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Uttar Pradesh and Kerala: Preparedness and effectiveness in 'battling' the pandemic

By Ajit Jha, Anmol Sehgal, Surya Tewari*
A country like India that accounts for the largest population in the world after China has not been left behind in witnessing the atrocities of the contagious spread of COVID-19. In the wake of the grim pandemic, it is crucial to take prompt measures strategically by central in alignment with state government to reduce the spread of infection.
With almost all states facing an emergency situation, Kerala and Uttar Pradesh have been lauded for their effectiveness in tackling the spread of the viral infection. Where states like Delhi, Maharashtra are struggling to support enormous amount of cases, Kerala has been able to effectively flatter the curve of infection spread.
Already known for its earlier health initiatives, it is interesting to highlight how the state has tackled the current pandemic whereas UP that accounts for the largest population in the country has taken stringent and harsh measures to curtail the spread along with becoming the first state to start pool testing.
In the article below we discuss the inherent preparedness in terms of demography, health capacity and disease burden profile of these two extremely diverse state and their current policies that are driven by a socialist perspective in detail.
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COVID-19 has thrown a never-before situation for the country which is affecting both lives and livelihood. Around 20 thousand people have been infected by this virus. Since the second week of March the cases of COVID-19 have spread from 3 to 32 states affecting more than 56 percent of districts in India.
However, implementation of national lockdown is helping in reducing the exponential growth of virus. As of now, active cases are increasing at the rate of 7.2 percent. The rate of recovery has also increased to 17.5 percent, while the mortality rate is around 3.2 percent.
Intensive contact tracing, containment strategy in hotspots and uses of machine-learning technology and unified screening along with the increment in the testing numbers are some of the evolving methods being used in different zones to contain the spread of virus.
But the economy has been badly hit at a time when it was already in a recessionary phase. GDP growth forecast for the current financial year has been lowered to less than 2 percent. It is anticipated that a huge number of people engaged in informal economy will be pushed out of work and millions will fall in the trap of poverty. 
India today is facing two challenges of managing medical and economic emergencies. Therefore, a common response from central and state governments is necessary to deal the two crises.
The central government has announced some measures to provide short-term reliefs to vulnerable sections, informal workers, farmers and small businesses. The announcement of Rs 1.7 trillion package under Pradhan Mantri Garib Kalyan Yojana (PMGKY) for the poor and disbursement of around Rs 30,000 crore to more than 320 million people is an illuminating first step in fighting the economic battle.
But to deal the extraordinary situation also requires extraordinary measures which are expected in due course of time. With centre taking the first step, state governments are aligning the battling strategy. Some states in the past few weeks have taken several measures to combat this medical crisis and providing short-term economic relief to vulnerable groups.
Kerala was the first state to have witnessed positive cases of COVID-19 has now caught attention to fight and “break the chain” of spread of this deadly virus outbreak. With its past experience of Nipah virus outbreak in 2018, the state had been proactive in taking prompt measures to deal with pandemic since the first three cases of infection came in existence on 30th January 2020 in Thrissur district.
The intermitted socialist ideology of state government of providing local governing body’s prominent stake in functioning, decision making along with working together with community workers at grass root level makes Kerala a state with strong health model.
Uttar Pradesh (UP) with its large base of population is another state taking effective but a different measure to deal with the impending situation. Since the first case of COVID-19 appeared in the month of March in Agra, the state government along with the local governance has started intensive contact tracing, pool testing, identification of hotspots and ruthless containment strategy to limit the spread of virus in communities.
Both these states are also praised to tackle the situation of migrant workers and for providing short-term incentives to vulnerable groups. Interestingly, despite great geographical and political divide between these two states, both are using similar means of socialism to deal with this situation. 
With both states being in limelight for their efforts, it is important to understand and dig deeper into their current situation, capacity of health infrastructure and competence in fight against this grim pandemic.

Current situation of COVID-19

All the 14 districts of Kerala have been affected by COVID-19 with Kasaragod, Kannur and Ernakulum districts identified as hotspots. As per the daily statistics by the Union Health Ministry, 408 positive cases have been registered and 291 infected have recovered which is 71.3 percent of the total cases with 0.7 percent fatalities as on 21st April, 2020. The state has so far tested 20,252 (till April 21, 2020) samples and a total of 36,667 people are currently under observation (GoK, 2020).
In contrast to Kerala, 64 percent districts have been affected by COVID-19 in UP. Out of total 1,184 positive cases reported, recovery rate is 11.8 percent and mortality rate 1.5 percent. Currently, the state is testing around 2500 sample per day and it has also become the first one to start pool testing. So far 21,384 (till April 17, 2020) samples have been tested in the state. Agra, Noida, Meerut and Lucknow are identified as major hotspot in the state.
Both Kerala and UP are actively working towards flattening the curve of Covid-19 cases, Kerala has emerged successful in doing so (figure-1). Following is a case wise comparison of total cases in Kerala vs. UP since 14th March till 21st April, 2020.
Source: https://www.covid19india.org
There has been an evident reduction in daily rise of cases in Kerala even with 100 percent districts being affected whereas the daily new cases has gone up for UP (figure-2). Out of the 1,184 cases in UP, 59 percent are linked to the March congregation of Tablighi Jamaat. The daily cases growth rate in Kerala is around 1 percent as compared to 8 percent in UP.
https://www.covid19india.org
With relevance to the current situation of COVID-19 in these two states, Kerala seems to have emerged as a model state in containing the spread of coronavirus with UP catching up quick to limit the spread.

