by Kandathil Sebastian — April 19, 2020

It seems Kerala state in India has successfully controlled the spread of COVID 19 virus in its geographical limits. Global community is now wondering whether this success model can be replicated in other parts of the planet.  This article examines whether there is any such possibility through a socio-epidemiological lens.

Kerala Model – Version 1

Historical moorings of Kerala model can be traced back to a UN study titled ‘Poverty, Unemployment and Development Policy (1975)’ though the term ‘Kerala Model’ was first used by Malcolm Adiseshiah in the book, ‘Kerala Economy Since Independence (1979)’.

‘Kerala model’ gained popularity in 1990s when Robin Jeffrey wrote his book ‘Politics, Women and Well-being (1992)’ in which he discussed how Kerala state which was earlier considered a ‘problem state’ in 1950s became a model in social development by gaining India’s lowest infant mortality, longest life expectancy and highest female literacy. Later, many articles by Amartya Sen and Jean Derez stated that Kerala State has attained high social development at a relatively low level of income by comparison to the rest of India.

However, a Kerala model which could not offer enough jobs to the state’s youth, welfare services financed by excessive borrowing, it’s still unfinished agenda of gender justice, marginalisation of tribal communities, unregulated land use in the state that led to excessive quarrying, environmental catastrophes and disappearance of food crops from the state’s farm lands was later criticised as an unsustainable model by many thinkers.

Despite these problems, Kerala’s achievements in the social sector, especially on literacy and education, health care, communication and demographic indicators have been widely appreciated. Can this model be easily replicated in other states too?

The answer probably is ‘No’! Roots of Kerala’s social development has already been well documented by numerous researches which inter alia include social interventions by progressive Maharajas and Missionaries, socio-political movements led by Marxists and other political parties, reform movements of both backward and upper castes and so on. These complex historical and social processes took place across a span of several decades and a replication elsewhere within a short duration is perhaps impossible.

Kerala Model – Version 2

When experts stopped calling Kerala a model for social or economic development, the state got global appreciation and recognition for its effective handling of the Corona pandemic. Kerala’s less disruptive, less costly, and more effective model of Corona virus control have following key elements.

• Presence of a robust Public Health System
• A popular campaign on ‘breaking the virus chain’ and non-stigmatisation
• Implementing strict home quarantine rules
• Ensuring uninterrupted supplies including food
• Aggressive testing, early detection, contact tracing
• Preparedness for a potential second wave

Robust Public Health System

The most important ingredient of Kerala model is the existence of a state-wide available, accessible and affordable public health system. This is not something Kerala has created after the arrival of Corona virus. Despite having a well developed Ayurvedic system in the state, in 19^th century, the rulers of the ‘state’ brought in modern western medicine.

In 1879, through a royal proclamation, vaccination was made compulsory for public servants, prisoners and students. Hospitals for curative care were in existence around this period in major cities. In 1928, there were epidemiological surveys to control parasitic infections (hookworm, filariasis etc.). Town improve committees set us during the British period had responsibilities to ensure public health, sanitation and distribution of safe drinking water.

Christian missionaries immensely contributed to educating women, lower castes and marginalised communities in the villages and towns. Educated girls were encouraged to become nursing professionals. Nursing started as a service to patients eventually got professionalised, though the service orientation of Nursing staff from Kerala continue to get applauses across the world.

In Independent India, successive Kerala governments made priority investments in expansion of health and education services not only in the public sector but also in the private sector. Government has set up extensive facilities for training health care professionals and ensured high standards of medical education in the state.

Campaign on ‘Breaking the Chain’ and non-stigmatisation

Kerala has a history of large social movements and popular campaigns. The temple entry movement of Dalits and movement of lower caste women to dress appropriately are examples of some successful early movements in the state. Campaigns of later years, for example, People’s Science Movement (led by Kerala Shastra Sahithya Parishad), Library Movement, Literacy Movement etc. were led by ordinary people of the state (with little or limited involvement by the government).  These campaigns were attended and led by people from all caste groups as these had messages of liberty and equality.

All these campaigns helped the people of the State to develop a scientific temper and spirit of enquiry and learning. Widely quoted words of state’s health minister are: “Fighting an epidemic like corona requires scientific temper, humanism and a spirit for inquiry and reform. We strictly follow scientists and experts”.

Through music and media, the state has communicated effectively in different languages to educate the entire population, including migrants, and prevented stigmatization of those infected. The campaigns organised by government are the most inclusive as it invited all key stakeholders, local bodies and civil society organizations to participate in campaign design and implementation.

