The Americas, Pandemic on the Back of Poverty: Peru and Ecuador; and a Southern Cone Contrarian

Environmental, Geography, Natural Environment, Public health,, Society & Culture

As Europe starts to pull itself out of the worst of the coronavirus outbreak, the Americas for the most part are still firmly mired in the devastating crisis of the pandemic…more worryingly, COVID-19 cases continue to rise and even accelerate in some countries as Latin America seems to be turning into “pandemic central”, the ‘new’ Europe❅. This is occurring despite the continent comprising only eight percent of the world’s population and having had the advantage of time to prepare for the virus which reached its shores some six weeks after ravaging Europe.

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(Source: www.maps-of-the-world.net)

Smallness helps
The picture of Central and South America is not uniformly bleak. Some of the smaller countries, such as Uruguay, Paraguay and El Salvador, have managed to restrict their nation’s outbreaks to low levels of infection and casualties. This last mentioned country was surveyed in an earlier blog entitled Courting Controversy in Coronavirus Country: Belgium and El Salvador – June 2020). Among the Southern Cone countries, Argentina and Uruguay stand in contrast to their neighbours Chile and Brazil. Argentina (population of >45 million)—its commendable performance vs the virus slightly tarnished by a recent upsurge following an easing of the lockdown—has a total of 39,557 COVID-19 cases and only 979 deaths, compared with Brazil (whose leader Jai Bolsonaro has taken a recklessly dismissive attitude towards the pandemic). Even on a per capita basis Argentina‘s figures are still a fraction of the human disaster befalling Brazil which has racked up 1,038,568 cases and 49,090 deaths (population: 212 million). The Argentine Republic’s results are also way better than Chile’s record of 231,393 cases and  4,093 deaths (from just 19 million) [‘Argentina’s president enters voluntary isolation amid coronavirus surge’, (Uni Goñi) The Guardian, 18-Jun-2018, www.theguardian.com].

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Brazil: COVID-19 mural message (Source: Getty Images)

Uruguay: Stellar success of an outlier
Uruguay has fared as well as anyone in Central/South America in avoiding a pandemic catastrophe on the scale of some of its neighbours. A tiny population (3.5 million) helps immeasurably but the sheer lowness of its corona numbers stands by themselves – just 1,040 confirmed cases and 24 deaths. This has been achieved despite a demographic profile that should have made it highly vulnerable to the disease: the largest regional proportion of  elderly citizens and a population which is 96% urban. And an outcome secured not by lockdowns and quarantines (allowing Uruguay to preserve its national economic health cf. the stricken economies of its large neighbours Brazil and Argentina), but by eliciting the voluntary compliance of its citizenry – and through the luxury of having a near-universal, viable health care system✺ [‘Why Is Uruguay Beating Latin America’s Coronavirus Curse?’, (Mac Margolis), Bloomberg, 30-May-2020, www.bloomberg.com].

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Uruguay (Photo: Daniel Rodrigues/adhoc/AFP via Getty Images)

Peru:   
Aside from Brazil the country in the region most in strife due to the pandemic at the moment is probably Peru. Peru’s statistics are stark – over 247,925 confirmed cases and 7,660 deaths in a population of 32 million. What is particularly troubling about Peru is that, unlike Brazil, at onset it seemed to be pulling all the right reins, implementing one of Latin America’s earliest and strictest lockdowns. Months of enforced lockdown have however failed to flatten the curve of infections. Peru finds itself in a demoralising “double whammy”, the public health catastrophe continues unabated❈ while the recourse to a tough national lockdown has further crippled the economy [‘Poverty and Populism put Latin America at the centre of the pandemic’, (Michael Stott & Andres Schipano), Financial Times (UK), 14-Jun-2020, www.amp.ft.com; ‘Peru’s coronavirus response was ‘right on time’ – so why isn’t it working?’, (Dan Collyns), The Guardian, 21-May-2020, www.theguardian.com]✪.

