Though an American now, I hail from the southern state of Kerala, in India; one with strong roots in commitment to its people. Historically, Kerala has been a state with much to boast of, achieving milestones in education, gender equality, and, perhaps most evident in our current times, healthcare. People have spoken of the “Kerala Model” in health along with other countries like Cuba and Sri Lanka. The state had the first public health clinic in India specifically focused on smallpox eradication. It has consistently improved or maintained high health indices in life indicators such as the infant mortality rate and life expectancy at birth. Kerala is one of the only states in India to have a higher ratio of women to men, significant due to the cultural pressures on gender preference for a male child commonly seen across Asia. Even during the pandemics of 1900’s, the state of Travancore and Cochin, having great visionaries in health, was able to take measures to dampen the impact of the tragedies occurring worldwide. These were all the glories of the past. Now we are in a different era; the post-Covid era.


Dr. Jacob Eapen.

Covid-19 has swept the world and has proved to be a litmus test to the leadership of many countries. My observation is where ever the leadership was weak the virus has come in strong. This is a fact that many may not want to accept, but we have enough evidence to prove the point. The USA and Brazil, two countries which are most hardly hit have leaders who refused to believe in the forecasts for the virus’ spread provided to them by their own public health experts. This is most definitely a war; a war between a pathogen and science. In January, when the epidemic was just taking hold in many countries, I was invited to Kerala for a panel discussion on Covid. When I stated that it is a war we are waging, a senior faculty of a local medical college who was also a speaker, questioned my use of the word “war” in this context. Even Tolstoy would agree that in this case, it is a war and there is no peace. It may not be fair to compare a state in India to a country the size of the USA. Kerala had much to brag about the numbers for Covid until about a month ago when numbers started rising. In a pandemic, there is no time to compare with others. The focus needs to be on the mission as we have no time to be distracted by laurels. The game is not yet over. Distractions do not help in this fight.

During a pandemic, it is vital for us to stay united in our message and provide respect to and space for our most experienced public health officials to make their recommendations based on science.  This is not the time to have a division between the government and local health care bodies. Viruses will always take advantage of the gaps in the system. This has happened both in Kerala and the United States, but the messages from both have been different. In the USA, leadership has turned away from on its former oracle of public health, The Centers for Disease Control (CDC). The decision-makers’ agenda did not align with the CDC’s science and so it has been thwarted in its work. Though K.K. Shailaja, Health Minister of Kerala, was internationally recognized for her effective leadership in Kerala’s Covid-19 response, even there science (the Indian Medical Association) and politics’ message has diverged. When politics is placed above science, the leadership is effectively turning their back on the hard work done by the healthcare workers and scientists. Egos must be put aside, and respect must be shown by leadership to the “boots on the ground” actively fighting in the trenches. These are the people that are most proximal to the virus and thus know its evolutionary changes best.


Today as the number of new cases rises in both Kerala and the United States, this will be the real test of their mettle. Kerala has been able to keep the case fatality very low so far (0.39%) compared to the United States (4%). Maybe it is because the state has started seeing the second surge only now. The case fatality will depend upon how prepared we are as hospital admissions surge. Are we prepared? Is the virulence of the virus different in that part of the world? Has BCG vaccinations that are given in India helped with the virulence?


At this current stage all we can do is to identify cases early and quarantine them to avoid a massive spread. This needs testing. Testing is a critical tool that helps us diagnose and treat those who become infected by COVID-19. Testing also helps us understand how COVID-19 moves through our communities so we can identify areas where transmission is occurring. The testing rates in the United States are still relatively low compared to many other countries. India, which is in the forefront of diagnostics should be having many cost-effective antigen tests approved by ICMR yet still has a very low testing rate.

The situation is also complicated by “super spreaders”, those that have a much higher rate of virus transmission compared to the general population. At this time, we need superheroes to help contain this outbreak. At the end of all this we will have to see if the honorable minister Shailaja is truly a superhero.


It is like watching the previews of a movie but still having to wait for the whole movie to reveal its ending. I hope the wait is not too long… and by then the roots don’t buckle.


[Dr. Jacob Eapen, a Medical Director at the Alameda Health System(AHS) and a member of the Board of Directors at the Washington Hospital in Fremont, California. The views expressed are his own.]