There is no doubt that delivering 100 crore vaccines in a country as vast and complex as India is an achievement. But instead of gloating over it as Prime Minister Narendra Modi and his fans have done, the ‘accomplishment’ calls for introspection. One needs to just recall the bout of triumphalism within the government early this year, before the massive second wave of the COVID-19 pandemic brought the government to its senses.
First, the numbers do not tell us the full story. India has delivered 100 crore (1 billion) vaccines, but to vaccinate the entire adult population twice we need 1,878 million doses. Seen in this context, we have just about achieved 53 per cent of the target. About 75 per cent of the population have been vaccinated with one dose; and 31 per cent have been fully vaccinated. This means we still have a long way to go.
Modi “birthday effect”
Second, although the vaccination rates have picked up in the last few months, especially since the pits of May when rates plummeted, serious imbalances and volatility in the vaccine delivery numbers remain a case for worry. For instance, as the accompanying chart illustrates, September was a great month for the Indian vaccine campaign. On September 17, coinciding with Modi’s birthday, a whopping 26.65 million doses were delivered. But if we remove the “Modi birthday effect”, the overall rate for September appears far more modest. In fact, if we split the 30 days of September into three equal parts, the average daily rates in the three phases are: 7.67, 8.79 and 7.19 million doses per day. The heavy concentration in mid-September can thus be ascribed to the “Modi birthday effect”. Previous short-bout spikes were also possibly because of a deliberate and conscious effort at boosting the government’s image.
More worryingly, the average daily rates in the first three weeks of October, has fallen by about 30 per cent when compared to rates in September. In fact, to borrow a phrase from cricket terminology, the current daily strike rate is below even rates achieved in August. The volatility of the vaccination numbers, coupled with the first issue raised — the fact that only about half of the vaccines required for the Indian adult population have been delivered — imply that much of the task is still very much work that is yet to be done.
Simply put, in terms of numbers, this means that 878 million does have to be delivered. At the current rate of delivery in October (5.55 million doses per day), this means that the remaining doses would be delivered in about 160 days. This means that if India vaccinates at the current rate all adults would be fully vaccinated only by April 2022.
Low hanging fruit already plucked
But several other factors further complicate this picture. It is evident that the low hanging fruit has already been plucked; further progress in delivering vaccines, especially of the second dose, is going to be more and more difficult. As India’s foremost and well-regarded vaccine expert Dr Gagandeep Kang has pointed out, the last 20-30 per cent of the target group are not only hard to reach but also hard to convince. “It is time to celebrate, but it is also time to prepare for what comes next,” Dr Kang said.
The nature of the pandemic, which some experts like Kang have already characterized as an epidemic, has implications for India’s vaccination drive. As the eminent epidemiologist Dr Chandrakant Lahariya observed in a recent event organised by The Federal, a combination of increased “natural” immunity and artificial immunity conferred by vaccination, implies that the probability of a fresh nationwide wave like the first two waves in India (in 2020 and 2021) is “very low”. Although this may sound optimistic, Dr Lahariya warned that this did not rule out the possibility of “sub-national wave(s)” that may be concentrated in specific pockets of the country. This raises an important issue: Is the Indian vaccination drive, which has largely been directed and driven by the Union government — but largely implemented by the states — flexible enough to quickly address those who may be vulnerable in more localised rounds of rising infections in the future?
Unevenness in vaccination
Such fears are not without basis. A disaggregated analysis of the Indian vaccine drive shows that poorer states such as Uttar Pradesh, Bihar and Jharkhand are significant laggards in vaccination. In fact, even a relatively more advanced state like Tamil Nadu — not just in terms of Gross State Domestic Product but also in terms of a much more advanced health services delivery infrastructure — is lagging behind several other poorer states. This implies that some geographical regions are at greater risk, if and when the localised “sub-national waves” occur.
The targeting of particularly vulnerable segments of the population requires an attention to nuance. For instance, the injustice heaped on India’s children by the prolonged closure of schools is no longer tenable. Dr Lahariya and others have been passionately advocating for the opening of schools because scientific evidence has decisively and clearly demonstrated that children are least at risk. However, the fact that children may carry the virus into homes once schools reopen implies that the elderly and those vulnerable at home need to be vaccinated on a priority basis. Moreover, experts like Dr Kang have pointed out that even within the sub-class of the child population, children with co-morbidities may need to be vaccinated on a priority basis. But there is no evidence that the Indian vaccination drive has the fidelity to respond to this nuanced prioritising of targeted populations.