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⇑ Andean pabluchas patrol Cuzco streets to enforce social distancing and mandatory mask measures (Photo: Jose Carlos Angulo/AFP/Getty Images)

Indicators of the poverty trap
The economic predicament Peru finds itself stems from the country’s high reliance on an informal economy (reaching some 70%). What Peru has in common with Brazil—and has been exacerbated by the pandemic—is very high social inequality. The poorest Peruvians cannot afford to stay home, to isolate as they should. Many are without bank accounts and under the informal economy have to travel to collect their wages, those without home refrigerators also need to shop frequently – all of which makes them more vulnerable to be exposed to the virus [‘Latin America reels as coronavirus gains pace’, (Natalia Alcoba), Aljazeera, 15-Jun-2020, www.aljazeera.com]. Disease and impoverishment have converged in Peru to make the predicament more acute for those of the poor who need life-saving oxygen of which there is now a scandalous critical shortage – the situation being exploited by profiteering hit men (the sicarios) controlling the black market oxygen supplies [‘In Peru, coronavirus patients who need oxygen resort to black market and its 1,000 percent markups’, (Simeon Tegel), Washington Post, 18-Jun-2020, www.washingtonpost.com].

Ecuador and Guayaquil

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Ecuador:  
In Ecuador the pandemic epicentre is the western city of Guayaquil, the country’s largest city. This is thought to be due to a couple of factors, the city’s sprawling slums where “many residents live hand-to-mouth and routinely violate the government lockdown…in order to work”, and because many Guayaquil exchange students and migrant workers came back to the city from Spain and Italy in March [‘COVID-19 Numbers Are Bad In Ecuador. The President Says The Real Story Is Even Worse’, (John Otis), NPR, 20-Apr-2020, www.npr.org]. The unpreparedness and inability of the authorities to cope with the crisis has affected the woeful degree of testing done, the lack of hospital facilities for patients and even the capacity to bury the dead as the bodies of coronavirus victims were left piling up on the city’s streets. In the wake of the disaster the Guayaquil Council entered into a slinging match with Quito (the national government), asserting that the government has under-represented the city’s death toll by as much as four-fifths, that it failed to provide it with the health care backup demanded of the disaster, as well as calling out the corruption of public utilities which has accentuated the crisis (Alcoba). Ecuador currently has 49,731 confirmed cases and 4,156 fatalities in a population of 17 million.

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End-note: The hypothesis of virus protection at high altitude 
Among the multitude of worldwide research projects triggered by the pandemic, a multi-country study looking at Bolivia, Ecuador and Tibet has advanced the theory that populations that live at a height of above 3,000 metres have significantly lower levels of susceptibility to coronavirus than their lowland counterparts. The study attributes the capacity of high altitude to nullify the disease down to the fact that living at high altitude allows people to cope with hypoxia (low levels of oxygen in the blood), and that the altitude provides a favourable natural environment—dry mountain air, high UV radiation and a resulting lowering of barometric pressure—reduces the virus’ ability to linger in the air. The COVID-19 experience of Cuzco in Peru seems to corroborate this hypothesis, being lightly affected compared to the rampage elsewhere in the country – the high Andean city has had only 899 confirmed cases and three deaths. Similarly, La Paz, Bolivia, the world’s highest legislative capital, has recorded only 38 coronavirus-related deaths to date [‘From the Andes to Tibet, the coronavirus seems to be sparing populations at high altitudes’, (Simeon Tegel), Washington Post, 01-Jun-2020, www.washingtonpost.com].

 
<Þ> all country coronavirus counts quoted above are as at 20-June-2020

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❅ for week ending 20th June 2020, confirmed cases for Latin America represented half of all new coronavirus cases (Source: WHO)  
✺ a like-for-like comparison to Uruguay might be Paraguay – also a small population (6.9 million), only 1,336 cases and 13 deaths but at the cost of a draconian lockdown with an economy-crippling end-game. 
even prior to COVID-19 striking, the Peruvian public health system was struggling due to “decades of chronic underinvestment” (eg, spending <$700 a day on health care) (Tegel, ‘In Peru’)   
the strict lockdown has been less rigorous when removed from the urban centres…in outlying areas, in the northern coast and the Amazonas region (particularly bad in the Amazonian city of Iquitos) it was less “honoured in the breach than the observance” leading to the formation of new virus clusters (Collyns)  

⊠ other experts discount the study’s findings noting that most coronavirus infections occur indoors, negating the relevance of UV levels (Tegel, ‘From the Andes’)

The Choral Powder Keg: A Health Hazard Tailor-made for the COVID-19 Crisis

Public health,, Science and society, Society & Culture, Town planning

When a pandemic or some similar “Black Swan” event sweeps the world, hitting many countries with great intensity, particularly in Western societies with a high degree of religiosity, comfort and solace is often sought within the spiritual “safe house” of the church. As soon as the novel coronavirus landed and spread, it was apparent the church services especially where high rates of attendance was commonplace, would pose a public health risk.

