Who Should Lead COVID-19 Vaccine Distribution In India? Experts Differ
There is disagreement among experts about vaccine pricing as well as the government's role in the vaccination process.
As India prepares for the eventual rollout of a COVID-19 vaccine in 2021, there is disagreement among experts about vaccine pricing as well as the government's role in the vaccination process.
According to one school of thought, the government should restrict itself to vaccinating frontline workers and government employees leaving private companies to supply vaccines to the rest of the population. However, other experts believe that the government should take the lead in vaccinating the population to ensure there is no inequity in the process.
The United Kingdom will start the vaccinating process after granting Pfizer-BioNTech's COVID-19 vaccine Emergency Use Authorisation. Over 50 hospitals will take part in the first phase of vaccination with distribution being stepped up over the course of the month.
While India may not acquire the Pfizer-BioNTech vaccine due to logistical and cost issues, the government has been monitoring the clinical trials of vaccine candidates being developed by Oxford-AstraZeneca, Bharat Biotech as well as Russia's Sputnik V vaccine.
At an all-party meeting on Friday, Prime Minister Narendra Modi said that a COVID-19 vaccine could be available for distribution in the "next few weeks". "As soon as scientists green light a vaccine the distribution will start," he said. Modi also said that the logistics and pricing of the vaccines will be done based on consultations with the state governments.
Dr Ajay Shah, Professor of the National Institute of Public Finance and Policy, believes that the government does not have the capacity to carry out a nation-wide immunization drive and should allow private players to lead the vaccination drive.
"A vaccine is a private good with an externality. A vaccine is a private good because I spend money, I get vaccinated, I benefit. Will the Indian state ban private people from rolling out vaccines to private customers? That would be kind of extreme. We saw what happened, for example, with testing. The Indian state tried to interfere with private labs doing testing. And that just retarded India's development of the testing system. These kinds of interventions are really suspect," he told BOOM.
"Let the government system do what it can but don't harm other people who are trying to do immunizations. And state capacity in India is very low. If they can immunize their own civil servants that will be pretty good," he added.
Noted epidemiologist Dr. Chandrakant Lahariya disagrees. Dr Lahariya, who is also the co-author of the upcoming book "Till we win: India's fight against COVID-19 pandemic", believes that free-market approach to vaccine deployment will give rise to inequities leaving vaccines to be out of reach of poor and marginalized people.
"We need to understand that we are in a pandemic situation where individual protection will also benefit the society. So, the vaccine is a public good. If it is left to the market forces, then the poorest and marginalized people, who cannot afford the vaccine, will be left behind while they are as much risk as anybody else. In this background, I strongly believe that it is the government who should be taking responsibility and front seat and offering the vaccine on the basis of priority.
"If it is left to the market, the cost is going to be very high and unaffordable. But when a government is involved in the purchase, the cost of vaccine is going to be low," he said.
Excerpts of the interview follow
Govindraj Ethiraj: Dr Lahariya, tell us about where you see the vaccine rollout from an Indian context at this point.
Dr Chandrakant Lahariya: As far as vaccine is concerned, we see it coming soon. It is going to happen in a week from now in United Kingdom, probably another two weeks in the United States. However, both of these vaccines which will get emergency use authorization have not been partnered or done clinical trials in India. So, availability of these two vaccines Moderna and Pfizer Biotech, is unlikely to be in India in a few months at least till February or March.
The one vaccine which is being seen as a hope for India is the Oxford-AstraZeneca vaccine of which there are bridging studies in India and we can hope that even that vaccine will receive emergency-use authorization in the United Kingdom in the coming weeks. And since there are bridging studies in India, we can hope that either late January or early February 2021, Oxford AstraZeneca vaccine might be available for use in India. Since there is an Indian manufacturer, we can expect that there would be reasonable quantity.
Govindraj Ethiraj: You're also saying that, you know for the Pfizer vaccine, for example, it cannot even be launched in India because we do not have a clinical trial and every country will have to administer clinical trials or go through the clinical trial process before it actually allows the launch of a vaccine.
