Some thoughts on above 18 vaccination policy, and the road ahead

Opening concerns 

The government yesterday decided to allow anyone above 18 to get vaccinated. There are a few caveats here. First, is that the government has decided to divide all of India's vaccine stock including Covishield and covaxin (produced and manufactured in India) and all other vaccines that the government cleared on an emergency usage basis (such as Pfizer, Moderna and J&J) into two parts. First half will be utilised for vaccinating the frontline workers, and anyone above 45 free of cost. The other half will not be bought or subsidized by the central government in any manner and will be open for purchase by the state and other entities in an 'open market'.

There are a couple of things to be noted here.

First, by announcing that states are free to purchase the vaccine from the open market according to their own requirements and needs, the center has simply shifted the burden of providing healthcare and finances from the center to the states. Shrouded in this language is arguably an abdication of responsibility as the union government. The states are on their own. It is too soon to predict the ultimate result of this policy, but after keeping the states from doing exactly what it now has announced when the situation could have been controlled, to now making the states accountable for any consequence when the situation is at its worst reeks more of abdication of responsibility than de-centralization. For de-centralization and what it really means, look at S. Korea and how it handled the initial impact of the virus.

Second, the only requirement for the vaccine manufacturers is that of declaring prices before selling it in the market. There is no cap for the prices and soon enough we will know what is the market price of vaccination. It is obvious that now that vaccines have entered the free market, competitive forces should drop the price of the vaccine (To ensure more profits that can only come from more purchases, vaccine manufacturers are incentivized to price their vaccine lower than others so as to boost purchase and thus profit. This is particularly the case in vaccines because there is no real comparison between the efficiency or safety of vaccines which is the main USP of a vaccine thus virtually eliminating any marketing tactic that could have convinced people to pay more. People will simply chose the cheapest vaccine. Thus it is in the interest of vaccine manufacturers to be that choice). However even after the market competitiveness, the absolute value might be too high for a lot of people.

A point I'm unclear on (and perhaps someone can clarify it for me and for other readers in the comments) is that by mandating 50% of vaccine stock to 'open market', does it mean that I, as an above 18 Indian citizen will be able to directly purchase the vaccine from any private clinic, like I buy any other injection dose, or does the phrase '50% will be available to state government' mean that it is only the state government that will purchase the vaccine and distribute the same on a subsidy or even free of cost basis? This is an important question, because there will be a large number of people that will not be able to afford the vaccination, and would need some kind of state assistance. Unless the state itself does not either subsidize or run its own free of cost vaccination program, many people will lose out on vaccinations. And that is a public harm. There is a major risk of mutation of viruses from the unvaccinated, and as long a particular number of people remain unvaccinated, the mutation will continue. Ideally (as I'm assuming) it will be both these cases. 

Two things follow from this discussion. First, it is good that the vaccine has been made available in the open market. It will allow individuals above 18 who can afford to be vaccinated to get the vaccination and thus increase the percentage of vaccinated rather than waiting for months to get the vaccine free of cost from the government. Second is the potential harm of tragedy of lottery of birth within India. Given that the union government press release did not state any overbearing frame of policies that the states have to abide by, the state social security policies with respect to the extent of subsidy, and state protection offered through vaccination will vary across states. We might have a situation where one state decides to offer free vaccination for all above 18, and the other state only gives a meagre subsidy to its inhabitants. This will solely depend on the financial, fiscal and infrastructural capacity of individual states. This to me, is a grave tragedy. Just because one is born in one particular state than the other within India, one should not have disparate impact on one's ability to access the vaccine. I acknowledge that such inequalities have always existed, but my argument is that since access to vaccination singularly decides the question of life and death, in this particular case perhaps a uniform policy needs to be adopted across states to eliminate this arbitrariness of birth. The ideal policy of course is to give the vaccination free of cost to everyone.

The moral imperative is to get everyone vaccinated, first within India and then globally. Because as long as a percentage of population remains unvaccinated, not only will it lead to new mutations that our present vaccines might be incapable to fight against, it will also act as an infectious source for even the vaccinated to get Covid again since the vaccine does not give 100% immunity. 

My prediction of the road ahead: 

Yesterday when I read of the news, I was euphoric for a second and started thinking about a pre covid world, but as things became clear to me, I understood that it is still a far gone dream and the worse is yet to come. We have two concerns right now. 

First, the Kumbh Mela, Hyderabad Mecca Masjid Ramadan gathering, political rallies and other large social gatherings have acted as a super spreader events. Even though many people have argued to the contrary by saying 'where is the data', one actually only needs common sense to come to the conclusion that these events were super spreaders. Recently, The Lancet published a research that showed that Covid transmission is mainly air borne and is not surface based. At least in the Kumbh Mela and political rallies, there have been people who were tested as positive. Put 2 and 2 together and we have our super spreader events. (Unless for some reason everyone who was positive did not breathe at all for all the time they were in these events). In these events Kumbh may act as the biggest super spreader because it is not localized as the other events. Devotees come from far away places, and thus the impact and scale of infection from this super spreader will be massive. The cases should spike even further in the couple of weeks to come due to these events. 

Second, individuals from 18-45 are the most mobile section of population. It is very likely that after taking the first dose of the vaccine, people will get lackadaisical and flout social distancing norms. Even though first dose does give considerable immunity, but it takes time to come into effect and even in full effect there is always a chance of infection. Thus people who start to roam around after taking the first dose are likely to get infected themselves and infect others as well. This behavior is likely to contribute cases to the super spreader events we have witnessed. 

Closing ideas

Thus as much as I hate to say this, the third wave will be even worse than what we are seeing right now. And it will come soon. Our healthcare capacity ran out a long time ago and we are surrounded by cries of people and their near and dear ones dying while begging for help. We're broken beyond repair.

I want one thing to be immensely clear. What we're seeing around us right now, could have easily been prevented by the state. The state cannot escape moral culpability out of this in any way whatsoever. I have purposefully avoided writing on the ideological bent of the government, because healthcare is (or sadly, at least should be) a state priority across party lines. In a welfare state people shouldn't primarily have to take to twitter and Instagram to access the resources the state is supposed to provide. That is not a welfare state. The state is responsible for not investing in healthcare and building India's healthcare infrastructure. And that's the end of the story. My biggest worry is that come election time there will be an impression of 'the government did what it could'. That is a blatant lie. There is a reason we have the state and an elected government to run the state. It is to minimize and control situations like these. Am I saying the state failed because it did not control all of Covid? No, that's impossible. Am I saying that the state failed because it did not do the bare minimum of what it should have done in a country like India, and thus is responsible for the majority of the failure? Hell yes. 

Policy matters. Decisions matter. Lives matter. And not just because they are votes in the next election, but because they are living, breathing, dignified people. Hold the government accountable. Never forget.

EDIT (21 April): If you'd like to read more on the open market vaccination policy, here are two good pieces arguing either side of the debate.

1. Ashish Kulkarni & Murali Neelakantan arguing that the new vaccine policy is 'mind bogglingly bad economics'  

2. Ajay Shah & Amrita Aggarwal wrote welcoming the government's new move