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(Source: www.newslocker.com)

Yet in the US eleven state governors chose to maintain freedom of worship over community safety by exempting religious institutions from the general prohibition on public gatherings, notwithstanding that some of the states registered the biggest clusters of COVID-19. Even in other states there was a pushback by church men and women against government bans on assembly in places of worship. As a consequent 71 members of a single church in Sacramento were infected by the virus [‘Pastor who refused to close church due to coronavirus killed by outbreak’, (Rebecca Nicholson), Express, 15-Apr-2020, www.express.co.uk].

This was mirrored in overseas scenarios, in South Korea in February, one infected churchgoer infected at least 37 other members of her church on a single contact [“‘Superspreader’ in South Korea infects nearly 40 people with coronavirus’, (Nicolette Lanese), Live Science, 23-Feb-2020, www.livescience.com].

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South Korean choir with face masks  (Source: AP)

The choral petri-dish
The holding of packed sermons in churches and other places of worship, like any close contact between confined, concentrations of people, breaches the prescribed social distancing guidelines and exacerbates the incidence of coronavirus infection. But just as dangerous and with even more potential to transmit the viral disease through communities is the choral activities of churches. The activities of choirs initially continued unabated in the early stages of the pandemic but an incident in Washington state in early March brought home how risky choir practice is. 61 people attended a choir practice at a Presbyterian church in Skagit County, within a short time 45 of the group had been infected by COVID-19 and two had died. Other choir outbreaks, some fatal, have occurred In Calgary (Canada), Amsterdam (Netherlands) and in South Korea [‘Scientists to choirs: Group singing can spread the coronavirus, despite what CDC may say’, Richard Read), Los Angeles Times, 01-Jun-2020, www.latimes.com].

Infectious diseases experts have pinpointed the obvious dangers of contagion associated with choir singing…unrestrained vocal activity at close quarters in often poorly-ventilated, confined space. The vocalists exhale and inhale deeply to sing which makes them highly susceptible to the passage of airborne particles. Through the process of aerosolisation, the virus floats freely in the air (and has been observed to survive for up to three hours) [‘Churches can be the Deadliest Places in the COVID-19 Pandemic’, (Kevin Kavanagh), Infection Control Today, 03-Apr-2020, www.infectioncontroltoday.com; Read].

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Inexplicable change of stance by CDC
With eyes fixed on the November elections and the need to shore up vital support from the Evangelical Christian Right, President Trump from his White House ‘pulpit’ intensified his call in May for 
governors to reopen religious institutions as an essential service, eliciting pushback from some governors. At the same time, surprisingly the Centers for Disease Control and Prevention (CDC) decided to drop their warnings against choral singing despite the inherent danger it poses. CDC justifies this change of position by downplaying the likelihood of airborne transmission beyond six feet [‘Behind Trump’s demands to reopen churches: Slipping poll numbers and alarm inside his campaign’, (Gabby Orr), Politico, 22-May-2020, www.politico.com; Read).

Heightening the risk of unleashing ‘super-spreaders’
CDC’s controversial move has drawn broad criticism from medical experts including specialists in bio-aerosol research who have refuted CDC’s claim, calling it “hazardous, very dangerous and irresponsible”, and that it exposes America to new waves of super-spreading from the activity of choir members (Read).

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  With religious singing relegated to the home, some American churches have tried to get round the prohibition on in-house congregational services by organising drive-in sermons

Fallout from the churches
Although many parishes and parishioners in the US have adjusted well to the new world of online sermons, some traditional congregationalists worry that 
the new ‘norm’ will spell the disappearance of the in-person church experience altogether [‘How the Pandemic Will Change Us’,  (Rod Dreher), The American Conservative, 13-Mar-2020, www.theamericanconservative.com].