Dr Chandrakant Lahariya: One is the large-scale clinical trials which are done on 30,0000 to 40,000 people are being done for different vaccines. However, if the country is not part of the two large scale trial the way Oxford AstraZeneca vaccine for example, the trials are being done mainly in the United Kingdom, Brazil, and the United States of America. But within India, there are something which is called bridging studies which are on a smaller number of people which are being done and those bridging studies are required before our national regulatory authority can license those vaccine even on emergency use authorization basis.
Considering those studies are not being done for Pfizer-BioNTech and Moderna vaccine in India, the first requirement, even if on large-scale these vaccines receive EUA in other countries, the bridging studies have to done within the country to get license. Since the bridging study, which is COVIShield vaccine, is already doing, that can get licensing as soon as the United Kingdom agency get the license for that vaccine. So it's not possible till we have some local bridging studies done in the country.
Govindraj Ethiraj: Dr Shah, you've tried to look at this subject from a distribution, logistics and cost point of view. So, tell us about what you feel are the key issues that will come into play in a few months' time as the vaccine doses start rolling out.
Dr Ajay Shah: It's important to think that you and I are happy to pay money to get the vaccine. So, there are paying customers, there is demand, and there are private firms who are willing to sell the vaccine. So, we should think about this market, where there are private producers, and there are private buyers, and the two will try to find each other. Now, when the vaccine goes through a large-scale clinical trial elsewhere in the world, there is merit in rapidly removing barriers to import and allowing it to happen in India. So, I would not see much gain by demanding large scale trials or a great deal of scrutiny here, once something has worked elsewhere in the world. So, I feel that the authorities should not come in the way of private initiatives to import boxes of vaccine and to roll them out.
So now think of this market where there are multiple players. There is Pfizer, there is Moderna, there is Oxford's AstraZeneca, there will be many others. The story is not going to end at three, there are going to be many others. So, there will be competition, there will be multiple vendors trying to sell vaccines, and there will be private people, you will be running shows where you will be helping customers choose should I be doing this vaccine? Or should I be doing that vaccine. Some vaccines will work better for older people, some vaccines will work better for women, and so on. And that's a market where there are many products and people should choose.
There are price points, like 2000-4000 rupees, and all over the country, there is a very large private sector in healthcare that is quite capable of rolling this out on a gigantic scale. The thing is that at the same time, while the producers are ramping up their output, the demand for the vaccine will be going away. Because many of us will get vaccinated and herd immunity will set in and the threat of the disease will really go away. So, it's a very interesting situation in India, unlike many other places in the world. In India, we've actually got large scale seroprevalence already. So relatively modest amounts of vaccination will tip the system over into herd immunity. And people will subjectively start understanding that, you know, I'm in Pune, and nobody's getting sick anymore. So, let's stop fighting with this anymore. And demand for the vaccine in Pune will evaporate. So, this is the interesting dynamic that will take place that there will be and there should be multiple private vendors offering vaccination. And at the same time, in a way pretty rapidly, vaccine demand is going to go away. So, the prices are going to collapse.
Govindraj Ethiraj: On the other hand, are you also saying that the government should not at all be involved in distribution or involved in distribution only up to a point?
Dr Ajay Shah: The government should pick a few important categories. In my mind, civil servants, public sector, health care professionals, policeman. This is really the job of the government, they're the employees of the government. So, I would like it if a lot of employers will take care of their own people. And the government should take care of civil servants. So, the employees of hospitals, the people who are policemen, the people who have any kind of frontline roles, that's the job of the government so that maybe 10 20 million people all over the country. If the government can organize that can manage that, that will be quite an achievement. In India state capacity is low. So, if we make large demands on the state, it will really not work out too well. We should ask for small things from the government and hope that competence will actually come about.
Govindraj Ethiraj: Dr Lahariya, how do you see what Dr. Ajay Shah is making from a medical standpoint?
Dr Chandrakant Lahariya: So, we need to understand that we are in a pandemic situation, where individual protection will also benefit the society. So, for example, if one individual is vaccinated, he will or she will stop spreading the virus or will reduce the risk and that will benefit the entire society. So, in this kind of situation, vaccine is a public good. One, if it is left to the market forces or if left to people will start buying and then they can use the vaccine, then the people who are the worst affected, the poorest, marginalized, who cannot afford will be left behind while they are as much risk as anybody else. So, in this background, I strongly believe that it is the government who should be taking responsibility and front seat and offering the vaccine on the basis of priority.
