The fiasco

As we keep reporting and writing about the ongoing crisis across the country, an irony keeps staring in our face — the country which is home to the world's largest vaccine producer, and is globally acknowledged as the pharmacy of the world, is clueless over its vaccine resources being dried up. Such an irony doesn't unfold as a natural course of action. There have been stories, of failure, of neglect and of indifference. It is crucial to peel off its layers and perceive what lessons do these have to offer.

At the time when daily cases and deaths started to peak each day, vaccination numbers are headed downwards. A few months back, India made a shining promise to act on its obligations to help out poorer nations — a promise that would laugh victoriously at the greed of the richest of nations, and leave those ashamed if they had even a bit of conscience. But a blot has maligned this shining promise as India is not just finding itself in a fiasco, but has also eclipsed the fate of millions from poorer countries who had seen in its promise a light of life. The present situation reflects that a single wrong decision and lack of foresight on the part of leaders during a 'critical phase' could lead to disastrous consequences.

It is high time to retrospect if indeed India's planning has been up to the mark, or if there was any 'concrete plan' at all? It is time to retrospect notwithstanding our noble intent what good and bad have we brought to the world and to ourselves. Most importantly, we need to yearn upon the 'could-be-saved' lives of our brothers and sisters, mothers, fathers and spouses. If proper planning and judicious use of vaccines could have saved many lives, then why didn't it happen?

What went wrong?

The first thing is to have a 'clear' target. The Central Government in December had set a target for itself of vaccinating 30 crore people by July. This translates to a demand of 65 crore doses by the deadline, taking two doses per person and the wastage factor into account. To support this affixed demand, the country had two prominent vaccines — Covishield and Covaxin — and the advantage of being home to the Serum Institute of India. So, it clearly had means at its disposal along with an end goal. All that was required was a plan to capitalize on its potential.

However, there have been multiple fault lines in the planning process that have impeded the process of vaccination in the initial stages. Those in the government are saying that they didn't anticipate "this unprecedented" surge. This lack of anticipation was the first failure on our part. A certain degree of foresight is necessary to tackle a huge crisis in a vast country like India!

Admitted that you didn't anticipate it in the first place but when it came rumbling at your doorsteps, why did you turn a deaf ear? It was only a fortnight after AstraZeneca got approval in India that the government decided to place an order for the vaccine. India's export trail continued unin-terrupted even as the cases were rising rapidly in mid-March. The belief that Indian leadership had defeated the mighty virus was too pleasant to be forgone, and the urgency of responding to scientific evidence took a backseat. It was time for carrying out a detailed demographic study parallel to the accelerated domestic vaccination drive. The focus, however, seemed to be diverted elsewhere.

Capacity-building is another essential activity that was completely overlooked. SII offered the government in December last year to raise its ca-pacity to 10 crore doses per month from five crore doses. The grants to augment vaccine supplies, however, came as late as mid-April. The present monthly capacity of SII stands between 5 and 7 crore doses. Bharat Biotech, on other hand, has a monthly capacity of between 2 and 3 crore doses. The cumulative capacity of both the vaccines falls well short of the targeted demand of 65 crore doses by July this year. And therein lies the biggest conundrum that India faces in the second wave. As the country faces an imposing number of new cases and deaths daily, the only recourse is to ramp up the healthcare infrastructure, in the shorter scheme of things. In the longer run, it is only vaccination that can save us. Even with Sputnik arriving from Russia through Dr Reddy's labs, the required number of vaccines will remain a tall, if not impossible, order. This is where governance, conscience and jurisprudence will come into play over the next few months.

Recently, both vaccine manufacturers have submitted their plan to ramp up vaccine production in the next four months. While Hyderabad-based Bharat Biotech will enhance its monthly production capacity to 3.32 crore doses in July and 7.82 crore doses in August, the Pune-based Serum Insti-tute is set to increase its monthly production to 10 crore in August. Russia's Sputnik V, which is a late entrant in India, has inaugurated its inoculation in India, and will be administered at mass scale from coming weeks. Initially, India had kept its market close to other vaccines initially, the decision from which it is showing a shift after having understood the gravity of the threat posed by the second wave. These efforts towards increasing vac-cine production may seem reassuring but we should understand that these are late responses and have pushed the initial deadlines months further. We know what a single day means in present times — many lost lives!

