Why Kerala is not the correct comparison for Maharashtra’s COVID response

Maharashtra with 9,318 COVID positive cases as of April 28, has the highest COVID disease burden in the country. The Maharashtra government implemented a number of measures after the first case was discovered on March 9. Stricter measures have come in, post the imposition of a nation-wide lockdown, but the cases of COVID19 in Maharashtra have outgrown any other state. Kerala, on the other hand, has been a shining beacon in the containment effort – and kudos to its government for a sustained and well-coordinated grass-root level response. On March 26, Maharashtra and Kerala had similar COVID19 burden – 122 and 120 cases. However, on April 28, Kerala had limited the spread of disease to only 485 people. Therefore, it is natural to make comparisons between Maharashtra and Kerala – however, simply comparing case numbers across the two states without considering the differences in ground situations is a fallacy.

Firstly, Maharashtra has eight times larger geographical area than Kerala and a significantly higher population. A majority of Maharashtra’s cases are found in Mumbai (6,169 cases) – which not only has a much larger intake of international passengers, but also has the highest population density – 26,357 persons per square km – in the country. On the other hand, Kannur which has the highest number of COVID-19 cases in Kerala, has a population density of 852 persons per square km. Social distancing in areas which are as densely populated as Mumbai, is a luxury. There are pockets of slums such as Dharavi and chawl systems in Mumbai, wherein a family of 5-10 members lives in a space as small as 150-200 sq. ft. and entire communities share water taps and toilet facilities, making social distancing impossible.

Mumbai is also the second busiest airport in India – processing nearly 50 million passengers annually. Kerala’s Trivandrum International Airport in comparison, processes one-tenth the number of passengers. In a crisis situation such as COVID-19, contact tracing and containment of individuals is important. Fewer incoming people, limited geographical movement and restricted access to others help contain the spread of the virus.

Another mitigating factor for Kerala is its excellent healthcare system and grassroot outreach, which has been honed over the past two years by the threat of the Nipah virus. Kerala’s health workforce has already been trained in surveillance and contact tracing due to its first-hand experience with Nipah. Globally, countries with previous experiences of deadly viruses have seemingly fared better than those who haven’t. In the case of Maharashtra, there have been local incidences of infectious diseases outbreak over the past few years, but nothing as threatening as the Nipah. While this is no excuse for having a poor outreach of the healthcare system, it is a lesson in public health preparedness and Maharashtra needs to learn from this experience to improve its health system.

Looking at absolute numbers, it may seem that Maharashtra’s COVID-19 cases are rising exponentially. However, the day-on-day growth rate of COVID-19 cases has reduced from 16.6% on April 19 to 8.1% on April 28 and that can be attributed to various containment strategies put in place. A striking example is that of Islampur: on March 23, four members of a family returning from Saudi Arabia tested positive for COVID19. While the family was asked to quarantine themselves, they organised a meal at their home and subsequently 22 of their family members who attended the event also contracted the disease. Following this incident, District Rapid Response Teams carried out detailed contact tracing. An area of 1 km radius was declared as a containment zone and all travel was regulated. Doorstep delivery of essential items was arranged in the containment zone and a buffer zone surrounding it. Subsequently, Islampur is now on the verge of becoming COVID-19 free, with no further detection of any new cases.

Maharashtra is also testing much more than any other state in the country. As of April 13, Maharashtra had tested 36,771 samples as compared to Kerala’s nearly 15,000 tests. Kerala’s projected highest rank at testing based on tests per million population results from its lesser population. Testing is limited by availability of resources – sampling personnel, testing capacity and diagnostic kits, which are in short supply globally. One can argue that Maharashtra should spend more on testing and import testing kits. However, in the international market, India has to outbid several other players with higher purchasing power. In a resource starved environment, we have to accept that testing will remain limited.

Expecting Maharashtra to contain the disease, in a way similar to Kerala without any consideration of the context – huge population, areas of high population density, influx of international passengers – is unfair. New York city which has less population density than Mumbai, but also gets twice the number of international travellers, has over 1 lakh cases and 10,000 COVID related deaths. Undoubtedly NY city also has more purchasing power, yet its healthcare system has been overwhelmed by the COVID19 outbreak. That scenario has not been seen in Mumbai.

Ad-hoc comparisons between states and cities are unhelpful and can pit states against each other. For India to win the fight against COVID19, all states need to fight it together, with help from each other. There are definitely lessons to learn from Kerala, but in the absence of the same context, those lessons may not work directly in Maharashtra. Long term measures such as strengthening primary healthcare infrastructure (particularly in locations of high population density), decentralization of government to empower local communities and creation of a network of self-help groups are some of the lessons that Maharashtra can certainly inculcate. However, this is not the time for unnecessary politicisation or comparisons – this is a time to work together to get rid of the threat of the coronavirus.