This picture is further complicated by several imponderables. One of the major unknowns is the extent and duration of immunity conferred by the existing vaccines. Although all the evidence still indicates that vaccines provide protection from the most serious consequences of COVID-19 infection, the evidence on how long immunity will last is still not conclusive.
Although it is comforting that experts like Dr Lahariya inform us that a fully vaccinated person can be expected to stay protected for at least one year, the supply worries on the vaccine production front are not trivial. First, full protection from two doses for a significant proportion of the population is still some distance away. Second, as by October 22 around 292 million persons have received the second dose, a similar number may be required to be vaccinated within a year from now. What this means is that within a year, India may need to secure vaccine supplies of a similar magnitude that it has mobilised this year. The scale of supplies does not even include the already existing backlog. The question to ask then is: has the Indian government secured supplies that may perhaps be needed in the future? Or, will it fail to learn from its fiasco in not having acted quickly enough to secure adequate supplies for the ongoing round of vaccination. Mind you, we are not yet even discussing the India’s preparedness in terms of developing second generation COVID vaccines.
The Covaxin flop show
Despite all the chest-thumping bravado, India’s vaccine production capacity has been its Achilles heel. The simple reason for this is the overwhelming dependence on one vaccine supplied from a single source – Serum Institute of India (SII). The company’s vaccine, Covishield, accounts for 88 per cent of the vaccines delivered to Indians so far. Covaxin, the home-made vaccine, developed using significant public resources, has been the laggard.
Several false promises later, production of Covaxin has just not picked up. In September, daily deliveries of Covaxin were a paltry 0.788 million doses; in October so far, this has dropped to 0.585 million, a drop of more than 25 per cent. On August 2, while participating in a TV show in which this writer was also a participant, NK Arora, chairperson, National Technical Advisory Group on Immunisation, promised that a significant “ramp-up” was imminent within the next four to six weeks; he promised that Covaxin supplies would increase to 100-120 million does per month. In September, a total of 24 million does were actually delivered, compared to projected supplies of just 18 million in October. In short, we are still waiting for that “exponential increase” to materialise.
Meanwhile, the only silver lining in this otherwise dim scenario is that Serum Institute’s CEO Adar Poonawala seems to have delivered on the capacities he had promised. Deliveries of Covishield appear to be close to SII’s current claimed capacities of 220-240 million doses per month. In September, 213 million doses were delivered, but administration of vaccines have slackened in October. Deliveries of Covishield at immunisation centres have dropped from an average of 7.09 million doses in September to about 4.70 million doses per day. At this rate, SII’s tally of Covishield deliveries in October would only be 146 million doses. This level of supply would only be about two-thirds of lower bound of SII’s claimed capacity.
There is yet another cloud that hangs over supplies from Serum Institute. This is its pending commitments to the Covax facility for which it has already received funds. In fact, funding from Covax was what enabled SII to install COVID vaccine capacities because the Modi government had not even decided to vaccinate the Indian population at that point. Postponing supplies to Covax is not an option that would be indefinitely available to SII if it is not to be violation of its contractual obligations. Seen from this perspective, the Modi government’s positioning of itself as a saviour of the world’s poorer countries is positively laughable.
The recent moves to authorise vaccines for children demonstrates that the Modi regime has hardly learnt from its mistakes. Recall that in April and May, amidst a severe shortage of vaccines, the government not only extended coverage to the 18-45 age group, but introduced dramatic changes to its COVID vaccination programme that were a significant deviation from its longstanding and successful commitment to an immunisation programme that was based on universal and free coverage. Although subsequently, multiple rollbacks were made, the lessons of that fiasco remain to be learnt. The move to introduce a vaccine for children is based neither on scientific evidence nor is in line with a rational ordering of priorities. Instead, Covaxin, which was touted as the trump card but which has proved to be a joker in the pack, is being allowed to dodge its commitments and tout its wares in a category of products that the country has no need for at this time.
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