All of us want a number of players and multiple manufacturers. I'm sure that there will be number of manufacturers, but still with the kind of advanced market commitment and advanced purchase is done by the multiple countries the availability of vaccine is going to be limited. So, this limited vaccine needs to be prioritized. So, the prioritization is most essential, and which most government including government in India is doing. And for the prioritization and optimal utilization of the limited vaccine, the government should take charge, otherwise private sector or if left to the individual, as I already highlighted, it will bring inequity and it will result in those who need vaccine being left behind.
Third issue related to this point in which you earlier highlighted is the cost. If it is left to the market, the cost is going to be very high and unaffordable. But when a government comes in the role, and when government is involved in the purchase, the cost of vaccine is going to be low. I want to reflect here at this point of time. What should be the cost of vaccine? The cost of vaccine should be looked from two perspective. From the people or citizens perspective and from the government perspective. In my considered opinion, the vaccine should be free of cost for majority of population, if not entire population. Let's say 60 to 70%, or even up to 80% population should get it free of cost. They don't have to pay because if they are protected, it will prevent the spread and then that's how pandemic will disappear.
So, the vaccine should be at the cost for them. The remaining 20% can be decided later on and they will need later on. How much should be the cost for the government? We know that some of the vaccines which are getting early are really expensive $20 to $40 per dose, which is unaffordable for a country like India, but we also know that there is mechanism which are working out so for the government, the cost would be $3 per dose. It is still very expensive; I foresee in the future. And for example, if the collaborative vaccine between Indian Council of medical research and Bharat biotech developed, cost coming somewhere down around $1 per dollar 50 cent per dose will be the real cost which we were looking for in India from the government perspective also. So, to summarize, per citizen up to 70% to 80%, we should be free of cost and should provide by the government, for the government, currently $3 per dose, but it should settle down somewhere around $1 per dollar or 50 cents per dose.
Govindraj Ethiraj: Are you saying that the government should be in full control, not even the blended approach that Dr. Ajay Shah is saying? If I can afford to pay and import on my own Pfizer vaccine from the UK, I should not be allowed to is what you're saying?
Dr Chandrakant Lahariya: I guess that discussion is already happening in India, that government should be taking charge of this work and vaccinating majority of the population. At the same time, there is a discourse that we need to keep the business continuing or economic activity should be continued. However, we know that the economic activities are done by the healthier adults who are not in the priority list. So, there would be some vaccines which are really expensive like Moderna, Pfizer-BioNTech vaccines. The government is unlikely to use those vaccine, but those if those vaccines become available, and if there are private player who are willing to buy and use those vaccine, I guess that's the kind of mechanism should be used. The government is already allowing or considering that private sector or industry can purchase some vaccine, and they can use. But immediately, government who should be in charge of vaccination in the country.
Govindraj Ethiraj: Dr Shah, how do you see this? Will we be able to manage this balance between government leading it and should government lead it? And I don't know whether you worked out the numbers on what a $3 dose means, in terms of affordability for the government as a whole.
Dr Ajay Shah: I'd like to come to this discussion with many, many elements of the logic. There are so many things that are different about the Indian context. To think about vaccines in India is profoundly different when compared with how you might think in the UK. Okay, so problem one. We have seroprevalence in India amongst poor people, which is already very high. There was a recent survey in Mumbai where 75% of the slum dwellers already have antibodies. So, in some sense, you know, the story with poor people has already unfolded far more than we may have liked.
But the point is, it's there. That there is a very large-scale expansion of the disease amongst poor people. So, when we start saying that we want to protect poor people, we have to be cautious in understanding that maybe it's too late that the epidemic has already swept through a lot of poor people in India. So, this is the first point that needs to be kept in mind that seroprevalence in India is unprecedented by international standards. There is no other country where you're getting these kinds of numbers of what we are seeing with seroprevalence in India today.
