KOCHI (NYTIMES) - When India's second coronavirus wave slammed the country in April, leaving many cities without enough doctors, nurses, hospital beds or life-saving oxygen to cope, Mr Sajeev V.B. got the help he needed.
Local health workers quarantined the 52-year-old mechanic at home and connected him with a doctor over the phone. When he grew sicker, they mustered an ambulance that took him to a public hospital with an available bed. Oxygen was plentiful. He left 12 days later and was not billed for his treatment.
"I have no clue how the system works," he said. "All that I did was to inform my local health worker when I tested positive. They took over everything from that point."
His experience had much to do with where he lives: a suburb of Kochi, a city in the southern Indian state of Kerala. State officials have stepped in where the central government under Prime Minister Narendra Modi has failed, in many ways, to provide relief for victims of the world's worst coronavirus outbreak.
Though supplies have tightened, Kerala's hospitals enjoy access to oxygen, with officials having expanded production months ago. Coordination centres, called war rooms, direct patients and resources. Doctors there talk people at home through their illness. Kerala's leaders work closely with on-the-ground healthcare workers to watch local cases and deliver medicine.
"Kerala stands out as an exceptional case study when it comes to proactive pandemic response," said Dr Giridhar Babu, an epidemiologist at the Public Health Foundation of India, which is based in the northern city of Gurugram. He added that "their approach is very humane".
An ad hoc system of local officials, online networks, charities and volunteers has emerged in India to fill the gaps left by the stumbling response of the central government and many states. Patients around India have died for lack of oxygen in hospitals where beds filled up quickly.
Kerala is by no means out of trouble. Deaths are rising. Workers face long hours and tough conditions. The situation could still worsen as the outbreak spreads.
On paper, Kerala's death rate, at less than 0.4 per cent, is one of India's lowest. But even local officials acknowledge that the government's data is lacking. Dr Arun N.M., a physician who monitors the numbers, estimates that Kerala is catching only 1 in 5 deaths.
A relatively prosperous state of 35 million, Kerala presents particular challenges. Over 6 per cent of its population works abroad, mostly in the Middle East. Extensive travel forces local officials to carefully track people's whereabouts when a disease breaks out.
Kerala's policies can be traced to the earliest days of the outbreak, when a student returning there from Wuhan, China, in January 2020 became India's first recorded coronavirus case. Officials had learnt lessons from successfully tackling a 2018 outbreak of the Nipah virus, a rare and dangerous disease.
As borders closed last year and migrant workers came home, the state's disaster management team swung into action. Returning passengers were sent into home quarantine. If a person tested positive, local officials traced their contacts. Kerala's testing rate has been consistently above India's average, according to health data.
Experts say much of the credit for the system lies with 64-year-old former schoolteacher K.K. Shailaja who until recently was Kerala's health minister. Her role in fighting the Nipah virus inspired a character in a 2019 movie.
"She led the fight from the front," said health economist Rijo M. John, from the Rajagiri College of Social Sciences in Kochi. "Testing, tracing and tracking of contacts was very rigorous from the beginning."
Local officials have come under intense pressure. Last year, Mr Modi imposed one of the world's toughest lockdowns on the entire country, a move that slowed the virus but drove India into recession. This year, he has resisted a nationwide lockdown, leaving local governments to take their own steps.
India's states are also competing against one another for oxygen, medicine and vaccines.
"There has been a tendency to centralise decisions when things seemed under control and to deflect responsibility towards the states when things were not," said Mr Gilles Verniers, a professor of political science at Ashoka University.
To coordinate resources, Kerala officials assembled the war rooms, one for each of the state's 14 districts. In the district of Ernakulam, where Mr Sajeev lives, a team of 60 staffers monitor oxygen supplies, hospital beds and ambulances. Thirty doctors keep tabs on the more than 52,000 Covid-19 patients.
The war rooms collect data on hospital beds, ventilators and other factors, said Dr Aneesh V.G., a medical officer in the district. When doctors, via telephone, determine that a patient needs to be hospitalised, they notify the war room. Case numbers pop up on a giant screen. Workers decide what kind of care each person needs and then assign a hospital and an ambulance.
A separate group monitors oxygen supplies, calculating the burn rate of each hospital. Pointing to a screen, war room coordinator Eldho Sony said "we know who needs supply urgently and where it can be mobilised from".
Dr Athul Joseph Manuel, one of the doctors who designed the war room, said triage had been crucial.
"In many cities across the world, lack of medical resources was not the primary issue," he added. "It was the uneven distribution of cases that led to many hospitals getting overwhelmed."
Other places have set up similar centres, with varying effectiveness. Health experts say Kerala's have worked because the state has a history of investing in education and healthcare. It has more than 250 hospital beds per 100,000 people, roughly five times India's average, according to government and World Health Organisation data. It also has more doctors per person than most states.
Officials have also worked closely with state health clinics and local members of a national network of accredited social health activists, known in India as Ashas. The workers make sure that patients stick to their home quarantines and can get food and medicine. They also preach mask-wearing, social distancing and the virtues of vaccination. (Kerala's share of fully inoculated people is nearly double the national average of 3 per cent.)
Kerala has also won praise for how it has tracked virus variants. Scientists are studying whether a variant first found in India has worsened the country's outbreak, though they have been hindered by a lack of data. Kerala has used gene sequencing since November to track variants, helping to drive policy decisions, said Dr Vinod Scaria, a scientist at the CSIR Institute of Genomics and Integrative Biology in New Delhi.
"It's the only state that has not given up at any point in time," he added, noting that "they're eager to use evidence to drive policies."