It is going to be almost a year since vaccination against COVID-19 was rolled out in India for the adult population. In the midst of this massive drive, there have been numerous challenges including vaccine hesitancy and shortage in supplies. The latest issue is that some States have come up with their own strategies to ensure wider vaccination coverage — such as by making vaccination mandatory for entry into public places and workplaces — even though the Central Government has maintained that vaccination is voluntary. In a conversation moderated by Serena Josephine M. , K. Kolandaswamy and G.R. Ravindranath discuss whether vaccination should be made mandatory. Edited excerpts:
What is your assessment of India’s overall vaccination performance so far? During the initial days, there was vaccine hesitancy and there were supply issues. Do you think we could have done better in terms of creating awareness among the people?
K. Kolandaswamy: I think the COVID-19 vaccination programme is going on well. These are new vaccines, and perhaps for the first time, the whole population is getting vaccinated in such a short duration. The issues in vaccine supplies and logistics have been rectified now. The vaccination drive was done in a phased manner. We started with healthcare workers, frontline workers, then persons aged 60 years and above, then persons aged 45-plus with co-morbidities, and finally, persons above 18 years. There is reasonable vaccination coverage across the country. I think more than 142 crore doses have been administered in India, of which 8.2 crore doses have been administered in Tamil Nadu. But the last mile reach has become a challenge, particularly among the 50-plus population who have either received the first dose but are reluctant to get their second dose or have not received even their first dose yet. It is important to reach out to people who are still reluctant to get vaccinated. I feel we need to intensify efforts to educate people and take other approaches to reach out to them. We can enforce legal measures as well.
G.R. Ravindranath: Not only awareness, but also factors such as availability, accessibility and acceptability are important. We had problems with all these factors in the initial stages. There was vaccine hesitancy initially.
Compared to some developed countries, India’s vaccination coverage is poor. Many countries are moving towards booster doses, but we have not completed vaccination of all the eligible persons with even the first dose of the vaccine. Almost 23% of healthcare and frontline workers are yet to get their second dose in India. This is a huge crisis in public health as they will have to treat patients in case of a third wave. Even in Tamil Nadu, one crore eligible persons are yet to take the first dose, while 93 lakh are due/overdue for their second dose. Governments should have promoted scientific awareness and ensured accessibility. So, we have a lot more to do. Anti-vaxxers are actively spreading a lot of rumours, pseudoscience and unscientific information. Rumours are spread on social media and through WhatsApp. So, we have a big task at hand. The government should make vaccination a people’s movement by involving people from all walks of life.
Is it feasible to make vaccination mandatory? Historically, have governments made any vaccination programme mandatory? Some States are aiming at 100% coverage. Is this possible?
K. Kolandaswamy: Yes, it is feasible. I can claim to have the right to not get vaccinated but others are at risk of getting infected by me. So, my right ends when someone else’s right starts. Rather than the individual’s right, the community’s right, safety and health are top priority. In a classic example, smallpox, a dreaded disease, was eradicated by making vaccination compulsory from 1965 to 1975. Across the country, COVID-19 has been declared a notifiable disease under different Acts of the States or the Epidemic Diseases Act. In Tamil Nadu, the State government declared it a notifiable disease under the Tamil Nadu Public Health Act of 1939. So, local health authorities have the power to make vaccination mandatory under Section 76. If anyone seeks exemption, they will have to approach the Judicial Magistrate. They cannot refuse to get vaccinated unless on acceptable medical grounds; unless vaccination could endanger their lives, which is very rare. So, enforcing legal measures to make people get vaccinated is highly feasible.
G.R. Ravindranath: It is possible to achieve 100% vaccination by intensifying campaigns, promoting vaccination and putting indirect pressure on the people. Some cities have already achieved 100% coverage (first dose). We have to study such models. The Nilgiris district model in Tamil Nadu is one. Many countries have made vaccination compulsory. Tamil Nadu has made vaccination mandatory for entry into public places.
The rights of an individual can be curtailed for the rights of the community. During a pandemic, we have to look at the community’s rights. But we ought to come up with counter campaigns against anti-vaxxers who are spreading several rumours such as ‘vaccines could produce infertility’ or ‘vaccines could alter the DNA in the body’. We need to educate people about the importance of getting vaccinated — we need to tell them that it is a powerful weapon against the pandemic and will prevent severe disease, hospitalisation and death. A vaccine not only protects the individual but also safeguards others. Vaccination has brought in several changes in our lives. It has eradicated smallpox. Polio should be eradicated soon. Millions of children have been protected due to vaccination.