The government has also been a late responder in terms of transferring technology to eligible vaccine manufacturing companies. It made re-course to the licensing process only when the cases started to peak towards the end of April this year.

The lost gamble!

India had an 'easy time' around the first two months of the year. The government and vaccine manufacturers were blessed with a buffer time to build a stockpile of vaccines, especially when warnings of the second wave were in the air. The manufacturers, by that time, had established a firm footing and were ready to penetrate their roots deeper in the venture of vaccine manufacturing. So, where did the vaccines they produced around that time went?

A small part of it went to poorer countries as a grant for their welfare, and they would in return send us their "goodwill". Among these "poorer countries", Bangladesh topped the chart with 33 lakh doses, Myanmar followed with 17 lakh doses and Nepal with 11 lakh doses. A total of 107 doses of India's vaccine grant was given to 47 countries; the above-mentioned three countries received 61 lakh doses cumulatively or 57 per cent of the total grants. As per the WHO COVID-19 dashboard, Bangladesh is registering 472 cases per lakh of its population, Myanmar is registering 262 cases and Nepal 1,480 cases. The per lakh cases in India stand at 1,742. A comparison of the above numbers for the four countries leaves little doubt that despite itself being a badly affected country, India threw its vaccine away to the nations that were 'lesser affected'. It won't be erroneous to claim that a major share of grants was targeted towards diplomacy and not the welfare of "poorer nations". True that Bangladesh, Myanmar and Nepal are strategically important nations, but who gives a government the authority to diplomacy by gambling the lives of citizens?

Next, a major share of India's vaccines went for a commercial dispatch to 26 countries. Bangladesh once again shares the top spot with Morocco by receiving 70 lakh doses of India's commercial dispatch. The United Kingdom received 50 lakh doses, Saudi Arabia 45 lakh doses and Brazil 40 lakh doses. The five countries cumulatively share 275 lakh doses out of India's commercial export of vaccines of 358 lakh doses, or 76 per cent of the total exports. So, when Indians were all set to be engulfed by the second wave, the vaccine manufacturers and the government were busy making money. Building a stockpile, after all, was not a lucrative option.

Thirdly, our vaccines went to some 'really' needy countries. Thanks to our collaboration with Gavi and WHO, we earned some real goodwill, although under contractual obligation. Around 199 lakh doses went to 47 countries. Even among these countries, our major share of COVAX contribution went to Nigeria (39 lakh doses), Democratic Republic of Congo (17 lakh doses), Ethiopia (21 lakh doses), Uganda (8 lakh doses) and Kenya (10 lakh doses). It must be noted that cases per lakh of the population were negligibly small in these countries when

compared to India. But India had to anyhow fulfil these obligations, the most it could have done is to stagger the supplies to build its capacity in the meantime. Most importantly, 17 crore doses of vaccines have been administered to Indian citizens as we write this column.

Vaccine inequality

It will be a grave fault to gauge the shortage of vaccines in a plain mathematical way. Even a balanced demand and supply figure at the national level is not the guarantee of universal vaccination. Inequitable distribution of vaccines could leave many deprived of the necessity. India's vaccination programme is unfortunately plagued by the inequality factor from top to bottom.

Starting from the inequity between states and Centre and among states, the vaccine pricing structure provides for differential rates. The states are currently required to pay double of what the Centre pays. This would overburden the states' health expenditure. Vaccine being a necessity, states will cut on other crucial expenditure over other chronic ailments like tuberculosis, diabetes, cancer etc. Among states, those who are relatively poorer will be pushed back.

