Let me start with a success story. Not one but two. First is small pox vaccination and eradication from India. India was one of the few countries where small pox still existed in the early 70s. With collaboration with WHO, focused program was launched in 1972. By May 1975, the last known Indian smallpox patient, a 30-year-old female, was identified. By April 1977, two-year search and active surveillance activities confirmed that India was free of smallpox. Within 3 years, small pox was eradicated from India.

This was when India’s GDP was low. In absolute terms, budget allocation for public spending was much less compared to what it is now. No digital India, tracking done with paper and pen, manually tallied and checked. What got achieved was phenomenal considering the challenges of those times.

Second success story related to polio vaccination. Fast forward 35 years. Better public health infrastructure than 70s, but still not there where it needs to be if we look at the health metrics. Pop Quiz: how many polio vaccines got administered in a single day in India? When India ran two National Immunization Days in 2011? Unless you knew the number already I can safely guess you are way off. It came as a big surprise to me – I missed it when I blogged on India Growth Story – Part 1, Part 2, Part 3, Part 4, Part 5. A whopping 172 million children were vaccinated. Yes, 172 million.  Looking at how it all got pulled together is mind boggling – 2.5M vaccinators, 2M vaccine carriers. No, there is no chest thumping here. What this tells us is, by getting the experts and getting the state, private, NGOs, and civil societies together, these are solvable problems.

As a country with state, WHO, NGOs, and civic societies coming together we successfully eradicated smallpox and polio. That begs the question? Where did we go wrong with COVID-19 vaccination? How did we end up in the situation we are in now – losing thousands of people every day to the virus. Severity of what the whole population is going through now could have been vastly lessened by pushing the vaccination with war footing. So, the question remains…where it got messed up?

It isn’t for lack of data. By March 2020, COVID-19 had entered most of the countries, but not much information was available. While we knew spread rate was high, effective medical treatment was not clear at that time. Doctors across the world were trying different combinations and sharing the data. But by Sep 2020 time frame, we had enough information about the virus. Multiple vaccines were undergoing trial. In India, first wave was slowly on its way out.

By that time, we knew lockdown is not preferable. Lockdown doesn’t kill the virus, it only slows down the spread. We all saw the plight of migrant workers who paid the highest price of the lockdown. Lockdown’s impact on economy is steep. Lockdown pushed lower income group in to poverty. India is a rich country with lots of poor people. With high % of population either living under poverty physical distancing, hand washing, and home quarantine are a luxury for them to practice. Burdening the citizens through another lockdown without a safety net and support system is inhumane thing to do. Which means to stop the spread vaccination is the only solution.

Our public health and healthcare infrastructure, while we have made good progress from the time of Independence, it is not where it needs to be. For various reasons (wait for my blog on this….no it is not a threat😁). This is a known fact. With our health infrastructure threshold being low – per capita doctors & nurses, number of beds, ICU beds, medical supplies etc. – we knew it will get overwhelmed and breakdown if the virus spreads fast and active cases go up. Which means vaccination is the solution to prevent the infrastructure from breaking down.

Events from across the world, what has happened and is happening in other countries, clearly showed there will be a second wave. Going by science, there will be more waves with less severity assuming more people get vaccinated and eventually virus will taper off as the herd immunity kicks in – combination of vaccinated people and people who got infected reaches 80% plus. Vaccination is the safest and easiest way to achieve herd immunity than waiting for COVID infection.

COVID-19 is a public health issue. Which means, no one is safe unless everyone is vaccinated / immunized against COVID. Herd immunity can come from combination of vaccinated people and people who got infected – it needs to reach >80%. We can’t wait for infected people to reach 80% – obvious considering loss of lives and cost to economy. Which again points to vaccination as the solution to achieve herd immunity.

When it came to implementation approaches, there are enough pointers to learn from other countries. Which worked and which didn’t. Realizing vaccination is the key to win over COVID, US, UK, Israel, and European countries, funded vaccine research. US invested billions of dollars in vaccine research and manufacturers, hedging, since only few will be successful and blocked initial production of vaccines for its citizens. UK and other rich countries followed suite. Then we had countries like Brazil – methods we should avoid.

One could ask why the state had to invest billions in private vaccine research and manufacturing. This is economy 101. Trade-off between money lost in a lockdown vs money you would have made not going in to a lockdown – spend billions now to avoid losing trillions due to weeks of lock down. A pointer to India how she needs to plan her vaccination policy, avoid lockdowns, and prepare for second & future waves.

For the vaccine policy and how to execute it, there are enough data points both from our internal vaccine drives, smallpox and polio, and tactics taken by other countries. US (and UK, Israel) went for state funded free vaccine for its citizens. While the policy of free vaccine can be questioned, it has worked so far in those countries. Even though it is state funded, it is a public-private partnership taking care of the supply chain – manufacturers, UPS & FedEx for shipping (meeting cold storage requirements) to all states and retail pharmacies (to increase vaccine access). We can argue, should it be fully state funded (meaning free for its citizens) or go for a tiered approach – government takes care of vaccine for those below certain income level and rest pay for vaccine. Again, multiple data points and enough time for India to come up with her COVID-19 vaccination policy – opportunity cost, public-private partnership, etc. Enough expertise available within our country to design the vaccination policy – been there and done that kind.