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(Photo: www.stjohnswhitchurch.org.uk)

 

Endnote: The economics of the choral closedown
The halt to choral activities due to COVID-19 has led to a whole bunch of “knock-on” problems worldwide. Like anybody else with their income source impacted adversely by the crisis, choristers, classical musicians and organists attached to the churches affected have been deprived of livelihood. But it goes even beyond that. As the Royal School of Church Music in the UK indicated, the pandemic ”has literally ripped apart the many close-knit groups of singers and instrumentalists who (need to) spend significant amounts of time together”. Church musicians who rely on the service are especially hard hit. It is doubly hard for self-employed church organists who have lost their access to practice – unlike other musicians who keep their instruments at home, they rely on “using instruments in public buildings for the vital practice which enables them to maintain their hard-earned skill” (Royal College of Organists). [‘Pandemic has ‘ripped apart’ church choirs’, (Hattie Williams), Church Times, 01-Apr-2020, www.churchtimes.co.uk].

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(Source: eBay)

PostScript: There is another side problem resulting from the non-use of organs in churches. Like the raft of airplanes grounded due to the coronavirus, complex and expensive organs require continual attention. They need “regular playing to ensure that the fragile technical components are kept in good working order“ and  free from damage (Williams).

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the Washington Post states that CDC acted on a White House directive to omit the choir warning from it’s website guidance information. CDC may have also relied on earlier statements from WHO contending that “there is no evidence of transmission of the virus as an airborne pathogen”. WHO’s conclusions have themselves been debunked as “decades-old dogma that held that droplets only travel an arm’s length in the air” (Read)

Coronavirus and Age Vulnerability: The Riddle of Japan

National politics, Politics, Public health,, Regional History, Society & Culture

Both the medical experts and the empirical evidence on the ground tell us that the elderly are the cohort in the community most susceptible to COVID-19. The Office of National Statistics (UK) calculates that people aged 80 and over have >59% risk of dying from coronavirus (www.ons.gov.uk/). The pandemic’ age bias skewed against older populations is one explanation, in the absence of much hard data, put forward to explain the African continent’s current low rate of mortality due to the virus – overall 111,812 confirmed cases and only 3,354 deaths (as at 25-May-2020) [‘Coronavirus in Africa tracker’, BBC News, www.bbc.co.uk/]. The percentage of the African population aged under 25 is 60% (in sub-Saharan Africa the number over 65 is only 3%)[‘Coronavirus in Africa reaches new milestone as cases exceed 100,000’, (Orion Rummler), Axion, 22-May-2020, www.axios.com].

And if we needed any more empirical proof of the salience of the age factor, there is the tragic example of Italy’s corona-toll. 32,785 dead from COVID-19 in a country with the oldest population in Europe. Nearly 58% of the country’s deaths in the pandemic have been Italians aged 80 and over [Statistica Research Department, (22-May-2020), www.statista.com/].

4E0F4A05-F587-45ED-BC34-E10F32BB0CFBWith Italy’s grim corona-death tally falling disproportionately heavily on the country’s senectitude, you would think that it would not bode well for Japan which has the world’s highest percentage of older people (28.2% aged 65 and more) [Population Reference Bureau, www.pbr.org/]. When you add in other demographic factors relevant to Japan, this would seem doubly ominous for the “land of the rising sun” – a population of >126 millions on a land area of 377,944 sq km, including the mega-city of Tokyo  with its notoriously packed commuter trains. On top of all these is Japan’s proximity to China, the virus’ original causal point.

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(Source: www.quora.com)

Japan, unpropitious conditions for avoiding an global epidemic?
With such cards stacked against it, worried Japanese health officials might have feared a catastrophe eventuating on the scale of that befalling the US, Italy and UK. And Japan has not come out of the pandemic unscathed but the result-to-date (25-May-2020)—16,550 confirmed cases and 820 deaths—is much better than many comparably sized and larger countries. Of course, Japan’s  public health authorities are very mindful, as is every country, of being swamped by a second wave of the coronavirus. 

