23 deaths out of a population of 35 million. How did they do it?
Kerala, in India’s south-west, has achieved what other countries could only dream of. Its Health Policy is simple yet powerful.
Not only do rates of infant mortality keep improving, but life expectancy also keeps getting better. Now, with such success with Covid-19, the world surely must ask: “What are they doing right?” The Kerala Health Policy has been described as respectful, sustainable and harmonious. These are huge adjectives for any public healthcare system.
Quite simply, the government encouraged people’s participation, respectfully listened to what their population asked of them and then acted upon it. It goes without saying, in the midst of this Coronavirus Pandemic, that only 23 deaths is just gobsmacking. (When this blog was first written there were 14, then 19 and now 23 deaths as of 30th June, which I will repeat is still quite incredible.)
The statistics speak of success, even though Kerala faces the challenges of:
- High unemployment rates
- 35 million people in a geographically small state
- High proportion of the elderly
- Recent financial constraints due to two major floods and Nipah virus outbreaks in 2018 and 2019.
How they did it
The government’s robust response in the pandemic included many not-so-small efforts designed to support and care for its people:
- Each district was asked to dedicate two hospitals to Coronavirus patients, while each medical college set aside 500 beds. Separate entrances and exits were designated
- Thousands of shelters for stranded migrant workers were built
- Accredited Social Health Activists went house to house checking on people and delivered staples
- Distributed millions of cooked meals to those in need
- Encouraged the use of homeopathy by distributing millions of preventative medicines
- Provided logistical support to quarantined people to access food and supplies
- Offered counselling
- Negotiated with Internet Service Providers to give better internet data packages for those in isolation.
The state has won praise for its handling of a pandemic that has overwhelmed other health systems in resource-rich countries like Europe and the USA which have suffered high mortality rates.
Last edited 30/6/2020. The information in the table below is from news.google.com
Covid statistics in the state of Kerala (India) compared to USA, UK and India
| State or country | Population | Confirmed Cases | Recovered Cases | Deaths |
|---|---|---|---|---|
| Kerala | 35 million | 4,310 | 1,046 | 23 |
| UK | 66 million | 311,965 | N/A | 43,575 |
| USA | 328 million | 2,638,086 | 811,095 | 128,103 |
| India | 1.38 billion | 548,318 | 321,722 | 16,475 |
What changes have been made by government of Kerala to improve healthcare facilities and achieve what many developing countries could only dream of:
- Success with sanitation and drinking water provision
- Kerala has the highest life expectancy in India of 72.5 years and 77.8 years for males and females respectively, due to general improvement in health care facilities
- Kerala has the lowest infant mortality in India
- In 1991, Kerala became the first totally literate state in India
- Everyone is assured access to health care. A primary health care facility in every panchayat (an aggregation of villages), above 1000 in number. Most of them have government run facilities of modern medicine, homeopathy and Ayurveda. People can choose any system of medicine for their treatment. Out of 941 panchayats only 32 don’t have homeopathy at the moment
- Accredited Social Health Activists
- Rapid Action Epidemic Control Cell, Homoeopathy (RAECH) since 2004
- 34 homeopathy hospitals in Kerala alone.
Some pandemic questions remain unanswered
Perhaps we can look at how Germany and South Korea tested widely to try to identify cases, compared to some countries such as India which offered testing (at least early on) to only people who had travelled or had close contact with a known case. But, this doesn’t help explain differences in mortality of coronavirus cases in different countries.
It has also been suggested that because Asian and African populations have been exposed to many coronaviruses previously, it may have given them some cross-immunity. There are many questions but the facts remain and from them Kerala get the thumbs up.
The importance of people’s participation and community in health care
The success of the present system started in 1996 when the People’s Plan Campaign for decentralised governance was adopted. In a democratic way, the system relies on people’s participation in planning and decision-making regarding local development. Working groups on health bring together community members, health workers and experts in a forum to plan projects together. These bodies of local self-government exist alongside the state government. This arrangement has been decades in the making, beginning with social justice movements which prioritised the welfare of the ‘Malayali’ over narrow caste and communal identities.
Kerala’s health policy design has long been informed by listening and learning from people’s experience of healthcare, rather than treating people as passive ‘targets’ of interventions. The government relies on a combination of transparent communication, people’s participation and empathy. This has measured up to the challenges posed by health emergencies such as the nipah virus and the coronavirus pandemic.
Kerala learned a lot from the Nipah outbreak
Nipah virus outbreaks in Kerala showed everyone that transparency is an essential part of communication with the public. Regular information was unflinchingly given out about the number of people under observation, numbers tested and deaths. This was no small thing because whilst Nipah virus infection may be asymptomatic in humans it also may cause a fatal encephalitis and has been described as “sort of like a new-age plague.” Nipah has no known vaccine or cure.