By Sep/Oct of 2020, there were multiple vaccines getting closer to approval – AstraZeneca (CovShield), Pfizer, Moderna, Johnson & Johnson, Covaxin, Novavax, and Sputnik. Countries like US went for multiple vaccines – one to take care of supply and second, different types of vaccines provide protection against future virus variants. Meaning, going with only one type of vaccine can expose the whole population to a new variant if the vaccine is not effective against that variant. With multiple cultures of vaccine among the population, probability of few vaccines being effective against the new variant goes up. This reduces severity of future waves and supply pressure on booster vaccines. Considering our population, it makes rational sense to go with multiple vaccines – gives cushion from future variants. Nothing new for India – we had similar experience from smallpox and polio vaccination drives. Enough expertise available within and from outside to design the vaccine choice.

Now then, it begs the question, with all the information available how did we end up in the mess we are in now? Losing 4000+ lives every day to COVID-19 as? One may say, this is all hindsight 20/20. No. We saw Italy, Iran and US getting overwhelmed with first wave. UK and few European countries got hit by second wave. Brazil still struggling (like us). We have enough data points from across the world on approaches that work and those don’t. No, this isn’t hindsight or post the fact. We had one year to prepare. By Sep/Oct 2020, there is enough information to come up with our vaccine policy.

• There are enough domain experts – public health experts, epidemiologists, expertise from WHO and other countries, state governments which have successfully managed pandemics like Kerala, economists, NGOs and civil societies – who could have helped the government to work through vaccine policies, vaccine choices, demand, supply chain, cost and funding, etc.
• I can hear people say, COVID vaccine is different, cold storage requirements etc. These are solved problems – other countries have solved it – UPS and FedEx have solved it – all we need to do is import the technology like we do with anything else
• Next question would be, what about the money needed to vaccinate 1.4 billion population? In this year’s budget 35000 crores got allocated for COVID vaccination. Doing simple math, enough to vaccinate nearly 700Million Indians fully with 2 doses – at INR250/- per dose (150 + 100). Government gets the INR150/- back, if the citizen gets the jab at a private hospital. Money has been accounted for in the budget
• For argument sake, let’s say government has to pay INR1500 per dose at market price and need to vaccinate 1Billion population (excluding those below 18 years), it comes to ~INR3Lakh Crores. If you look at the opportunity cost, loss to GDP from 40 day lock down in 2020 is estimated to be anywhere between 40 to 66 lakh crores. As we speak, Karnataka, TN are entering lockdown, and Delhi already under lockdown. These states being under lockdown will have an impact on other states too. I am not arguing for public funded vaccination – there are enough economists and public health policy experts out who could come with creative ways to meet the funding needs
• No, I don’t have solution for all hurdles we may face. My argument as a lay person is, if I can think through these, with so much expertise available within our country at government disposal, they are in a far better position to handle this. Then why and how did they led our country to this horrible, hideous situation?

So, what happened? Our top leadership focused on narration building than solving the problem. Focus is more on grand standing and headline management than governance. Science is frowned upon. Subject experts with differing opinions are either moved out or ignored. Focus is more on stifling and silencing criticism and open discussions. No respect for other party leaders or building all-party consensus. Their social media brigade goes after any criticism about the leader or governance with barrage of insults. No hesitancy in charging people with acts of sedition or bunch of FIRs. Keep the population distracted and occupied with divisive tactics. Our PM is projected as larger than life leader, and a god’s gift for India (this from our Vice-President Venkaiah Naidu). Cabinet ministers instead of doing their job, have become YES Minister and YES Prime Minister guys. With more control moving to union government – both fiscal and administrative, state governments lost their constitutional powers. One by one institutions have become an extension of the executive rather than being a counter balance.  With no one there to confront the top leadership, incompetence, arrogance, and complacency crept in. The revelry continued. They continue to ride this due to their divisionary tactics – Hindutva (not be confused with Hindu), Us Vs Them, nationalism, anti-national.

Unfortunately, COVID is something they didn’t anticipate. Current lot believed, even though reality was otherwise, first lockdown and Indian (pseudo-science) immunity (reasoning from social media) killed the virus. Science and reasoning went out of the window. When the rest of the world is struggling with second wave, our leader declared in Jan 2021 that India has vanquished COVID. Our Union Health minister announced we are in end game with COVID.

What led them to believe India will not have a second wave? What was the rationale behind locking ourselves with 2 manufacturers who couldn’t meet the demand requirement? When two stringent regulators, US FDA and Europe, have approved Pfizer / Moderna / J & J, why can’t we freeroll on them and allow it in India? Especially when we know we don’t have the state capacity similar to those countries? No for Pfizer but our Union Health Minister launched Coronil with much fanfare.

When it became clear we didn’t have required vaccine supply, rather than assuming responsibility, and solving it, union government shifted the responsibility to state governments and private guys (the tagline was giving them freedom)? We ended up with 3 tier pricing for the same product. With only 2 suppliers and no free market how do we know what is the right price? This wasn’t giving freedom. This is shifting the blame.

Amount of intensity they showed in campaigning and winning elections, if they had shown in COVID-19 preparation and vaccination drive, we wouldn’t be in this horrendous situation. Indian citizens wouldn’t be running around for beds, oxygen, and medicines. Yes, we will come out of this in few more weeks – like in any other calamity (floods, earthquake, Tsunami) civil societies, NGOs, doctors, and nurses has risen up to the challenge. Corrective/mitigative action we have to take now will have lead time, which means, we are going to lose many precious lives by the time we come out of it.

As citizens, what we are we going to do about this? Move on thinking this also will pass or learn from this and start asking the right question? Rather than keep answering the wrong question. Cultivate the reasoning skill to arrive at the right question…answer will reveal itself.

References:

1. Polio in India – Fact Sheet
2. The Secret to Polio eradication in India
3. Smallpox eradication in India – 1972-77