Further, there is a disparity between the pricing of vaccines for public and private players. Since the private players are forced to pay double and triple what the government is paying, it is obvious that they will charge the patients more. Thus a large chunk of vaccines will go beyond the reach of marginal sections of society — a shortage despite availability!

Way out

The opposition quit "defaming the Central Government" and found out a new way to address the vaccine shortage which "wasn't there". This new way — global tenders — is the talk of the day. Many states see it as a viable option. The attempts, as we know, were spearheaded by Maharashtra and Uttar Pradesh. The Municipal Corporation of Greater Mumbai invited expressions of interest for 10 million doses and Uttar Pradesh for 40 million doses. Delhi, West Bengal, Rajasthan, Tamil Nadu, Karnataka, Uttarakhand, Andhra Pradesh and Telangana are set to join the fray.

Prediction of success or failure of this approach cannot be commented upon at this stage. Though, certain limitations are visible as of now. Different vaccines have varied storage requirements. The vaccines manufactured by Moderna, Gamaleya and Pfizer require storage temperatures much below the freezing temperature of water. This could be a big hurdle in the path of Indian states to attract tenders. States have put a precondition for the manufacturers to provide storage facilities for the vaccines. Unless the manufacturers agree, these major options are ruled out from the tender game. Even if they qualify after conceding to storage demands, there comes the price issue. The vaccines of Moderna, Pfizer and Sinopharm are much higher than that of AstraZeneca and Covaxin. Are states in a position to pay exorbitant prices?

States are already facing financial constraints with a major part of their budgetary health allocation going into the fight against the pandemic. Certain states have proposed that the Centre is better placed to float tenders to fill in shortage gaps. States are also exploring local development funds to arrange money for tenders.

Foggy future

India's capability to tide over the issue of vaccine shortage in future is the last thing to be doubted. The potentials are as high as they were at any point in time; the only issue is about the intent and meticulous planning. In any case, the lackadaisical approach has added two-three months to the window of time within which the country had aimed to accelerate its vaccination drive to meet the set target of administering the jab to 30 crore people. It is significant to note the cost of this extended window. We are losing thousands of

precious lives daily; every single day is a disaster in itself. The claims of meeting the target "towards the end of the year" or "in coming months" look simpler against the complexities they hold within themselves.

All the steps taken by the government, after it woke up, could take time to bear fruits. The approval of new vaccines like Sputnik V will require the backing of infrastructural and procedural establishments. The manufacturing companies that are taken in for the licensing process will certainly not end up producing as per their stated capacities in immediate future. Neither would the capacity building for SII and Bharat Biotech take shape in days or weeks. The only things that can be done in the short term are to rely on imports and strengthen the compliance to safety protocols so as to provide a window to reduce the burden over the unprepared system. Till then, one could just wait, looking at the rise and fall of the graph, with eyes wide awake.

Conclusion

As part of the solution, the first thing that needs to be done is to come out of the fantasy world and accept that the situation is indeed grim and concrete actions need to be taken. Acceptance of failure is the first step forward. India currently has two important things at stake — most importantly, the lives of its people; and secondly, its prestige in the global arena. Fortunately, these things are not unrelated; safeguarding the former would ensure the latter. A positive image of the government is not something that needs to be guarded against winds and storms. It has to be made strong through actions so that it can withstand the ravages of time. It needs to be strengthened first, protected later.

India's assumed role as the Pharmacy of the World can be boosted only after it stands strong on its feet. A very detailed and holistic approach is required at the national level which takes into account the vulnerable sections of the society. An umbrella plan for all is bound to fail. It is high time the government should mine its own demographic data, set committees to mark out the communities and single out their concerns in the vaccination process. This is a parallel process that must go hand in hand with capacity-building for vaccination drives. India could also not fail the global community, particularly poor nations, who look towards us in this time of crisis, and towards whom we owe a 'moral' and 'contractual' obligation.

This is a test, a time that shall separate the 'speakers' from the 'doers'. The actions of our authorities today will decide how history remembers them tomorrow.

Views expressed are personal