What Happens After the Vaccine?
Even assuming a COVID-19 vaccine is discovered soon, past logistical challenges in India show that it is unlikely to be a quick fix. Instead, we need to address the structures in place that are causing the disease to spread rapidly around the country.
For the most-vulnerable in India, the daily routine often begins with lining up (and often paying) to use a bathroom, exposing them to crowds, and bringing large populations closer together under the risk of COVID-19 spread. For those who have lost their jobs post-lockdown and economic downturn, buying litres of water—on prices based on supply and demand—can become increasingly unaffordable.
But they have been promised that a coronavirus vaccine—whenever it appears—will magically end these woes, that the harsh realities of risk in their daily lives will end. They are told that, even if they don’t have access to the water and sanitation that should be afforded to all citizens, they will get a vaccine that may or may not prevent them from getting the virus.
However, I believe that this promise of a vaccine can become a distraction, and undermine the importance of delivering the basic needs. Governments around the world have us convinced that a COVID-19 vaccine is the only way we can return to “normal”. But the discovery of this vaccine is unlikely to serve as the immediate cure-all we are hoping for. To begin with, many scientists and epidemiologists are sceptical of the timeline and effectiveness of the vaccine. Even assuming an effective vaccine does come out in the next couple of months—judging by past vaccine programmes in India, the logistical challenges of distributing the vaccine, and the spread of anti-vaxx disinformation—it is unlikely to be a quick fix. Instead of pinning all our hopes on the vaccine, now is the time to address the structures in place that are causing COVID-19 to spread rapidly around the country.
There is no consensus amongst the scientific community on whether producing an effective vaccine is even possible. I don’t pay much heed to Donald Trump’s claim that the vaccine will be out by October 2020. Earlier this week, Russian president Vladimir Putin announced that Russia had produced the ‘world’s first’ vaccine, ready for mass inoculation. He highlighted that the vaccine had been tested on his daughter—but not on himself. Meanwhile, the Indian Council for Medical Research’s (ICMR) claimed last month to produce a vaccine by Independence Day!
What is known is that other efforts to create vaccines for coronaviruses to-date have been less than successful. It is possible that, if a vaccine does come out, it will only serve to weaken the severity of illness and not prevent people from contracting the virus, with the USFDA indicating that it would approve a vaccine that “prevent disease or decrease its severity in at least 50% of people who are vaccinated”. The timeline for this vaccine range from next month to 2-3 years.
Part of the reason why immunisation rates have been so low is the logistical challenges of mass roll-out of vaccines… A strong vaccination programme that reaches the most remote villages would require an army of trained health care workers, and the ability to mass-produce large amounts of vaccines that do not expire by the time the health care workers reach the village to administer them. All of this requires significant human and capital resources that many states do not have.
There are simply too many unknowns around this vaccine for people to be putting their lives on hold till a solution is found. Instead, I hope to explore the aftermath, of what would happen if a vaccine is indeed miraculously discovered soon—and hopefully, made available in the Indian market.
India’s vaccination rate has been historically low, despite having a Universal Immunisation Programme since 1985. The current government had set a goal of 90% of infants to be immunised with twelve essential vaccines by March 2020 with the launch of Mission Indradhanush in December 2014, and with the subsequent goals of Intensified Mission Indradhanush in October 2017 and Intensified Mission Indradhanush 2.0 in December 2019. Since we are past this deadline and in the midst of a pandemic, it's safe to assume that the missions have not been accomplished. Official data on India's immunization coverage in the National Family Health Survey 4 (2015-16) puts it at 62% (though the Union Health Ministry claims the vaccination rate is at 83% in November 2018). Amongst the poor in India that can least afford medical expenses, 47% are not immunised.
Part of the reason why immunisation rates have been so low is the logistical challenges of mass roll-out of vaccines. Though these programmes are mandated by the Central Government, it is up to the state governments to implement them. Thus, the poorest states such as Bihar and Uttar Pradesh have the lowest immunisation rates in the country. A strong vaccination programme that reaches the most remote villages would require an army of trained health care workers, and the ability to mass-produce large amounts of vaccines that do not expire by the time the health care workers reach the village to administer them. All of this requires significant human and capital resources that many states do not have.
In addition, there is a growing distrust in the health system leading to an anti-vaxx sentiment. While there is not yet a self-identifying anti-vaxx movement in India like in the USA or Europe, we do have our own home-grown variety of medical disinformation that leads to much the same result. The promotion of alternative medicine by our Government through the Ministry of AYUSH as defences or cures against COVID-19—much of which is unproven pseudoscience—serves to build distrust in modern medicine, including vaccines. An increasing array of voices are calling out the fact that the Indian government is helping to undermine science with focus on untested ancient beliefs.