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(Photo: www.english.kyodonews.net)

How has Japan done as well as it has?  
Good question! The Japanese themselves can’t really explain how they’ve managed to escape a major outbreak of the virus. WHO has called it a “success story”, but it’s one that continues to mystify. In so far as explanations were forthcoming from Japan’s health ministry, it was attributed at least in part to a raft of cultural factors. First, hygiene and cleanliness is something ingrained in the Japanese psyche, Japanese people tend not to shake hands and hugs others, preferring to bow as the form of greeting. Second, the practice of wearing face masks was already the norm in Japan ante-COVID-19 (the Japanese go through 5.5bn a year, averaging 43 per head of population) [‘Most coronavirus success stories can be explained. Japan’s remains a ‘mystery’’, (Jake Sturmer & Yumi Asada), ABC News, 23-May-2020, www.abc.com.au; ’How Japan keeps COVID-19 under control’, (Martin Fritz), DM, 25-Mar-2020, www.dm.com].

Other cultural factors 
Other suppositions put forward to explain the Japanese success include the practice of inoculating young children with BCG vaccinations, which according to its advocates give Japanese people a basic immunity which helps their defence against coronavirus. Physiology was also cited as a factor in guarding against the disease, the low obesity of Japanese is thought to help, as is the Japanese diet (eg, natto, a soybean yoghurt, is thought to boost the immune system) [‘’From near disaster to success story: how Japan has tackled coronavirus’, (Justin McCurry), The Guardian, 23-May-2020, www.msn.com/; ‘Has Japan dodged the coronavirus bullet?’, Richard Carter & Natsuko Fuhue, Yahoo News, 14-May-2020, www.au.news.yahoo.com; Sturmer & Asada].

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(Photo: www..Forbes.com)

The “Diamond Princess”
In addition to all of the domestic factors hindering Japan’s fight against COVID-19, an external element exacerbating the early outbreak in Japan was the debacle of the “Diamond Princess” cruise ship. When the international ship docked at Yokohama in February, the Japanese authorities injudiciously prevented healthy passengers and crew on-board from disembarking during the quarantine – with no separation made between well and contaminated passengers, and no self-isolation of the sick! This led to a blow-out of virus contamination which eventually infected 712 passengers, creating the first big cluster of coronavirus outside of Wuhan [‘How lax rules and missed warnings led to Japan’s second coronavirus-hit cruise ship’, (Ju-Min Park), The Japan Times, 07-May-2020, www.japantimes.co.jp]

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A cautious reaction from politicians, one eye on the XXXII Olympiad?
Let’s look in detail at what Japan did – or didn’t do! When the disease first arrived, the government took a cautious approach to tackling the virus. Borders initially remained open and Chinese visitors were still allowed into the country in huge numbers, 89,000 came in February (after the first outbreak), which was on top of the 925,000 who visited during January! Prime Minister Abe came in for a lot of flak, some including a former PM, Yukio Hatoyama, accused him of holding off from going full-tilt against the pandemic so as to preserve the Tokyo Olympics event (Fritz). Critics railed against a lack of leadership  from the Abe government, criticising its failure to appoint anyone to take firm control of the crisis, and that those efforts to counter the virus were hamstrung by the multiplication of bureaucratic silos [‘A Japan divided over COVID-19 control’, (Hiromi Murakami), East Asia Forum, 08-Mar-2020, www.eastasiaforum.org].

Lockdown-lite, testing-lite
The Abe government’s belated state of emergency saw sport suspended and schools closed,  but overall only a partial lockdown was imposed, many businesses, restaurants were permitted to stay open, albeit with reduced hours. Citizens were asked to stay home but compliance was only on a voluntary basis, with no surveillance technology deployed and no punitive action taken against anyone failing to adhere to the government’s request.

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(Image: www.japantimes.co.jp)

Targeted testing

It was in testing that Japan adopted a very different crisis approach to most of the leading western countries. Rather than going for high volume, it deliberately tested under capacity. By mid-May it had tested a mere 0.185% of the country’s population, averaging two tests per 1,000 people, cf. Australia, >40 per 1,000 (Sturmer & Asada). It was highly selective, only those with serious virus symptoms were tested. The rationale for such a low-testing regime was concern for the capacity of widespread testing infrastructure, by limiting testing this would lighten the load on testing centres. Rather than mine-sweep the country with testing, the Japanese pursued a strategy of targeting virus clusters as they were identified to pinpoint the sources of the infection [‘Has Japan found a viable long-term strategy for the pandemic’, (Kazuto Suzuki), The Diplomat, 24-Apr-2020, www.thediplomat.com; Gramenz].