Second, I'm a little uncomfortable with the word public good. The word public good is a technical economics term. So, I will have a copyright on it. A vaccine is a private good with an externality. A vaccine is a private good because I spend money, I get vaccinated, I benefit. It has an externality, which is I stopped transmitting the disease. So, we should be careful about the use of these words. So, there is a case for government subsidy to encourage me to get vaccinated, but it's not a public good.
The third point that we should think about is, what use of state power do you want to use? What state violence do you want to bring into the picture? Does the State ban the import of mobile phones into India? Do you want the Indian state to ban the import of vaccines into India? I doubt it. Will the Indian state really prevent you and me from importing a vaccine into India? That would be kind of extreme and we really should think 10 times before doing that. Will the Indian state ban private people from rolling out vaccines to private customers? That would be kind of extreme.
We saw what happened, for example, with testing, the Indian state tried to interfere with private labs doing testing. And that just retarded India's development of the testing system, we just last two, three months because the Indian state tried to tell private firms, thou shalt not test individuals who are willing to pay money for a COVID-19 test. So, these kinds of interventions are really suspect. And we should think a lot before using state power.
So, let's imagine we're only trying to do good, can the government go out and vaccinate some more people? I'm all for that. Without interfering in the private behavior. That is key. Don't harm other people trying to do vaccination, you do vaccination. So, let the government try to vaccinate more people, but don't harm other people who are trying to do vaccination. I think this, you know, above all, don't do any harm. Some kind of Hippocratic Oath should be a part of health policy, thinking above all that. Let the government system do what it can but don't harm other people who are trying to do immunizations. And state capacity in India is very low. If they can immunize their own civil servants that will be pretty good. Beyond that, let's see what they feel like doing.
Govindraj Ethiraj: Let's address that seroprevalence. We've seen the reports on seroprevalence, not just in Mumbai, but also in Delhi, and in the south, where clearly a large number of people are already carrying the antibodies, and therefore, have likely contracted the disease and overcome it. So, in that sense, as an epidemiologist, how do you approach this? Do we really need that many vaccines? And even if we do, how do you distribute it in a way that the right people get it?
Dr Chandrakant Lahariya: It's good that we have brought the issue of seroprevalence in this discussion. We know that across the country, there are around 30 different cities and states which have conducted seroprevalence studies. And what we know that the seroprevalence in these studies have been found somewhere ranging from 5% to around 56% in Mumbai slums. But we also know that there were two nationwide studies conducted by Indian Council of Medical Research. The first one found the seroprevalence of 0.7% to 2% and then second one found seroprevalence of 7% across the country. So, definitely there is no study which can say that all poor people have been impacted. Mumbai was the outlier and there are reasons.
I have written a paper on that which was published in The Wire about why this is slightly higher in Mumbai settings. But we cannot say that poor people have been fully exposed. There is a wider agreement that globally only 10% of people were affected by end of October. 90% are still susceptible. If we go by Indian Council of medical research study, second national seroprevalence survey, only 7% affected 93% were still susceptible. So, there is a wider susceptibility.
Second point I want to bring here is that the concept of herd immunity is not applicable in a setting of a smaller geographical area. The herd immunity is applicable in a wider setting where there is limited in or out migration of people. So, for example, a person who in any setting, even which can have a 70% seroprevalence, if he lives in that area, the moment he walks out to the work in other setting, he again exports. So, he's not protected by that seroprevalence or herd immunity. So those are the challenges.
To summarize, we don't have that big protected population or population which had developed infection. There is a wide susceptible population. I want to go back to the point of public good and social contract. And I want to really emphasize that health is a social contract. Here people have given some rights to the government, so government needs to act on their behalf. And in the pandemic, which is affecting everybody, people do agree with the government that government has some right to work on their behalf and do some of the good.
Also, any health intervention, this is a moral and scientific principle, should not result in increasing inequities. Anything, which is market-based principle where people who can afford to buy a particular limited good, it will result in inequities and it will affect poor the worst. So, we need to remember many of those concepts and probably require a second discussion on public good, social contract, and what government should do in a special setting such as pandemic. This is not a routine setting.
