India began the “world’s largest COVID-19 vaccination drive” in January in a climate of misinformation and hesitancy. Across the country, Accredited Social Health Workers (ASHAs) have been on the frontline, going door-to-door, urging eligible rural populations to get vaccinated. In the northern state of Uttar Pradesh, ASHA worker Gyanwati Devi was told “we will die but not vaccinate ourselves” by fellow villagers who had heard, often via WhatsApp or social media, of the vaccine’s supposed dire side-effects.
Throughout the winter and spring, vaccination progressed at a dismal rate as large religious gatherings and election rallies were allowed, further perpetuating a sense of non-urgency.
This meant that India was wholly unprepared for the second wave that arrived in April and quickly left its health system overwhelmed and overburdened. For weeks, social media was filled with SOS calls for oxygen, medicines and hospital beds as the country repeatedly reported the highest single day increases in cases and deaths globally (reaching over 400,000 and 4,500, respectively), which most experts believe underestimates the real toll.
While now we are looking to the government sector [to produce vaccines], until now there was complete reliance on the private sector without exploring government production capacity, which should have been done.
With the surge in cases, many of Devi’s fellow villagers were affected and began to ask about how to get vaccinated, but by then centers were either asking for online registration or running out of vaccines.
Faced with a new variant that is considered the reason infections are severe, widespread and impacting all ages, India shifted its vaccination approach and expanded vaccine access to its entire adult population in May. However, its method of doing so reflected its lack of preparedness.
To scale distribution, it instituted an online registration system and allowed private hospitals and other private medical providers to both procure and offer vaccines, which caused many to pay for their shots and provided uneven access across the country. In recent rulings, India’s Supreme Court has defined this new approach as arbitrary and irrational and ordered the government to conduct a review. As a result, Prime Minister Nerendra Modi just announced that as of June 21, all Indians will be vaccinated for free.
In the face of this crisis, social activists and non-profit organizations are stepping up to help bridge gaps, mainly by working with local administrations and communities to make vaccines accessible for those in rural India, which is home to more than half of India’s population.
As India’s challenges with vaccine distribution were making news, it also became clear India had not purchased enough vaccines and was running out of supplies. Unlike the United States or the European Union, which secured large quantities of vaccines in advance, India did not reserve enough vaccines to meet the targets it was setting.
“While now we are looking to the government sector [to produce vaccines], until now there was complete reliance on the private sector without exploring government production capacity, which should have been done,” said Chandrakant Lahariya, a public health specialist and co-author of Till We Win: India’s Fight Against the COVID 19 Pandemic. “India barely had any vaccination analysis or study. The kind of planning and understanding required was not there, and that’s why we are in this situation.”
In the face of this crisis, social activists and non-profit organizations are helping bridge the gaps, mainly by working with local administrations and communities to make vaccines accessible for those in rural India, which is home to more than half of India’s population.
In the states of Jharkhand and Madhya Pradesh, Transform Rural In
dia Foundation has engaged its network of youth volunteers who have access to smartphones. They’re responsible for scheduling vaccination appointments for their own families along with other neighborhood families. While vaccine availability is out of their hands, they are “ensuring that nobody who wants to take the vaccine is left out of the registration process,” said the foundation’s senior manager, Neeraj Ahuja.
Similarly, in the remote villages of Palghar district of Maharashtra, which has a large indigenous and migrant population, the RAAH Foundation is training and providing additional funding to ASHAs to collect data during door-to-door visits, which the local administration has agreed to then upload online for vaccine registration.
Both organizations are sharing easily understandable scientific content in local languages to increase understanding of and comfort with the vaccines. In some states, such as Rajasthan, similar efforts are being led by local leaders, ASHAs and community volunteers with positive results.
Experts are already warning of a third wave, and Indians “will continue to remain vulnerable until everyone is vaccinated”, says Vineeta Bal, immunologist and professor at the Indian Institute of Science Education and Research. “We need to get businesses going, work going, and hence we need protected people. That’s where the vaccine is needed.”
With less than 5 percent of India’s population fully vaccinated and supply shortages, it could take as long as two years to reach a 75% vaccination rate. While many experts say it is only understandable that India reserves vaccines for its own population right now given the health crisis it faces, it does bring the debate of global equity and leadership to the forefront once again.
India is a major pharmaceutical hub and home to the privately-owned Serum Institute of India (SII), the world’s largest vaccine manufacturer. Even before the pandemic, SII produced about half of all vaccines sold globally. Earlier this year, SII had committed to send about 200 million doses of AstraZeneca vaccine to COVAX to be distributed to low- and middle-income countries.
With the crisis growing at home, India suspended all vaccine exports in March. This means that at least 140 million doses that COVAX expected to receive from SII by the end of May remain in India. Over 40 African countries, as well as neighboring Nepal and Bangladesh, have large populations awaiting their second dose but no supply as their initial stocks came from India. Vaccinations in several other countries and of marginalized groups, such as the Rohingya refugees, have been indefinitely delayed.
I think this wave, if nothing else, has brought a lot of people together, and overall, the country has come together to stand up for its people.
“The vulnerabilities (of India) only got exposed due to the vaccine issue, but it is not the cause of the vulnerability, which already exists,” said Giridhar R. Babu, professor and head of life course epidemiology at Public Health Foundation of India. “We have to address this comprehensively, understand the global health security agenda, and ensure that we build a strong and resilient health system in India first (so we can) be a role model for others also. We can’t be a leader without strengthening our own health system and workforce. I think this should be the priority.”
In the absence of clear planning and leadership at the top government levels, citizen efforts and response have stood out. “I think this wave if nothing else has brought a lot of people together, and overall, the country has come together to stand up for its people,” says Sarika Kulkarni, co-founder of Raah Foundation. With it has also come a greater awareness that a more sustainable and systemic approach is required if India is to truly address its inequities.
As the pandemic continues to severely affect India in all ways, vaccination, Kulkarni says, “will be the only way forward”.