By the time the call came, the virus had raced ahead. Two brothers were dead, and several others had had their defences infiltrated. “It is Nipah,” a senior virologist on the line told KK Shailaja, the Kerala health minister. “It was the first time I had heard of it,” she recalls. The night before, on May 18, 2018, Shailaja had been informed of the worrying death of a young man, at a private hospital in Kozhikode. “I set off the next morning from Kannur. On the way, the call came. Till I reached Kozhikode, I Googled and tried to read up. I realised this was a killer virus. There was no medicine, no treatment protocol. We were afraid, but we had to act,” says Shailaja.
Kerala did act, weathering the paranoia of Nipah-1, which claimed 17 lives, and containing the second outbreak swiftly this year. The 63-year-old minister was the face of the state government’s response; she camped in Kozhikode, coordinated with the medical community as it raced to isolate the human carriers of the virus. A rare public healthcare success story in a country not known for many, the Nipah fightback has inspired acclaim, as well as a Malayalam medical-thriller Virus, directed by Aashiq Abu.
Actor Revathy plays Shailaja, nailing the appearance of the senior CPI (M) leader — in a neat cotton sari, hair pulled back, strong and mostly silent. But the affable woman at the Kerala Legislative Assembly in Thiruvananthapuram, frowns much less. “It is true,” she says, breaking into a laugh. “She looked desperate and worried all the time. I was handling all meetings. I couldn’t afford to show any fear,” says Shailaja. Experts had anticipated that the virus, transmitted from bats to humans, would lead to “at least 200 deaths”.
Without the urgent response Kerala mounted, that prophecy might have come to pass, says G Arunkumar, director of the Manipal Centre for Virus Research, who had called Shailaja that day with the test results. He was also a part of the core medical and administrative cell that assembled at Ground Zero under Shailaja. “She was there at the epicentre, with senior members of the health department. So, decisions were taken swiftly. She was open to suggestions, took technical advice seriously and put in place a system of transparent communication. That gave confidence to the system,” says Dr Arunkumar.
But the fear spread faster than the virus.
People with a cough were being turned away from buses and autorickshaws, weddings and large gatherings had been cancelled. Within the core Nipah cell, there were worries of a biomedical weapon attack (ruled out later when the genome sequencing of the virus showed no mutation, says Dr Arunkumar). More importantly, there was uncertainty about how far the virus had spread.
At Changaroth village, home to Mohammad Sabith, the first Nipah victim to whom all but one infections were eventually traced, people were fleeing their homes. Shailaja recalls being counselled against heading to the village. “My team said if the minister catches the virus, everything will collapse. But I said no, people will not listen if you don’t go there,” she says. Accompanied by another minister, doctors, ICMR (Indian Council of Medical Research) officials and Dr Arunkumar, she went to the panchayat office.
There, they met residents, wearing masks, and afraid of the air they were breathing. “Should we leave the village? Does it spread through the air?” they asked. “I let the scientists explain everything. That it doesn’t spread through air, but through droplets of bodily fluid. That if someone has a cough, one should stand at least two metres away,” she recalls.
A grassroots politician in Kerala for close to four decades, pitching herself into the midst of a crisis came naturally to Shailaja. Born a year after the first communist government took office in Kerala in 1957, Shailaja grew up in a political family in Kannur; her granduncles were communist workers and freedom fighters. Her inspiration was her grandmother, an Ezhava matriarch with a fierce belief in political life. “My grandma was a social reformer. She fought against untouchability and false beliefs. She was drawn to Communism,” says the minister. Little Shailaja accompanied her grandmother to political meetings as a child; when she grew older, her grandmother nudged her into the public sphere. “She was eager that I join politics,” says Shailaja.
Shailaja joined politics as a student, but only after 15 years of work in the CPM’s women and youth wings did she contest an assembly election from the Koothuparamba constituency in 1996. “Till then, I had not contested a panchayat election,” says the three-time MLA, who has risen through the ranks. In 2016, she was made minister for health, social justice and woman and child development.
