Science's COVID-19 reporting is supported by the Pulitzer Center and the Heising-Simons Foundation.
When the World Health Organization (WHO) issued its first statement on the spread of a novel coronavirus in Wuhan, China, on 18 January, few local governments in India paid close attention. But K.K. Shailaja, the diminutive woman running the health ministry in the southern state of Kerala, immediately perked up her ears.
Shailaja knew many students from Kerala were studying at Wuhan University; some had asked her for internships the previous year. She also knew firsthand the havoc an outbreak could cause. In 2018, during her first stint as a minister, she faced an outbreak of Nipah virus, another deadly pathogen spread from animals to people. "We knew anything could happen at any time," she says.
By 24 January, Shailaja had called a meeting of her rapid response team, set up a control room, and mobilized surveillance teams. On 27 January, the first group of students flew back from Wuhan. Three days later, one of them tested positive for COVID-19, becoming India's first confirmed case.
Kerala was ripe for the spread of the virus, with its large urban population, many residents living abroad (and traveling back and forth), and high influx of migrant laborers from other states. Yet with targeted testing, contact tracing, and isolation measures, the leftist state government brought the number of daily new cases down to almost zero in the first few months, flattening the curve far better than the rest of India. As national lockdown measures eased, infections have risen again, but the state seems prepared to keep things from going out of control. Only 0.36% of those confirmed cases have died, a mortality rate among the lowest in the world. (Like the rest of India, Kerala has the advantage of a young population, but many observers attribute its low death rate to the quality of its health care and hospitals that have not yet reached capacity.)
"In many ways, [Kerala] got it right," says virologist Shahid Jameel, director of Ashoka University's Trivedi School of Biosciences. "They possibly got it right the most of any Indian state."
Much of the credit goes to Kerala's calm and cheerful health minister, often called "Shailaja Teacher" because of her old job as a high school teacher. Although Kerala benefited from historical advantages including the country's highest literacy rates and arguably its best primary health care system, experts say Shailaja's leadership has been critical to the battle. "She listens to people, she visits hospitals privately, she talks to doctors," says K. Srinath Reddy, director of the Public Health Foundation of India. "She comes across as a person who is blessed both in ability and humility."
Shailaja is not a scientist, but she has a passion for science that goes back to her time as a physics and biology teacher in the late 1970s. She and her students would read the science section of local newspapers in class, she recalls. "We would have the most interesting discussions about space, the Moon landing, so many things not on the syllabus," she says. Politics, however, eventually drew her in. In the 1950s, members of her family joined the growing communist movement and the struggle against caste oppression.
Her grandmother took part in local movements against untouchability (the persecution of caste groups seen as lesser or "impure"), sometimes taking young Shailaja along to tumultuous protests. Shailaja says her grandmother taught her to be brave, and not only in politics. Smallpox was once widespread in Kerala, and the sick were often shunned or abandoned to die; many people believed patients were cursed by a goddess. But not her grandmother. She would visit patients in their homes and offer them clean water, good food, and traditional herbal remedies. "She was very bold," Shailaja says. "Everybody should have such a grandmother."
After working her way up to leadership positions in one of the state's communist parties, Shailaja was appointed minister of health and social welfare when a left-led alliance was elected to power in 2016. Memories of smallpox may have been in her mind in 2018 as she was grappling with the state's first outbreak of Nipah, a bat-borne virus with a case fatality rate in people of 50% to 75%. Ignoring everyone's advice, Shailaja visited the worst hit village to calm residents and explain that, although low person-to-person transmission can occur with Nipah, especially in hospitals, the risk is low in everyday life. That ultimately prevented a mass flight from the area.
India had seen only two Nipah outbreaks before, in 2001 and 2007, both in the state of West Bengal. WHO later concluded that Kerala's early response was improvised and health personnel were inadequately trained. The outbreak was contained, however, by isolating patients and tracing and quarantining more than 2000 contacts. In the end there were 19 confirmed cases and 17 deaths. And Shailaja and her team resolved to be better prepared for the next outbreak. They put in place a raft of measures, including improved surveillance and contact tracing systems, standard operating procedures, and hospital protocols. Jameel notes that not every state has remembered the lessons of past outbreaks. "It's important to build capacity in peacetime," he says, adding, "They've done well in that."
Shailaja also learned how to deal with the thorny social aspects of an epidemic. In the Nipah outbreak, the government initially cremated the dead—which was unacceptable to Kerala's many Muslims. One relative called Shailaja in tears, and she, in turn, asked her team to find a solution. Finally, they settled on a technique of deep burial, in which a body is wrapped in airtight plastic and buried 3 meters underground. "We understood that we have to make our own protocols sometimes," she says.
Kerala's traditionally strong social services have helped fight the new pandemic. During the national lockdown early this year, it provided migrant laborers with shelter and generous food stocks to keep them from fleeing back to their home states—and potentially spreading the virus. The state started with some of the best health indicators in the country, including infant mortality rates comparable to those in many wealthier countries. Devolution of power has also strengthened citizens' participation and public communication, Reddy notes. "Despite political polarities, at the [village council] level, there is a great deal of social solidarity, especially in the support for the primary health system," he says.
Shailaja built on those advantages, Reddy says, by engaging scientific advice, generating support across ministries, and communicating with the public. "With a fairly educated and politically agile population, so much depends on gaining citizen trust and cooperation, and she has been able to do that effectively," he says.
Still, she has met with resistance from political rivals seemingly resentful of her success as a woman. One sarcastically called her "Nipah Princess," especially after a feature film called Virus was made about the outbreak with a well-known actor playing Shailaja heroically taking charge. More recently, a politician called her the "COVID Queen." Opposition seems likely to increase with the recent surge in cases.
As India's economy reopened and travel increased, clusters of cases cropped up in parts of Kerala, growing into a surge after the harvest festival in late August. By October, the state was seeing some of the country's largest daily increases in cases. Some observers say the government became lax and did not test enough. Others point to the influx of migrant labor. "A lot of people also returned from the Gulf [countries] after the lockdown lifted," Jameel notes.
Fatigue with the early strict measures may have set in, especially among health workers, and the state's governor, a federal appointee, suggested the good health care and low death rates made people unafraid of the virus. When Shailaja spoke with Science in August, she said she was preparing for a possible second wave with an expansion in the number of beds and recommendations to renew some lockdown measures. Her goal, she said, was to keep the death toll as low as possible and protect the elderly. "Until we get a vaccine, all of us will have to sacrifice some pleasures in our lives," she said.
Recently she acknowledged that festival gatherings and political protests had contributed to the recent surge, and recommended stricter restrictions on travel. Now, more than ever, Kerala's hard-working health minister will need to draw on all her abilities—and her grandmother's plucky spirit—to find new strategies against the virus.