Consequently, Japanese medical experts concede that the official counts may be well short of the reality, which puts a rider on the country’s achievement. Even with a smaller number of cases Japan found itself lacking in IPUs (only five per 100,000 people cf. 35 in the US) , there was also a shortage of PPE as well as face masks which were rationed out only two per household (and derided as “Abe-no masks”). This calls into question the faith that the Japanese placed in the robustness of the nation’s health system [‘Japan’s Halfhearted Coronavirus Measures Are Working Anyway’, (William Sposato), Foreign Policy Magazine, 14-May-2020, www.foreignpolicy.com].

Self-complying social distancing?
Social distancing, a nightmare to try to enforce in people-dense Tokyo, was not a major focus for authorities. This was largely left to the goodwill of the individual, aided by some subtle social shaming – government workers walking through Tokyo nightlife areas with signs asking people to go home (Sposato). In any event the authorities’ measures were only partly effective – Japanese people continue to flock to the cherry blossom spring events in large numbers. Where social distancing was more manageable was in shutting off obvious potential hotspots, closed spaces with poor ventilation (karaoke clubs and pubs), crowded places with many people people in the immediate vicinity and other close, intimate contact settings (Suzuki).

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Cherry blossom time: no voluntary social distancing here (Photo: www.bloomberg.com)

Tokyo transport
Tokyo’s mass transit network is a petri dish in-waiting for coronavirus, but it appears that preventive measures (some pre-planned) have lessened the impact on public health. Tokyo business working hours have been staggered and large companies like NEC started to adopt telecommuting and teleworking, as well as a big increase of people riding bikes to work occurring. Consequently, transits at Tokyo’s central station on May 18th was down by 73% on the corresponding day in 2019 [‘Remote possibilities: Can every home in Japan become an office?’, (Alex Martin), The Japan Times, 23-May-2020, www.japantimes.co.jp]. 

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(Image: Getty Images/AFP. P Fong)

Most pundits and observers conclude that Japan, with its ageing population and all its drawbacks and encumbrances, has (so far) warded off the worst of the pandemic. With no “silver bullet” in sight, we are left to speculate whether that they have achieved this outcome by sheer good luck, by good judgement, by the personal habits and cultural traits (especially hygiene) of its citizens, or by a combination of all of the above (McCurry).

Endnote: Low tester, early starter
Another Asian country which has mirrored Japan’s pattern of choosing not to test in high volumes is Taiwan. The Taipei China republic, commencing measures to counter the virus as early as anyone did, had tested only 2,900 people per million of population (Worldometer, as at 20th May), but it’s mortality rate (deaths per million) was only 0.3 (total of seven deaths) compared to Japan which was 6.0 per million.

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as at 25-May-2020
the largest metropolis prefecture in the world, around 14 million people
Japan’s health officials had themselves projected a worse-case scenario of up to 400,000 deaths (Gramenz)
to be fair, there are constitutional impediments in Japan that prevent the declaration of a full, European-style lockdown (McCurry)
a Kyodo news poll indicated that 57.5% of people were unhappy with the government’s handling of the emergency. In so far as Japanese people have given credit to the success, it has gone to medical experts for efficiently managing Japan’s cluster tracing and containment efforts, rather than to Abe who many view with distrust based on its past track record [‘Time to Give Japan Credit for its COVID-19 Response’, (Rob Fahey & Paul Nadeau), Tokyo Review, 18-May-2020, www.tokyoreview.net]

The Kerala COVID-19 Template: How to Lead in the Fight against a Pandemic

Comparative politics, Natural Environment, Politics, Public health,

When the coronavirus pandemic eventually reached India, it was always going to pose a challenge of epic proportions for a country of 1.3+ billion people, with such a dense population domiciled  in such close quarters, and with a widespread underbelly of poverty. The Spanish flu of 1918 inflicted a death toll on India in the many millions, something no doubt in the back of the minds of public health officials. So, two or three months into the crisis, on paper, India’s COVID-19 record, on paper, doesn’t look as frightening as many other nations. As at 17-May-2020, so far it has had a shade under 91 thousand confirmed cases and a total of 2,872 deaths (www.worldometers.info).

