Over a year after the SARS-CoV-2 struck the world, it is now clear that the virus is not going away any time soon and breaking the chain of transmission seems unlikely. The best policy against COVID-19, thus, appears to be to ensure that the infection is mild in most people, and that in those in whom the disease might be more severe, it can be pushed towards a milder form by vaccination. Therefore, it is important to vaccinate as many people as possible .
Unfortunately, the number of vaccine doses available is limited at present. Technicalities of vaccine production make it likely that indigenous manufacturers will require three to six months from now to increase capacity significantly. The whole virion vaccine from the National Institute of Virology, Pune, currently being manufactured by Bharat Biotech, is produced in facilities where biological safety requirements are essential and will take time to be upscaled.
The mRNA vaccine technology is new. Though the Moderna vaccine does not have intellectual property constraints and Gennova is making its own mRNA vaccine based on science from HDT in the United States, it is unrealistic to expect Indian manufacturers to be able to embrace this new technology without handholding through the process.
Import of vaccines in quantities that can make a difference will be possible perhaps from August, when wealthy nations would have made substantial progress in the immunisation of their populations.
India is thus faced with the unpleasant reality of having to decide the priority in which it is going to vaccinate its population, i.e., the order in which the different groups should be vaccinated. However, it can take comfort in the fact that all countries were forced to make this decision, and nowhere in the world has it been possible to vaccinate the entire population at one go.
The experience of vaccine hesitancy should not distract us from the goal of inoculating as many people as quickly as possible. The speed with which the vaccines were developed, the introduction of new technology, reports of a few serious adverse events, the decision of certain wealthy countries to halt using the AstraZeneca shot due to concerns over blood clots and because they had other vaccines, contributed to doubts about the safety of vaccines in India.
But it is now clear that vaccines are highly effective and the risks are extremely low. Indeed, vaccines are the only way that we can stay ahead of the virus. It is, hence, important to draw in behavioural scientists to address vaccine hesitancy and ensure that the population is covered.
Should we vaccinate the most vulnerable, i.e., those who are most likely to succumb to the disease if they get infected, or should we vaccinate the population which contributes the most to the economy? This is a stark and perhaps unpalatable way to delineate the choice, but it is a factual position. Should we first vaccinate the elderly who are at high risk of serious illness and death, or should we vaccinate the working population so that we can open workplaces and revive the economy? Wealthy countries with small populations went with the first option, but India must design a vaccine policy carefully because breaking the chain of transmission is not an option currently. Repeated lockdowns do not break the chain of transmission of the infection. They only slow the spread of the virus for a period, and when they are lifted, as they must be, the virus surfaces again.
The ethical and humane choice would be to vaccinate the most vulnerable first. If this is impractical, then the choice would be to vaccinate some combination of the elderly vulnerable and the working population in every tranche. This should be worked out using data and the basis of the decision should be made public. Opaque decision-making leads to a loss of trust in governance and social discord.
Access to all
Leaving the vaccination policy to market forces is neither ethical nor practical. Allowing all adults to access the vaccine at the same time introduces ethical distortions, which no humane society should face. Those with the resources to get vaccinated early are the least vulnerable because they also have the ability to protect themselves.
Attempts to make vaccination more accessible through technology, as is being done with the Co-WIN app, are failing at the moment. Many States have declared that they will bear the cost for all their citizens, but this is a decision that they should not have been forced to make; the approach also does not address the dilemma of who will get the vaccine and in which order, given the very limited supply.
Governments are elected to represent the will of the people. In a civilised society, when a life-saving resource is in short supply, the government must take it upon itself to both enhance the supply and formulate a policy to allocate the resource. In India, the Centre should desist from being opaque in its decisions, abdicating its responsibility, transferring expenses to State governments, and allowing market forces to decide on vaccine access for a substantial part of the population.
Comment | Undermining ‘vaccination for all’
Given our current circumstances, the State governments are struggling to find a way forward amid the scramble for vaccines. There are many options for distribution, and as a society, we ought to make decisions that are based on science and fairness. The logical basis of the decision should be explained.
Dr. George Thomas is the former editor of The Indian Journal of Medical Ethics; Dr. Gagandeep Kang is Professor Wellcome Trust Research Laboratory at the Christian Medical College, Vellore; Dr. Jayaprakash Muliyil is former Principal of the Christian Medical College, Vellore