Soumitro Banerjee of the Indian Institute for Science Education and Research notes that “a mentality of accepting beliefs without evidence is being propagated in the country [that] will curtail the space for science in the future generations. Science is not a set of beliefs. It is essentially a way of thinking. That is being undermined in India.” With growing state-sponsored pseudoscientific and anti-vaxx beliefs, coupled with the general spread of disinformation by our government, we have to ask the question: Even if the vaccine were to be freely available, how many would refuse to take it?
An important frame of reference here is the aforementioned polio vaccine, which has been deemed as a success in India, and the country has been declared polio-free since March 2014. The main reason for this success is that an oral vaccine was developed which was easy to administer, addressing the logistical challenge of reaching remote villages and needing medical professionals to administer the vaccine. But in order for the oral vaccine to be effective, it has had to be given to an entire village at the same time. Hence, country-wide vaccine drives have happened for a few days every year and have involved nearly 200,000 Rotary volunteers.
In addition to addressing logistical challenges to polio vaccination, Rotary volunteers and UNICEF spent significant time building trust amongst the communities, especially some among the minority communities that distrusted the vaccine for causing infertility, as a ploy by the government to target them. Another reason for its success rooted from the ongoing efforts to detect and suppress polio outbreaks. Sewage sampling is done regularly with the help of the WHO to detect poliovirus in the water, which triggers vaccination drives based on the specific type detected. It is only with persistent monitoring and regular vaccination drives that polio was able to be controlled.
It took India over a decade to figure out an effective immunisation strategy for polio, time we would not have in a desperate fight against COVID-19.
In the case of the COVID-19, the logistical challenges will be even greater. Several Indian pharmaceutical companies are racing to develop the manufacturing capabilities to mass-produce the vaccine. How quickly can hundreds of millions of these vaccines be produced (especially if India is going to be producing not just for India, but also for much of the world)? Once produced, who will get them first? CDC recommends that health care workers and the immunocompromised are first in line—but who will be next? Should it be the poor, and if, how are the poor to be defined? And if left to the states—many of whom are already facing a cash-crunch—who is going to fund the distribution? If the vaccine is to be injected instead of provided orally, its distribution would require the availability of millions of health professionals. It is also possible that the vaccine would have to be stored at a temperature of -80 °C, and be administered in two doses, adding to further logistical challenges.
Medical experts believe it would take a minimum of two years for the vaccine to be administered to 60-70% of the population, the coverage required for herd immunity. Are we expected to stay locked-down for two years?
With growing state-sponsored pseudoscientific and anti-vaxx beliefs, coupled with the general spread of disinformation by our government, we have to ask the question: Even if the vaccine were to be freely available, how many would refuse to take it?
I would hope that, if and when the vaccine does become available, that the Government of India would have an effective strategy in place that would address these challenges. However, there are too many unknowns surrounding the COVID-19 vaccine for the government, and us, citizens to wait around for this unknown solution. Nor can we afford to stay locked-down until there is some clarity around the vaccine. There are, however, evidence-based actions the government can take immediately to slow the rate of infection and the severity of the infection.
For instance, there seems to be consensus amongst the medical community that the virus spreads, and causes more deaths, from the absence of water and sanitation. But regular hand washing for a family of four (assuming each member washes their hands for 20 seconds, 10 times a day) would require 80 litres of water per day, an impossibility given 82% of rural households and 60% of urban households do not have piped running water in India. According to the National Sample Survey’s (NSS) 76th round (2018), 24% of households access their water through unrestricted public sources, making regular hand washing and safe distancing a challenge. Having regular access to clean water would not only allow for handwashing, but it would also prevent many water-borne diseases such as diarrhoea and polio that reduces the body’s defence against viruses such as COVID-19.
It is also critical that health (dis)information be regulated. I do not advocate for any limits to free speech, but I do argue for a flat ban on all health advertising by authorities that are non-governmental, semi-governmental, or from political parties about misinformation or cures for ailments that one can buy or treat at home. It should be illegal not only to sell these ‘snake oil’ solutions, but it should also be illegal to pay millions to advertise these medicines, which damage the faith in our serious medical establishment.
We can’t wait around for the vaccine. It is obviously imperative that our and other governments are investing time, money and resources to create a vaccine. But they shouldn’t be giving us the impression that it will be the perfect cure-all.
While resource investment in the vaccine is a must, the overt focus of the media and policymakers on this vaccine can be a harmful distraction to fixing other problems before us today. We need to provide basic water and sanitation for our fellow citizens, end harmful state-sponsored health disinformation, and take a more pragmatic approach to saving lives.
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Shefali Saldanha is Singapore-based working for an Impact Investing firm managing the India portfolio. Previously she worked for a social enterprise based in Mumbai. She has an MBA from Oxford, a BA from the University of Virginia and over a decade of experience working in the social sector space in India and regionally. You can find her at linkedin.com/in/shefalisaldanha.