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(Photo: Indranil Mukherjee / Agence France-Presse – Getty Images)

There is a perception within medical circles however that these figures don’t portray the full extent of the outbreak. India’s urban areas are packed with masses of people living face to face, beset with poor sanitation conditions, up to 100 people sharing the same toilet in some cases, adding up to a recipe for catastrophe in plague time. Obtaining a test for coronavirus in India has tended to not be straightforward, thus the level of testing has lagged woefully behind what is desirable, eg, by well into March India was averaging only five tests per ten lakhs (one million) people, compared with South Korea which had managed 4,800 per ten lakhs.

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Too many migrant workers waiting for too few buses to take them home after the lockdown was announced (Photo: Yawar Nazir – Getty Images)

Containment measures have been far short of perfect, and with some glaring omissions…there has been passive resistance to the lockdowns from sceptical Indians, and the ban on public gatherings has from time to time been skirted round (some ‘scofflaw’ political parties continue to hold mass rallies). Although India’s borders were closed fairly promptly, some have been critical of the procrastination of Indian leaders’ during the crucial early days of the crisis, one Indian epidemiologist characterised it as a “let’s wait till tomorrow” attitude [‘India Scrambles to Escape a Coronavirus Crisis. So Far It’s Working’, (J Gettleman, S Raj, KD Singh & K Schultz), New York Times, 17-March-2020, www.nytimes.com]. This early reticence to act emanated from Delhi. The Modi BJP government, initially seemingly more concerned with the impact on India’s under-performing economy, issued no public health warnings or media briefings at the onset of the pandemic [‘What the world can learn from Kerala about how to fight covid-19’, (Sonia Faleiro), MIT Technology Review, 13-Apr-2020, www.technologyreview.com].

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(www.anayahotels.com)

Kerala, leading from the periphery
Kerala is one state that these general criticisms of Indian public health efforts against COVID-19 cannot be levelled. The small southwestern Indian state is one of the most picturesque parts of the land with its coconut trees and irenic and serene back-waterways. Known as a tourist mecca, Kerala, population 35 million, is more affluent than many parts of India (GDP per capital GB£2,200). 20% of India’s gold is consumed here, and it produces over 90% of the country’s rubber. Literacy is nearly 20% higher than the overall Indian average, and life expectancy too, is higher (www.holidify.com). All of these were contributing factors buttressing Kerala’s capacity to cope with the disease when it came.

Local vulnerabilities to the epidemic
Kerala was coronavirus “ground zero” for India’s very first patients. Three students returning from Wuhan were tested positive and hospitalised (in all 70% of the state’s total virus patients have come from outside India). Certain preconditions pertaining to the state exacerbated the risk of disease outbreak, including a large number of Keralite migrant workers in the Gulf states, a huge expat population (working in Kerala from other Indian states), porous borders, and an early summer monsoon season (contributing to Kerala’s high rate of annual communicable diseases) [‘Coronavirus: How India’s Kerala state flattened the curve’, (Soutik Biswas), BBC News, 16-Apr-2020, www.bbcnews.com].

Preparation and planning
Kerala was prepared for COVID-19 before the onset of the disease. The earlier Nipah viral outbreak (NiV) In Kerala (2018) proved a good trial run for the health service, giving the local authorities an opportunity to iron out chinks in it. Kerala’s communist-left coalition  government had established a strong social welfare foundation, investing in the state’s infrastructure with a focus on health and education, and on tackling the state’s poverty. [‘How the Indian State of Kerala flattened the coronavirus curve’, (Oommen C Kurian), Guardian,  21-Apr-2020, www.theguardian.com].