How do you communicate this to your population and stir them into taking the necessary precautions at the same time as not wanting to scare them senseless. So the Kerala Government decided on the path of giving accurate information in the press. This is remembering that they have total levels of literacy and that there is state wide pride in reading the newspapers daily. Mainstream media was co-opted and in another plus for Kerala, journalists literally try hard to ensure as much as possible that sensationalism is avoided and instead the emphasis is on accurate health education.
Health activism in India
In Kerala, health care is easily accessible at the grassroots level in the form of Accredited Social Health Activists (ASHAs) who help people with minor ailments. The ASHA’s are local women who are chosen by the community. They work in their own village to help improve the health of their community and help increase access healthcare services.
Agi Mary Joseph is a Brisbane homeopath, who grew up in Kerala. She has seen first hand the impact the ASHA’s have on local people, especially marginalised people. She says “The ASHA’s are kind of like a volunteer but they do get paid. At present they are getting a minimum of RS 5000 a month. In rural areas there is one ASHA for every 1,000 people. They co-ordinate government health and social welfare programmes.” What is the ASHA worker training? Agi Mary says “They are given training in modules, according to community needs. One ASHA I know has done 8 different modules so far – things like prenatal and postnatal care, communicable diseases etc. They look after pregnant women and babies and do home visits, in a very I’m-here-with-you way. People really like them, they are well accepted. During the pandemic they have been going from house to house checking on people and delivering staples. At the beginning of the lockdown everyone, rich or poor, all got a kit of food. 15kgs of rice; tea; coffee; lentils; kerosene; hand sanitisers. This was initiated by the state government.”
Kerala’s current health minister Shailaja the ‘Rockstar’
There have been articles saying that the Hon. Minister Shailaja Teacher who is the Minister of Health and Social Welfare of Kerala is the reason why they have such good statistics when it comes to the pandemic. She has even been called Coronavirus Slayer and Rockstar Health Minister. Perhaps she actually does deserve the accolades because the truth is Kerala came through two Nipah virus epidemics under her watch. This highly contagious disease for which there is no treatment, was a true preparation for managing Covid-19.
When asked about the Kerala Health Minister, Agi Mary Joseph said “Shailaja is really understanding. Everyone can see that she gets the job done and efficiently.”
Shailaja came from a lineage of freedom fighters with a background as a Communist and she was encouraged to study a Bachelor of Science and a Bachelor of Education. Her grandmother was a campaigner about untouchability. So as a child Shailaja grew up surrounded by activism when the ‘Kerala model’ was being designed. The foundations of this health activism in India were built from the start to include a decentralised public health system and investment in public education. So the Kerala model was ready to respond to Coronavirus.
Hon. Minister Shailaja Teacher, is the Minister of Health and Social Welfare in Kerala.
Shailaja included the use of homeopathy in Kerala’s plan
Tactics used by Shailaja included encouraging the use of homeopathy. In a recent media meeting, she talked about the need “to improve the immunity and resistance power of each individual not yet positive to Coronavirus, with the help of Homeopathic/ Ayurvedic medicines. That will help them resist the Coronavirus infection, help them to tide over the infection well, if at all they contract it…… everyone should take Homeopathic & Ayurvedic preventative treatments available.” [thank you to Dr Sam Punnoose for this translation of a video of the press conference.]
According to Dr E.S.Rajendran who practices in Kerala “The total number of people who received the homeopathic preventive medicine Ars alb 30 through Kerala government as on June 1st was 10 million. An equal number of people have also received the same through voluntary organisations. The remaining population is expected to receive the preventive medicine in another one month.” This distribution was carried out in each district with the help of resident associations and was achievable because there is a huge demand for homeopathy from the people.
Rapid Action Epidemic Control Cell – Homeopathy
The Government of Kerala started the Rapid Action Epidemic Control Cell Homoeopathy (RAECH) in 2004. RAECH supervised recent epidemic control measures using homeopathy:
- Distributed preventive medicines
- Conducted medical camps
- Designed health awareness programmes
- Conducted seminars throughout Kerala, wherever epidemics break out.
One of the Kerala Government floating homoeopathy dispensaries – the most efficient way to access villagers living in the mangroves. 2018. Dr Isaac Golden (left), Dr Muhammed Rafeeque (middle) and Dr. Leena (right).
For the past five years they were successful in ‘contributing a remarkable role in prevention activities.’ According to RAECH, the efficacy of Homoeopathic prophylaxis medicine in prevention of epidemics was well established during an epidemic of Chikungunea.
The people and the government of Kerala has appreciated the work of RAECH in prevention of Cholera, Gastroenteritis, Japanese encephalitis, Dengue, and Chikungunea.
Respectful, sustainable and harmonious
To summarise, Kerala health care deserves the praise it gets. It has achieved a lot through decentralised governance and people’s participation in community development as well as the use of homeopathy as prevention. As with any state in India there are remaining challenges and progress continues towards making health care affordable, accessible, respectful, sustainable, harmonious and responsive, especially in epidemics.
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