The TLDR: As the second wave recedes, Covid cases are falling across the country—except in Kerala. Has the state dropped the ball—or is it the victim of its own success? We take a quick look to see why Kerala’s numbers remain high.

First, the numbers

Kerala added 22,064 new cases on Thursday—taking its total number of active cases to 154,000—which is 37% of the national total. Just a couple of days ago, that number was 50%—when Kerala became the first state to report over 20K daily cases in 50 days. The state has a high test positivity rate of 13.53%—which indicates the percentage of tests that turn up positive. For comparison, on the same day, Maharashtra reported 7242 new cases, while Delhi had 51 new cases. 

And unlike the rest of the country, the number of cases are still rising across the state: They have jumped by 64% since June 28 in Kottayam, by 59% in Malappuram, and 46.5% in Ernakulam. 

Silver lining: Kerala’s Case Fatality Ratio—the number of infections that result in death—is happily still the lowest in the country at 0.5%, i.e. only one in every 200 Covid cases lead to a fatality.

Ok, so what’s going on?

Depends on which factor you consider.

The Eid factor: The union government is very clear about the reason: “politics of appeasement.” This refers to Kerala’s decision to ease shopping restrictions in the lead up to Eid-ul-Azha (July 21) for people who have taken at least one Covid-19 vaccine dose. And it was reprimanded by the Supreme Court for doing so—but the Court did not strike down the order. The justification offered by the state government: Pressure from shopkeepers and traders who had stocked up in anticipation of festival sales. And as Kerala’s numbers continue to grow, BJP leaders have pointed to its Eid policy as a reason. For example, cabinet minister V Muraleedharan declared:

“The Kerala government has tried to utilise this pandemic for political benefits and that’s the whole purpose of these relaxations. In fact, there was fake propaganda right from the beginning of the pandemic when the state government claimed that they have contained the Covid-19 due to their effective management.”

Others were more blunt: “Eid relaxation is coming home to roost. Silence of the secularists is deafening.” Even the Health Ministry in its letter to the state government made mysterious references to “superspreader events.”

Point to note: It usually takes a month for the effects of any event to show up in overall Covid numbers.

Low immunity: Seroprevalence surveys conduct random sampling to figure out what percentage of the population have antibodies—which shows that they have been exposed to the virus within the last few months.  The nationwide survey results released earlier this month shows that only 44% of people in Kerala have antibodies—compared to 67.6% for all of India. In fact, Kerala’s numbers have been consistently lower than the national average across all four such surveys. This means Kerala simply has a more vulnerable population. In comparison, the percentage for Andhra Pradesh is 70.2%, and Tamil Nadu is 69.2%—which could explain their lower numbers. OTOH, Maharashtra is only 58%—and it has higher numbers than the rest.

Point to note: This means Kerala has actually been successful in implementing Covid-safety protocols in earlier waves—which is why most of its population has not been exposed to the virus. 

Higher testing: Kerala has consistently administered more Covid tests than other states—and only Delhi conducts more tests per million in comparison. And this is why there isn’t a huge gap between the official number of cases—and far higher percentages thrown up by sero surveys. Kerala has been able to detect one in every six Covid cases while the ratio at the national level is one in 33. Simply put, more testing throws up more infections. But there is still the worrying test positivity rate—i.e. the number of these tests that turn up positive—which is consistently higher than 10%. One possibility is that it is high because the state only tests symptomatic cases. But a high TPR still indicates a worrying spread of the disease—and ironically, flags the need for even more testing. 

Vaccination rates: Kerala is vaccinating its citizens at a faster rate than the rest of the country. Over 37% of its population has received at least one dose, and 16% are fully vaccinated. In comparison, all-India numbers are 25.63% and 7.1%, respectively. But the numbers are still not high enough to stave off the possibility of a third wave. It is also why the Kerala government responded to the jibes over Eid by telling the union government to dole out more vaccines rather than “free advice.”

Delta variant: The presence of a highly contagious variant will push up cases in a mostly uninfected population—and in the absence of widespread vaccination. As a leading virologist puts it: “Delta virus is like a heat-seeking missile. It will seek out uninfected people.”

So should we be worried about Kerala?

Yes and no. Some medical experts argue that the state, in fact, is doing exactly the right thing: flattening the curve. It is keeping the numbers under control—and slowing down the spread—so hospitals are not overwhelmed. So it’s managing the pandemic until the vaccinations kick in:

“While [the numbers] provide the inadvertent impression that the state is unable to contain the epidemic, a slower spread imposes lower stress on the public healthcare system and improves the chances of saving each life… Kerala has not failed in containing the pandemic. If anything, the state has done a reasonably good job of managing it and its healthcare system is reasonably well-placed to manage future waves of COVID-19 as well. But such waves are expected to not be as severe as the second one was, given the pace at which Kerala is vaccinating its population.”

OTOH: Kerala’s numbers have plateaued at a fairly high level—and its test positivity rate is still worryingly high. And with a vulnerable population and a short supply of vaccines, a third wave is a very real possibility. Plus: Onam is coming up soon.

Reading list

There isn’t much else on the subject. Times of India has a bunch of charts that show why Kerala is a worry. Health economist Rijo M John takes a deep dive into those numbers to show why Kerala is actually a-okay in The Wire. Hindu Business Line spoke to leading virologist T Jacob John who is also not that worried. And Gagandeep Kang offers a resounding defense of the Kerala model in this interview with Karan Thapar.