Minister Shailaja (Source: www.manoramonline.com)

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Shailaja ‘Teacher’, a woman with a plan
When the epidemic arrived in Kerala, the proactive state health minister KK Shailaja took charge. With the full backing of Kerala chief minister, Pinarayi Vijayan, she had already organised a rapid response team to focus on targeted clusters, and liaised with the provincial councils. Kerala adopted the WHO protocols of test, trace, isolate and support. Rigorous contact tracing was employed, utilising detailed “route maps”. Testing of suspected carriers was decisive, with a quick, 48-hour turnaround of the result [‘Kerala has best coronavirus test rate in the country, but is it enough?’, (Vishnu Varna), The Indian Express, 01-Apr-2020, www.indianexpress.com], allowing them to move quickly on to the quarantine phase. 17,000 people were quarantined under strict surveillance, the poor without quarantine facilities were placed in improvised isolation. Recovered patients were duly released back into the community. Quarantine compliance was achieved through an admixture of phone monitoring (>340,000 calls and a neighbourhood watch system [‘The coronavirus slayer! How Kerala’s rock star health minister helped save it from Covid-19’, (Laura Spinney), The Guardian, 14-May-2020, www.theguardian.com; Kurian].

One of the sternest challenges, very early on, came from the district of Pathanamthitta. A family returning from Italy tested positive, but refused to disclose their movements upon return to Kerala. The civil servant in charge of the district, PB Nooh, and his team, worked round this obstacle by accessing the family’s GPS phone data, allowing them to trace all of their contacts (almost 300 people!). Nooh’s staff then tested the contacts for infection, thus shutting down the risk of the virus being exponentially transmitted to others in the community, ie, “breaking the chain” (Faleiro).

The coronavirus certainly didn’t miss Kerala, one-fifth of all Indian cases of the disease have occurred in the state. Under Shailaja, Kerala hit the ground running, before the end of January, screenings of arrivals at all four of the state’s international airports was introduced. The government imposed a lockdown even before the national lockdown was called…schools, malls, cinemas, public gatherings, were closed down, and the lockdown was stricter and longer than the national one (Kurian). Face masks were distributed to slum dwellers. Planning was precise and focused, a state stimulus package of Rs20,000 crore was directed towards the economic and medical crises.The medical task force was mobilised (doctors on leave were recalled, others asked to delay their leave). Those suffering hardship included migrant workers from other states were provided with free lunches by the state.

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Communication with citizens informing them about all aspects of the crisis was clear and consistent (“Break the Chain” campaign which emphasises public and personal hygiene). Accordingly, community participation, both voluntary and active, was forthcoming. Some Keralites made accommodation available (including vacant homes in some instances) to those in need when requested to by the government [‘The Kerala Way of Tackling a Pandemic’, Times of India, 20-Mar-2020, www.timesofindia.com].

The Kerala government’s campaign against the virus has been aided by the polity’s decentralised nature of it’s structures. The coordination achieved allows the local councils to follow through on a lot of the public health measures needed to be implemented in the crisis (Biswas). The result of all this detailed planning and effort by Kerala – 587 confirmed cases and only four deaths and apparently no significant community transmissions (17-Apr-2020).

The state of Kerala and Shailaja ‘Teacher’ (so known because her occupation before entering politics was that of science teacher) are not resting on their laurels, being very mindful of the chance of a second wave of COVID-19 due to impending factors—Prime Minister Modi’s anticipated ending of the national lockdown, which will trigger a mass return of Kerala’s migrant workers based in the Gulf, and the approach of the tropical wet season in Kerala (June) [‘Kerala Lays Down Specific Plans To Tackle Monsoon Amid COVID-19 Pandemic’, NDTV, 15-May-2020, www.ndtv.com]. Minister Shaijala has been making preparations for such an event, many of the state’s teachers have been retrained as nurses to cope with a new upsurge in virus hotspots (Spinney).

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EndNote: No time for Kerala complacency but a most worthy blueprint on offer 
The threat of new clusters emerging in Kerala remains very real, especially coming from outside, with a spike as recent as this past Friday—imported from neighbouring Tamil Nadu and Maharashtra as well as from overseas—reminding Shailaja and Co that the battle’s still far from won. Nonetheless, for elsewhere in India and beyond, there are lessons from Kerala‘s formidable achievement to be had from the state’s “nimble-footed, community-oriented, cautiously-aggressive approach” to the outbreak [Kurian; ‘Kerala reports 11 new Covid-19 cases’, (Ramesh Babu), Hindustan Times,16-May-2020, www.hindustantimes.com].

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the Kerala government is Marxist in ideology but pragmatic in practice, it’s policies are moderately social-democratic, with a highly-privatised public health system (Kurian)