government bridged the gap in governance and helped Kerala prepare for the health emergency of the COVID-19 pandemic.
KK Shailaja, health minister of the state of Kerala, having successfully handled the deadly Nipah virus outbreak, found that being well-prepared when China reported its first case helped in controlling the initial numbers and preventing community spread. Three cases in three different districts were detected and isolated early on. Having been affected with massive floods in the year 2018, suffering losses close to 5.6 billion US dollars and with little support from the Central government, Kerala could hardly have been expected to be fiscally prepared to invest in healthcare. However, the move toward prioritizing the provision of affordable and accessible healthcare to all, approved by the State cabinet in 2019, sought to realize health as a fundamental human right in the state. Community participation and clear risk communication through Chief Minister Pinarayi Vijayan’s daily press conferences in the earlier months have also been significant factors in the state’s solidarity against the virus.
Walk-in kiosks, modeled after South Korea’s, helped in reducing the need for personal protective equipment and significantly reduced costs as well. Early testing (with merely a 48-hour wait period before results) and strong community participation led to isolating and contact tracing for patients who did test positive. Front line workers continue to tirelessly follow protocols for contact tracing through social-distanced physical visits to quarantined households. They also make phone calls to keep databases constantly updated.  Providing rations to people in need in the form of rice and other staple foods, with three free meals a day for stranded migrant workers,  the state begs the question of why more resources are not available for below poverty line citizens and migrant laborers in the rest of the country.
One of the struggles faced by residents in Kerala with the state-wide ban on non-essential services is the lack of access to liquor, affecting alcohol “dependent” members severely through withdrawal. Six suicides were reported as of April 1, 2020. Recognizing the seriousness of the problem and the rights of users, the state government issued an order that would allow people suffering from alcohol withdrawal symptoms to approach doctors for “passes” that would let them procure rationed quantities of alcohol. The rights of habitual alcohol users and refusal of doctors to “prescribe” alcohol through passes raises ethical concerns. 
Kerala will face new challenges in the immediate future as the state slowly lets up some of the restrictions on Lockdown 4.0. An exponential rise in cases is seen at present, the highest being 42 on May 22, 2020. The numbers are set to rise further as the surge period continues across India. However, authorities appear confident about managing the virus at this stage, since travel is being closely monitored through testing and contact tracing.
As healthcare workers at the front line continue to labor tirelessly across the globe, a study of the best responses to the pandemic and brainstorming the adaptability of those policies might be essential steps for regions struggling to flatten the curve. There is much to be learnt, for instance, from Vietnam where there are zero deaths despite a shared border with China, or South Korea’s expansive testing program, to cite a few. Kerala’s specific combination of a land area of 38,863 km² with a population of 35 million and its successful efforts to control community spread, however, invites due scrutiny, interest, and approbation.
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