Chennai, India – Rajendran Dilip waits anxiously outside Chennai’s dedicated 500-bed government hospital treating critically ill COVID-19 patients in the city’s commercial hub where his 53-year-old father Rajendran has been brought in an ambulance a couple of hours ago.
Rajendran’s oxygen levels began dropping precipitously two days after he tested positive for COVID. This was after he took his first dose of the AstraZeneca vaccine late last month.
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“We tried several hospitals, both private and government, but there were no beds available. Finally, when his oxygen level began fluctuating, we had no choice but to dial 108,” Dilip, 24, told Al Jazeera, referring to the emergency response number for medical, fire and police services in the southern Indian state of Tamil Nadu.
“They arrived within 10 minutes, and my father’s oxygen level, which was around 93, was bettered to 99 by the time we reached the hospital,” the 24-year-old IT worker said.
But not everyone at the hospital was as fortunate as Dilip’s father.
Another man, who did not wish to be identified, said he brought his father-in-law, who was in his 70s and developed severe COVID-19 symptoms, only to find that there were no beds available.
A member of the cleaning staff at the hospital says the virus is a “silent killer” and that she witnessed 20 deaths on Friday, the day the state’s newly elected administration announced a two-week lockdown starting the next day.
“How can we accommodate 400 people when there are 40 (available) beds? We would need hundreds more such hospitals, and even that would not be enough,” a flustered nurse at the hospital’s COVID-19 “control room” said.
Tamil Nadu reported 26,465 new coronavirus cases last Friday, the highest until then since the outbreak began a year ago.
Over the next two days, reports on lack of medical oxygen and hospital beds across the state began to pour in as cases spiked to nearly 30,000 a day.
Things have not been much different in neighbouring Kerala, which announced a similar 10-day lockdown beginning Saturday. A day later, nearly 36,000 people in the state tested positive.
On Monday, Tamil Nadu reported 28,978 new cases while Kerala recorded 27,487.
Robust healthcare systems
India’s two southernmost states, home to about 110 million people – 35 million in Kerala and 75 million in Tamil Nadu – are often cited as models for their robust public and private healthcare systems.
It was in Kerala that India’s first case of the coronavirus was detected on January 31 last year. But the state was able to effectively contain the spread of the virus in the early stages of the pandemic, winning global acclaim.
Much of the state’s success is attributed to its political leadership, an alliance of communist parties that returned to power for a rare second term on May 2, beating the centrist alliance led by the Indian National Congress as well as Prime Minister Narendra Modi’s Hindu nationalist Bharatiya Janata Party (BJP).
Kerala’s Health Minister KK Shailaja, a former school teacher who had already become the face of the state’s fight again COVID-19, won her seat by the largest victory margin ever in the state’s assembly election.
The doctor to patient ratio in Kerala is 25 to every 10,000 people, better than Canada’s at 24.43. In Tamil Nadu, it is 16:10,000, which is above the 10:10,000 recommended by the World Health Organization.
Both states also began putting in place contingency infrastructure early last year, expecting cyclical spikes and troughs of COVID-19 infections. Medical oxygen production was augmented and hospital capacities were increased.
Their governments also began triaging coronavirus patients into three categories – mild, moderate, and critical – to ensure targeted treatment, which kept the virus-related mortalities lower than the rest of the country.
Until late March, Kerala’s case fatality rate (CFR), which is the percentage of deaths to positive coronavirus cases, hovered at 0.32 percent, while in Tamil Nadu, it was 0.52.
Experts however say India’s CFR might not give an accurate picture of fatalities as many mildly symptomatic people go untested, coupled with a generally low rate of testing and widespread reports of massive undercounting of virus-related deaths.
Cases rise in the second wave
It came as no surprise that Tamil Nadu and Kerala were more effective than other Indian states in containing the pandemic in its initial stages.
But since mid-April, about 10 days after both the states went to regional polls held every five years, the infections began to rise again.
Kerala’s former health secretary Rajiv Sadanandan, who oversaw the state’s initial coronavirus response, squarely blamed the “entire political class for behaving irresponsibly” during election campaigns. He said the administration expected a rise in numbers after the polls.
Sadanandan added that the “sheer ferocity” of the new strains of virus “was a shock to us”, leading the government to “press the panic button and ordering a lockdown”.
Journalist Binu Aravind, who works for Kerala’s popular Manorama news channel, told Al Jazeera that the contact tracing and quarantining protocol developed during the Nipah outbreak in 2016 and the volunteer support groups formed following the 2018 floods helped the state government.
Aravind said there is a wide perception among residents in the state that “the government will take care” if things get out of hand.
Amid a nationwide shortage of medical oxygen, the Tamil Nadu government assured the Madras High Court on April 23 that the state had a manufacturing capacity of 400 metric tonnes of oxygen compared with its need, which was 250 metric tonnes, and a storage capacity of 1,200 metric tonnes, or three times higher.
But two weeks later, the government returned to the court, blaming the Modi government for diverting medical oxygen to other states amid a surge when demand in the state outstripped manufacturing capacity by 50 metric tonnes.
Tamil Nadu’s health secretary Jeganathan Radhakrishnan told Al Jazeera the state could handle the surge provided there was cooperation from New Delhi. He said the central government’s “national allocation plan has hit us badly as some amount of our oxygen goes to other states”.
Experts attribute the spike in infection rates in the two states to a significant number of diaspora returning from abroad.
Of Kerala’s 4 million expat community, more than half returned to the state during the pandemic, with nearly a million jobless now, according to government data.
Tamil Nadu is India’s most urbanised state, with about 50 percent of its 75 million people residing in cities and towns. Kerala is often described as a state without the urban-rural divide, with civic infrastructure in rural areas being comparable to those in cities.
Kerala also has the highest elderly population in the country, with about a fifth of its population over 60, who are more susceptible to COVID-19 infection. Tamil Nadu is third on the list.
Rukmini, a Chennai-based data journalist who has been tracking India’s coronavirus trajectory on her podcast, The Moving Curve, says these factors make Tamil Nadu and Kerala more susceptible to experience greater spikes in infections.
Rukmini said the yardsticks used to measure successes and failures need to shift in the second wave. For instance, in cases of Tamil Nadu and Kerala, Rukmini said “the real test of their health systems would be their ability to keep the mortality numbers low”, like during the earlier wave.
Ironically, Kerala reducing the infection rate to about one-tenth of its population, almost half the national average, left a larger pool of vulnerable people, according to serological surveillance published by the Indian Council of Medical Research in December 2020.
Vaccine hesitancy is another problem facing several parts of India, fuelled by fake news on social media.
The death of popular actor Vivek in Tamil Nadu a day after he took his first dose of vaccine led to widespread speculation over the shot’s side effects, despite the hospital that treated him announcing he died of a heart attack.
A 28-year-old autorickshaw driver Thirunavukarasu Krishnamurthi said his family decided not to take the vaccine after hearing the news. He said his 90-year-old grandmother “still cooks for herself, cleans and occasionally works the fields”.
“Why kill her with this injection?” he asked.