How Do You Vaccinate 1.3 Billion People?

India is expanding its Covid-19 vaccination drive but a second wave of infections is moving fast. Credit Anupam Nath/Associated Press
India is expanding its Covid-19 vaccination drive but a second wave of infections is moving fast. Credit Anupam Nath/Associated Press

The second wave of Covid-19 in India is here. The country of more than one billion people already has 11.3 million cases and more than 158,000 deaths. After a low weekly average of less than 11,000 cases per day in the second week of February, the cases have risen to a weekly average of more than 18,000 cases per day. On Friday, India reported more than 23,000 new cases.

This lends greater urgency to India’s vaccination drive, which aimed to inoculate 300 million people for Covid-19 between mid-January and August.

When the vaccine rollout started on Jan. 16, I was pretty certain it would go smoothly. And why not? India is a global pharmaceutical powerhouse, with proven capacity to meet high production volumes, and by mid-January it was already manufacturing more than three million vaccines a day. The country has a long history of successfully running immunization programs across daunting, difficult geographies and inoculating hundreds of millions of people against polio, measles, tuberculosis and other diseases.

To get a sense of the effectiveness and the scale of India’s immunization programs, consider this: Amid the pandemic, on Jan. 30, India carried out its annual polio immunization campaign, inoculating over 110 million children in three days. Around 700,000 vaccination booths were staffed with 1.2 million health workers — many of them Accredited Social Health Activists, or ASHA workers, who for $50 per month check on mothers and children at bus terminals and bazaars to ensure the immunization program is a success.

But the current vaccination drive has been hobbled by bureaucracy, inefficient delivery and a rich-poor disparity. India managed to vaccinate only 14 million of the 30 million health care and other frontline workers it intended to between Jan. 16 and March 1, the first phase of the drive.

From the beginning, the Indian government’s pandemic response has been shrouded in secrecy and lacking broad consultations. A year ago, on March 24, Prime Minister Narendra Modi abruptly imposed a nationwide lockdown, forcing factories, offices and educational institutions to close with a mere four hours’ notice. Millions of daily-wage workers woke up to find they had suddenly lost their only source of income.

Public transport was shut down. Throughout April and May, millions of hungry, jobless workers left Indian cities and began walking or hitching rides to their distant villages, in some cases carrying the virus with them.

In August, Mr. Modi’s government created an expert group staffed largely with federal bureaucrats to formulate India’s vaccine rollout policy. It did not allow Indian state governments to make independent decisions or consider the views and experiences of state authorities and community leaders. Its cardinal mistake was failing to tap the decades-old and highly efficient national immunization program networks and following its best practices.

On Jan. 16, the first day of the rollout, Serum Institute of India, a company in the western Indian city of Pune that manufactures the Oxford-Astra Zeneca vaccine, was already producing 2.5 million to three million doses of the vaccine every day.

Another company, Bharat Biotech, was producing its own vaccine in collaboration with an Indian government body. India’s drug regulator suddenly approved the company’s Covaxin for public use before it completed its Phase 3 trials. The hasty decision, seemingly motivated by nationalism, created doubt about the vaccine’s safety and efficiency. Health care and other frontline workers were reluctant to take it.

And India, which takes pride in its information technology prowess, set out to develop a digital vaccine management system. The health ministry introduced CoWIN, a website, and Aarogya Setu, a contact tracing mobile application introduced after the pandemic’s outbreak, to handle registrations, create vaccination schedules, direct people to vaccination centers and create vaccination certificates.

The focus on online registrations ignored a fundamental fact: More than half of the Indian population doesn’t have access to the internet, computers or smartphones. Reports in the Indian press suggest a stark class divide in the vaccination drive: The middle and upper classes arrived at the vaccination centers in much greater numbers than the urban and rural poor.

Mr. Modi’s vaccine rollout group proceeded to limit the first phase of the vaccination program to India’s public health system, which caters to about one-third of the population, and left out the privately run health care facilities, which two-thirds of the population rely on. The wise members of the expert group also limited the vaccination sessions to 100 people per session at a facility, which slowed down the process.

After the infections started to rise by mid-February, a combination of political criticism and popular backlash eventually pushed India to correct course. On March 1, as the second phase of the vaccination drive started, eligibility was expanded to citizens above age 60 and those above 45 years with comorbidities.

The government has also roped in the private hospitals, opened up in-person registration at vaccination centers and allowed people to choose their vaccination center. On March 3, the release of the trial data for Bharat Biotech’s Covaxin demonstrating 81 percent clinical efficacy significantly increased trust in it.

As of March 10, 54 days into the drive, India had administered 25 million doses of the vaccine. In number of doses administered, India is third after the United States and Britain, but it still covers merely 1 percent of the country’s 1.3 billion people.

The second wave of the pandemic is surging through smaller towns and villages, which lack the medical infrastructure and resources of the larger cities. I spoke to scores of heads of village councils, who told me they had not been consulted on the vaccine drive, and most of them did not know about the timeline of the rollout.

India can still meet the challenge by tapping into the infrastructure and networks of its immunization program. The country has 20,000 vaccination centers, but the number has to be increased significantly.

There are signs of movement in that direction. In recent weeks, India’s army of rural health workers has finally been deployed to knock on doors and register villagers for the vaccine. In the village of Yusufpur Nagalia in the northern state of Uttar Pradesh, Zakeen Fatma drew up lists of people eligible for the vaccine by going door to door.

Here, too, the bureaucracy is getting in her way. Ms. Fatma passed on her list to the district authorities, who updated the names on the CoWin portal. She informed the approved beneficiaries about their vaccination appointments and then listened to their complaints that the vaccination site was at a hospital nine miles away from their homes, a trip that would cost them 50 rupees by autorickshaw.

“If the government would let us vaccinate people in the village itself like we did in other immunization drives, we could cover the entire village in three days”, she told me.

The second wave is moving faster than India’s bureaucracy. India needs to keep pace.

Alia Allana is a writer based in Mumbai, India.

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