These campaigns provided essential epidemiological information to understand the threat and related issues, ensure compliance with prescribed precautionary measures, and avoid panic. Many individuals, groups and communities aggressively campaigned on steps to be followed to break the chain of virus spreading like the people of the state did in earlier campaigns too.

Following Strict Quarantine Rules

Most viruses and bacteria are crowd dependent for survival. Kerala, though the most densely populated state in India has a housing pattern which is scattered and spread across the state. Upper and middle classes stay in farmhouse like settings. This has helped the middle class of the state to maintain social distancing.

In fact, state has a controversial and notorious history of prescribing strict distances to be maintained by polluting castes when they approached non-polluting upper castes.  Memories of this bitter past has come up during this campaign too, but public intellectuals in the state were quick to call this rule as ‘physical distancing’ and not ‘social distancing’.

Washing hands, face and feet whenever you come home from outside is a rule generally followed by the Kerala households for centuries. Most houses in the state even today keep water in a long-knobbed vessel called KINDI at the entrance for hand and feet washing to ritually follow this tradition. Hygiene and handwashing are ingrained in people’s tradition.

Kerala is also the destination for many Indian internal migrants. There were problems with the migrant labourers in maintaining physical distancing. Unlike other states, Government of Kerala which considers these migrant workers as ‘guest workers’ (unlike many other states who consider migrant workers as parasites and burdens) has provided many welfare services to them, even before the arrival of Corona. The state has successfully slowed the spread of infection in the state by promoting physical distancing, sanitary precautionary measures, and by providing better protection for health care staff, by learning lessons from its earlier implementation of NIPAH prevention activities.

Ensuring Uninterrupted Supplies

Adequate supply of essential commodities, particularly food and medicines, has been ensured, especially to protect the most vulnerable sections of the state. Effective and functional food distribution through Public Distribution System is something which only few states like Kerala can boast about. Immunity boosting through food supply was ensured throughout the state. In many cases, people were provided with their rations at their doorsteps using police and official volunteers. The quarantined migrant workers were provided supplies of their local food, maintained the stress levels low by providing TV based entertainment in their own languages at their quarantined premises and made public announcements in relevant vernaculars to keep them informed about strict quarantine measures. “No one will go to bed hungry in the state” was a promise repeatedly made and delivered by the Chief Minister of the state.

Aggressive Testing, Early Detection, and Contact Tracing

The state has previous experience in effectively dealing with a similar virus called NiV. In May 2018, a Nipah virus disease outbreak was reported from Kozhikode and Malappuram districts in Kerala. This outbreak was successfully managed by the state government and has been acknowledged as a success story. Coordination structure and mechanisms that were instituted by the state and performance of surveillance and interventions including non-technical support functions during the NiV outbreak were rated as the best by agencies like WHO through assessment of reduction of transmission. The outbreak of NiV demonstrated the importance of preparedness for similar events in the future. Based on lessons learned from the NIPAH management, the state health department promptly went into action, setting up a coordination centre on 26 January 2020. Recognizing there was no time to be lost, the Kerala state government set up mechanisms to identify, test, isolate and treat those infected, quickly.

Preparedness for a Potential Second Wave

Keralites are one of the most migrating communities in the world. They are present in all the high prevalent states in the world. The state understands that it is not yet time to become complacent. Accordingly, the state has already drafted plans to deal with a likely second wave of epidemic, when the migrant Keralites return after the lockdown period.

Can the Kerala Model be Replicated?

As explained above, the Kerala models of social development as well as epidemic control are products of various historical and social processes and has evolved over a period. Trying to implant the model to other states may not work always.

Model making is often a fallacy as models are made with simplifications and assumptions from observations that discount many nuances a model maker could not consider in the modelling process. This is especially true of models based on social and human behaviours which lack historical and social contexts of observed realities. I will go with George Box who said in 1970s: ‘all models are wrong, but some are useful’.

Kerala model of Corona control cannot be replicated ‘as it is’ to other states. Kerala has a health services system it created through decades of investment and hard work by visionaries, which cannot be replicated elsewhere. Its health systems and processes have been evolved based on complex multiple processes in the geographical, social and political context of the state. But the Kerala model offers very valuable lessons for epidemic control and management across the world. Kerala is indeed a ‘model’ to be studied by not only public health historians but also by social and political thinkers of the future.

(Kandathil Sebastian is Social Scientist, Novelist and Researcher based in Delhi. He has been part of many Public Health programs implemented by INGOs in South Asia.)