She admits she has had it easier than most women politicians in Kerala, which, despite its glowing HDI (human development index) indicators, is not an island of gender equity. “My colleagues suffer because of the restrictions placed by in-laws and husbands. Even outside, people are not ready to accept women as leaders. When the 50 per cent reservation for women in panchayats was announced, someone asked me: ‘What will be the fate of the panchayat now?’ And see how well women did,” she says.
For years, Kerala has been ahead of the pack in India, where healthcare systems range from barely functional to dystopic. Its impressive health indices have been sustained by a political culture that invested in public health and education. “From 1957 onwards, we created a network where there is a primary health centre in each panchayat; a subcentre for every 7,000 people; we built medical colleges, secondary and tertiary hospitals,” says Shailaja.
But the irony is unmistakable: while the containment of Nipah is a credit to the health community’s robust response, the virus spread the most in two crowded hospitals. In a paper written after the first outbreak was contained, Dr Arunkumar pointed out that Nipah would not have claimed as many lives if basic infection control measures were followed in Perambra Taluk hospital, where Sabith was first admitted, and the Kozhikode Medical College, where he died. It is at the mortal and final stage of the disease that the Nipah victim becomes a toxic spreader of the disease. “For instance, when Sabith began coughing badly in Perambra, he should have been given a mask. Nurses should have worn gloves and masks while assisting him. In a crowded hospital, he should not have spent four hours in a corridor waiting to be taken for a CT scan. He ended up giving the infection to 10 more people,” says Dr Arunkumar.
While these are simple lessons for the future, they are linked to the manpower and financial crunch in Kerala’s government hospitals, Dr Arunkumar argues. “If there are two nurses attending to 60 people, how will they follow infection control? Are there enough gloves and masks? These are necessary investments,” he says.
Shailaja agrees that Kerala’s healthcare is under stress. “When I took office, I found 67 per cent of patients were going to private hospitals. So out-of-pocket expenditure is very high. We realised the problem began with primary health centres, which have only one doctor. So, people head directly to medical colleges or private hospitals, even for simple ailments. We started a programme to make public hospitals people-friendly and technologically modern,” she says. In the way stands a resource crunch, she admits.
Critics argue that while the Left government has gone to town over Nipah and its No.1 rank in a recent report by Niti Aayog on state healthcare, it has not addressed the ground reality. “IMR (infant mortality rate) and MMR (maternal mortality rate) indices cannot remain the benchmark. There is no policy on how to counter non-communicable diseases, the biggest problem in Kerala. The Nipah response was commendable, but we need a health minister, not just a Nipah minister,” says Joe Thomas, public health expert.
Despite these many constraints, the Kerala government did not let down its guard. “The scientists had warned us. Once Nipah-1 was over, we contacted doctors, health workers and officials and told them to be careful next year,” says Shailaja. From November 2018 onwards, almost all severe cases of encephalitis and respiratory disorders in government hospitals were tested. As expected, a Nipah case turned up this May in a private hospital in Ernakulam. Fortunately, the 23-year-old student did not have a serious respiratory ailment, which minimised chances of contagion. “Last year, no one taught us the protocol. But this time we were prepared and we could contain it,” she says.
Nipah-1 disrupted both life and death. Shailaja recalls how difficult it was to call nurse Lini Puthussery’s husband to tell them that her body could not be handed over for the last rites. When Sabith’s father Moosa died, another challenge emerged. “His relatives were in tears. They said we can’t burn the body. I went back to the health officials and asked them if there was any other way. Some of them said that in the Ebola cases, burial was done in deep pits, after sanitisation through chemicals. But when we decided to take the body to the graveyard, people — Hindus and Muslims — gathered there to block our way. We had to call the religious leaders to break the deadlock,” she recalls. Moosa was finally buried.
Miracles happened, too. Two patients survived the infection in 2018, both health workers (nurse Ajanya and Ubeesh). When they were finally disease-free, Shailaja went to meet them. “We were sending those people back to society…but will people believe they are fine? So, I had to go. I did not wear a mask when I meet them. We spoke, and, at last, I touched the girl,” she says. It was a moment that nurse Ajanya recalled with gratitude. If all goes well, in a few weeks, Shailaja should be heading to the Ernakulam hospital — to meet the sole Nipah patient when he is discharged into health and freedom.
This article appeared in the print edition with the headline ‘Extraordinary Measures’