Govindraj Ethiraj: But if you were to look at the data on seroprevalence, are you saying that the data is not believable or there are not enough surveys that's been done. The reason is that I want to connect that to something else. If we look at the overall fatality ratio right now, we are clearly doing much better than we thought. We were expecting a massive Diwali surge that does not seem to have happened at least in Mumbai and in many other parts of the country. So, there is some data points that are available, some there are not and some we are able to extrapolate by looking at whether fatality levels are going up or down and clearly in Mumbai, they are not. As in they are going down. So how are you looking at that?
Dr Chandrakant Lahariya: What I'm saying is that each of the data is believable but those are applicable for smaller settings. If we have seen seroprevalence of around 25% to 30% in Delhi, which is believable. But we see seroprevalence of 56% in Mumbai slums, and then 46% in second survey in Mumbai slums. But we have seen that Indore had a large number of cases being reported, but seroprevalence in that setting was only 7%. So, what we know is that there have been smaller pockets which have a higher transmission, but there are other pockets which have less transmission.
But as a whole, for the nation, the number of people who are still susceptible was around 90% in mid-September. This number might have gone to 15% or 20%. But nearly 80% would still be susceptible and would need to be protected. The second point that want to bring at this point of time is that we don't know how long the protection after natural infection would last. We don't know what is the level of herd immunity or the level of population which should be infected for herd immunity to develop. It has been discussed from the range of 43% to 70%. And if we know that over a period of 10 or 11 months, if the country has reached 15% to 20%, it is unlikely to reach that level.
There are many unknowns. In those unknowns, the best intervention is that we don't simply rely too much on seroprevalence studies, we simply don't focus too much on herd immunity, and we use the interventions which we can do and the vaccine is one such intervention which is coming to our rescue. We also have seen in the past pandemics that the pandemics do not disappear without effective intervention and the vaccines appears to be promising, especially when we are seeing that these vaccines are highly efficacious. So, if something is efficacious, it should be prioritized. It should be used, made available to those people who need the most irrespective of their buying or purchasing capacity. That's something only government can do.
Govindraj Ethiraj: We are of course, basing a lot of these interpretations on data or available data, which of course is limited at this point of time. Dr Shah, what is your sense on where we can go with our interpretations? Assuming the state plays a leading role in giving out vaccines to everyone or most people, what is the kind of cost that we're looking at? Because economically, we are not obviously in the healthiest of shape either.
Dr Ajay Shah: There are many seroprevalence studies. We need to index them by date, because the speed at which the epidemic is going through society is quite remarkable. And as an example, recently, there was a Bombay slums paper which got a number of 75%. There is a good Karnataka paper, high quality statistical random sample of Karnataka that was conducted from 15th June to 29th August where the overall average answer is 50%. And that's a survey conducted if you take a weighted average date, the average date on which the measurement was done was 21st of July. Now, every month that goes by after that, actually, the epidemic is spreading in the country. We're already standing in December, there is no reasonable possibility of a significant rollout before January or February. So, by that time, the pandemic will have made significant progress.
There are different numbers for different locations, that's entirely correct. And that, in fact, is the beauty of a market-based system. If, as you say, we in Bombay are understanding that our neighbors are not getting sick, people around us are not getting sick, the threat perception changes, and then our demand for the vaccine goes down. That's the beauty of the market process. Whereas in a place where lots of people are getting sick, where the threat perception is high, there will be a greater clamor for the vaccine, and then there will be demand and then private persons will take vaccines there.
So, I would just reiterate, the Hippocratic Oath of public policy should be that the government should not interfere with, for example, Govind, importing 10,000 doses. The Government of India should not interfere with Govind giving out doses to his friends and family. If the government wants to run a program. Great, please do so. I have my own skepticism about what the Indian state is capable of.
There's going to be a rapid price collapse, because one by one, these factories will come into motion, and the demand is collapsing. So, this is a very interesting market. There will be like an infinite price for the first dose. And there's going to be a rapid price collapse after that, because one by one, more and more vaccines are going to be approved and there will be a ramp up of manufacturing capacity and the demand will go away. So, you're going to have a crazy imbalance between supply and demand. Every month the prices of the vaccine is going to collapse.
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