The Central government has maintained that vaccination is voluntary, while noting that any misconceived doubts could result in vaccine hesitancy. Do you think governments have created adequate awareness on vaccines and their possible adverse effects? There are still some who fear vaccines. Has enough trust been built among the people?
K. Kolandaswamy: The vaccination coverage achieved so far would not have been possible but for the education, awareness and trust built among people. At the same time, we should further educate people in a very focussed manner. Governments and health departments are taking adequate measures but we can still list out these population sub-groups and take up targeted efforts to create awareness. We need to focus on educating people and make sure that 100% immunisation is achieved. This may take a little more time. In public health, we believe in the education and service approach much more than the legal approach. At the same time, legal measures could be used appropriately — by restricting entry, incentives or disincentives — to convince people to get vaccinated. Rumour-mongering groups and anti-vaccine lobbies must be dealt with seriously, and legal action should be taken against them.
G.R. Ravindranath: Steps to create awareness have been taken by governments but they are inadequate. There should be innovative and creative advertisements in the media to draw people towards vaccination. We can take up door-to-door campaigns with local groups. In some districts, they have achieved complete vaccination by involving local people for campaigns. Panchayat leaders, ward members and women from self-help groups should be first made aware and then educate the public. We have to make a lot of effort to promote vaccines. There are aggressive campaigns against vaccines. We have to rely on science.
Let’s look at vaccine equity and access. Has vaccination reached even the remotest villages in the country?
K. Kolandaswamy: Yes. We have come across several video clippings of healthcare workers travelling to inaccessible and remote places such as hillocks and forest areas. Initially, we had issues in the availability of vaccines and logistics. These issues have been solved gradually. Accessibility and availability have been fully addressed. Now the real challenge is to reach the reluctant population.
G.R. Ravindranath: Eligible persons should be vaccinated by the middle of next year. For this, vaccine equity is very important. Many Western and developed countries have more vaccines than they require and are wasting/stockpiling vaccines, while low-economic countries do not have sufficient vaccines. In fact, only less than 20% have been vaccinated in low-economic countries. This is a huge problem and will create a lot of new strains or variants in the future. This is why the World Health Organization has stated that instead of giving booster shots to all, we must provide two doses of vaccines to all the eligible people across the world. Developed countries have a big role to play. They should understand their responsibilities and the problems faced by developing and low-economic countries. The COVAX programme should be respected. All countries producing adequate vaccines must supply them to the COVAX programme of the WHO. India has a lot of manufacturing capacity. So, the government should take measures, and also involve public sector companies in vaccine production.
Do you think there is transparency on reporting adverse events following immunisation in the country?
K. Kolandaswamy: Reporting of adverse events is systematically done at the primary, sub-centre, block and district levels. There are various committees that include specialists who go through the reports. I strongly believe that adverse events following immunisation are reported in a transparent manner. There is no need for any doubt on the reporting of adverse events following immunisation and the safety of vaccines. People who have any fears can get vaccinated in a larger facility where there are many doctors and emergency services.
What should be the way ahead in promoting vaccination among people?
G.R. Ravindranath : Governments should come up with advertisements on television or newspapers. There should be adequate stock of vaccines, while newer vaccines should be introduced. We should vaccinate children, while booster doses should be administered to the eligible population. We must increase vaccine production and supply for poor countries to end the pandemic. Governments should provide incentives for people who get vaccinated. Building the confidence of people is very important.
K. Kolandaswamy: The focus should be on educating people by involving doctors, community influencers such as religious leaders, political leaders, panchayat leaders and other influential groups, frontline and healthcare workers. I think we can promote vaccines by putting social and legal pressure on the reluctant population and taking stringent action against anti-vaxxers. If full vaccination is achieved in the next few months, and we consider vaccinating children, the overall incidence of COVID-19 will come down.
G.R. Ravindranath is the General Secretary of Doctors Association for Social Equality; K. Kolandaswamy is a public health expert and formerly director of the Public Health and Preventive Medicine, Government of Tamil Nadu