Three Factors Formula

One state in south with smaller population and laudable health initiatives, the other in the north which is one of the largest having newer and prompt battling strategies. Having a glimpse of such diversity in demography, governance and health models provides an interesting edge to study their health infrastructure and disease profile to better understand their track record and preparedness.
Before exploring the above parameters, one aspect of medical research provides a hidden explanation stating which section of population succumb to casualty due to COVID-19 which gives us our first factor of importance:

Age structure

In figure-3, the difference in the age structure between two states can be noticed in the age groups of 0-14 years and 40-69 years. In UP more population belong to younger age group (i.e. 0-14 years), while proportion of elderly population is higher in Kerala.
Source: Census of India, 2011
With an ideology that elderly people have weaker immune system moreover have diseases like diabetic etc. which makes them less resistant in fight against COVID-19. Health ministry, during the media briefing on COVID-19, said that 75.3 percent of the COVID-19 deaths in India have been recorded in those who are 60 years of age and above and 83 percent had co-morbidity condition. With regards to this, Kerala should have had higher mortality as well but that is not the case. This brings us to our second and third factors of importance in dealing with the pandemic situation:

Disease burden scenario

Figure-4 (constructed from the data obtained from "India Health of Nation’s States: The India-State Level Diseases Burden Initiative, 2017") depicts disease burden in terms of Disability-adjusted Life Years (DALY). DALY measures health loss due to premature death and disability due to disease or injury. 
While Kerala outpaces UP in non-communicable diseases, UP sees three times more burden of communicable disease vis-à-vis Kerala and burden is high for UP in non-communicable disease as well. 
Based on the Epidemiological Transition Level (ETL) score of 0.16, Kerala has made highest transition from communicable to non-communicable diseases indicating significant control over communicable diseases. In UP there is a decline in communicable diseases vis-à-vis non-communicable since 2010 onwards, but the transition is low. The ETL score of the state is 0.68. 

Competency in health infrastructure

Kerala having more number of elders is still showing major recovery of aged patients. This is a feather in the hat of the competent health infrastructure of the state. The state is much ahead in the major infrastructure parameters, while UP is lagging behind. As per the data obtained from the National Health Policy, 2018, actual per capita public health expenditure was Rs 1,463 in Kerala and Rs 733 in UP in 2015-16.
The gap in turn translates into heavy expenditure on the part of the population. The NSS 75th round report on health shows average expenditure incurred by population as Rs 19,589 in Kerala and Rs 26,929 in UP in the year 2017-18. The high cost of treatment might be one reason for underreporting of illness. While in Kerala 24.5 percent of the population reported illness, in UP the proportion is only 7.4 percent.
The mismatch between the population and health infrastructure and consequent health system can be assessed from figure-5 and figure-6.
Source: National Health Policy, 2018
The hospitals in UP are twice as overcrowded as in Kerala. As compared to four hospitals per one lakh population in Kerala, in UP, only two hospitals are available. Similarly, availability of beds in hospital is also high in Kerala.
With respect to health professionals also the two states stand apart. There are 1.5 registered doctors per 1000 population in Kerala; in UP the ratio is 0.3:1000. In terms of nursing staff the ratio is 8 and 0.5 respectively. 
The quality of care in hospitals and nature of outcomes is very much dependent on adequacy of nursing staff. The hospitals in UP are found to be understaffed with respect to nurses as well. For pharmacists, the linking pin between patients and doctors, the ratio is 1:1000 in Kerala and 1:10,000 in case of UP.
Source: National Health Policy, 2018

 COVID-19 mitigating strategies: An example for other states 

Kerala was the first state to have announced a complete lockdown before the central government proposed a 21 days lockdown in the first phase on 24th March. The state also succeeded in slowing down the doubling of active cases with rate of recovery much higher than national average.
In terms of fiscal measures, the Kerala government announced R. 20,000 crore package to fight the pandemic before the central government announcement of PMGKY. Of this total amount, Rs 1,000 crore is assigned for rural guarantee programme, Rs 1,320 crore for welfare pension and Rs.1,000 crore for social security benefits and Rs 500 crore for health sector.
With the announcement of lockdown, migrant workers devoid of food and shelter assembled across many states to return to their homes. Kerala also witnessed such movement of migrants. However, the state thwarted their movement, insisted on their stay and promised them all assistance. The migrant workers were hailed as “guest workers.” 
State actively established relief camps and community kitchens for the migrants. As per the news, in this second phase of lockdown they are engaged in agriculture and local economic activities.
UP has adopted much stricter measures to contain the spread of pandemic similar to the one adopted in some East Asian countries. The government is taking staunch action against those violating the norms and spreading the virus into communities. In some case National Security Act is also imposed against the violators.
Along with the central government package, the state government has taken several measures to deal the issue of migrant workers crisis, Rs 1,000 cash incentives for daily wagers, rickshaw pullers and construction workers. The government announced a financial package of over Rs 333 crore to give cash handouts to an estimated 3.53 million daily wagers.
Since March 24, the state government is sending Rs 1,000 through RTGS in the accounts of more than 21 lakh construction workers under Workers’ Maintenance Scheme and UP is the first state announced free ration for card and non-card holders. 
Along with the arrangement of food and temporary shelters, One District One Product (ODOP) programme has been started to involve migrant workers in suitable economic activity in the respective districts.
Having witnessed the comparative advantages of two states with respect to demographic distribution, disease burden and health capacity along with upcoming mitigation measures, the two demographically, linguistically and culturally different states highlight many common lessons to adapt in working proactively with a socialist approach.
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*Respectively: Assistant Professor, Institute for Studies in Industrial Studies (ISID); Research Assistant, Centre de Sciences Humaines (CSH); Assistant Professor, Institute for Studies in Industrial Studies (ISID)

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