The slogan that India’s most humble Prime Minister ever gave to a troubled nation at a rally at the hallowed Ramlila Maidan in 1965, still rings true — ‘Jai Jawan, Jai Kisan’. Now, our soldiers are bravely staring down the Chinese in Ladakh, while agriculture is the only sector recording positive growth in the first half of the year. But that isn’t why Lal Bahadur Shastri’s words should be taken seriously in the context of the yet-to-be-proven Covid-19 vaccine, which like the monsoon rains, are expected not to fail us.
Union Health Minister Dr Harsh Vardhan has been quoted saying that 250 million Indians would be covered with a two-dose Covid-19 vaccine by July 2021. Although we currently don’t know which vaccines that are currently in the race will make it; we do know for sure that it won’t be a ‘winner takes it all’ market. The Covishield vaccine is still the front runner, in spite of the setback of a serious adverse event, reported from the UK. The Serum Institute of India (SII)’s decision to stockpile the vaccine, before the trial results, puts it in the leadership slot. Bharat Biotech and National Institute of Virology, Pune’s Covaxin, with its swadeshi roots is on its heels though. The Russian vaccine, Sputnik V’s recent partnership with Dr. Reddy’s gives it a distribution boost in the private sector, if it successfully gets through the evidence phase.
India’s share of the 200 million doses that the Serum Institute is producing for 61 low and middle-income countries is not known. Assuming that 25-33 per cent of this would be made available for India, we may have around 50-66 million doses of Covishield. That hypothetically leaves 400-450 million doses, according to the Health Minister’s promise, as an opportunity for Covaxin, Sputnik V, or another black horse candidate to fill.
India’s 250 million target would translate into 18 per cent of the population. If Dr Harsh Vardhan’s claims are to be taken seriously, he will need to make hard choices and gear up for difficult implementation plans to vaccinate two out of eleven Indians by July 2021. Lal Bahadur Shastri’s call to action is, thankfully, there to guide us.
First in line
India has 3.8 million health workers — MBBS & AYUSH doctors, nurses, Auxiliary nurse midwives paramedics are all frontline jawans in the fight against Covid-19. If we add the 3.5 million Accredited Social Health Activists (ASHA workers), plus Anganwadi workers, we have a 7.3 million-strong army of healthcare workers and associates who conduct immunisation drives, treat sick patients, and form the backbone of a healthy nation.
These health workers are at a higher risk of exposure to Covid-19. If they fall sick, or worse die, in greater numbers, it would be a serious setback for India. The Indian Medical Association wrote to Prime Minister Narendra Modi in August citing 87,000 infections and 573 deaths amongst health workers. Therefore, we can assume there would be no opposition to our healthcare workforce being the first recipients of the Covid-19 vaccine. By being protected, they will protect the patients they attend to and the beneficiaries they vaccinate, thus preventing a rapid spread in the community.
Next come the armed forces, the paramilitary, and the police, all of whom are critical for defending our borders from external threats as well as maintaining internal law and order, as witnessed during the lockdown. The Indian armed forces have about 1.4 million personnel in active service. Our Central Armed Police Forces (CRPF, BSF, etc.) have about 1.1 million personnel, and the state police forces have approximately 2.1 million personnel.
The Chinese have approved the use of the CanSino Biologics developed Ad5-nCoV vaccine candidate for their military, and we should be willing to consider the indigenously developed Covaxin for our forces. Even if we decide to vaccinate all the armed forces and police personnel across the country, we would need just under a crore doses (9.2 million). Add that to the 14.6 million doses for the healthcare workers and we would need 23.8 million doses to protect the jawans who guard us in the fight against the dreaded coronavirus.
Covid in rural India
The recent round of the Indian Council of Medical Research (ICMR) sero survey across 21 states indicates that only about 7.1 per cent of adults showed signs of being infected, prompting most commentators to say that herd immunity is far away. However, the prevalence in slums (15.6 per cent) is twice that of non-slum urban areas (8.2 per cent), and almost four times higher than rural areas (4.4 per cent). This clearly indicates that while the virus is running through the crowded urban agglomerations, it is yet to pick up speed in rural areas.
The serial seroprevalence studies in Delhi have shown that the prevalence has dipped from 29 per cent in August to 25.1 per cent in September, indicating that infection rates have started to fall and the evidence of infection prevalence from earlier months is starting to wane away. By the time the vaccine will become available in early 2021, a large proportion of the urban population, at least in the major metros, would have got infected at least once. The top 53 cities, which have more than a million residents, are home to nearly 20 per cent of India’s population. Another 14 per cent are spread over 6,000 plus towns, largely contiguous with rural areas. We know that natural infection may not confer lifelong immunity, but it is likely to protect from severe disease.
So, if we wanted to prioritise vaccination, we should target our kisan (farmers). Rural India is where the pandemic will play out further in the first and second quarters of 2021. Our rural population is very young, with more than 45 per cent of them in the working age group. The Pradhan Mantri Kisan Samman Nidhi (PM-KISAN) targets more than 100 million families owning less than 2 hectares of land, of whom 94 million have been validated using the JAM (Jan Dhan-Aadhaar-Mobile) Yojana. Using this database will help us reach 180 million men and women in rural areas of working age. Our public health infrastructure for immunisation is paradoxically better in rural areas compared to urban towns. The combination of PM-KISAN data and our health system (including the Anganwadi network) in rural areas will ensure that we can immunise 200 million Indians in a relatively short time.
All vaccine trials currently are targeting healthy adults (18-55 years) only. Safety and efficacy data from trials on children and senior citizens won’t be available for at least a year, if not more. Meanwhile, in order to prioritise we should use Shastri’s dictum to enhance the possibility of herd immunity being achieved. The private sector will continue to cater to urban India and those with co-morbidities in the interim. While this strategy may evoke criticism from the literati, we should remain humble and steadfast in our approach, like the man himself, prioritising our jawan (healthcare workers, armed and police forces) and kisan (small and marginal farmers). Protecting them against Covid-19 will need science to stand up, deliver and make the vaccines count. After all, Atal Bihari Vajpayee did famously in 1998 add ‘Jai Vigyan’ to Shastri’s clarion call.
The author is a public health specialist, and founder & CEO of AddressHealth. Views are personal.