The Challenge of Vaccine Distribution

AS ISRAEL, LIKE many other countries, begin their rollout of the Covid vaccine, its Prime Minister Benjamin Netanyahu announced that he would be the first to take it there. This was the mRNA vaccine developed by Pfizer whose first lot had arrived, with the programme to begin from December 27th. Netanyahu was going to be recepient No 1 so that, according to him, the rest of the country would have confidence that it is safe and necessary. That is a good enough rationale. Many still find vaccines suspect and in the atmosphere of fear, would take convincing. And if everyone is not getting vaccinated, then the very nature of the virus means that it will keep circulating. Netanyahu’s announcement, however, also brings to the forefront the aspect of who should get it first. What if there is someone at greater risk and urgency than him? By what ethical imperative can Netanyahu get first claim over someone else’s life? This is an academic point. Leaders of countries are considered more valuable lives. Tomorrow, if a nuclear attack is going to wipe out a country and only 5,000 people can get sanctuary in a bunker, then the first to enter through that door will be a prime minister or president.

But the question remains an illustration of the priority list once the vaccines roll out. The problem is of magnitude.

Everyone on earth is a potential and necessary recipient of a vaccine. The requirement is then more than seven billion doses. Double that if the vaccines, as many of them do, require two shots spaced across a period of time. To make 14 billion doses will take time. To get it to all those who need it will take even longer. And until then, some will have to get it before others.

Who will these be? This week, the Union Ministry of Health gave a media briefing where they spelled their policy out. ‘Prioritized Population Groups include about 1 crore Healthcare Workers in both Government and Private Healthcare facilities, about 2 crore Frontline Workers (including personnel from state and central police department, armed forces, home guard, civil defence organizations, disaster management volunteers and municipal workers) and also about 27 crore people in the Prioritized Age Group, which includes those aged above 50 years & those with co-morbidities,’ said their press release.

This seems fair but one important group is not mentioned here. In a podcast where he was a guest, the Yale sociology professor Nicholas Christakis, who recently came out with a book, Apollo’s Arrow: The Profound and Enduring Impact of Coronavirus on the Way We Live, had an interesting take—that the first to get it must be those who participated in the vaccine trials but were part of the placebo wing of recipients. Since they took the risk of adverse events and were instrumental in the vaccine’s development, it was just they have first claim to it. He also had another interesting point to make. It might seem like the obvious thing to do to give the elderly who are at maximum risk the vaccine first but it could, in fact, be more beneficial, even if counterintuitive, to give it instead to the working population despite their being young and healthy. That is because the elderly usually remain confined to homes while the workers interact more in society and so are greater spreaders. If the virus is defeated by breaking the chain of transmission, this might be an equally effective strategy. He wasn’t recommending it but merely stating the questions involved.

That specific scenario, however, is an option probably relevant to Western developed societies where the elderly can be insulated, unlike India where the extreme crowding of even living spaces makes the policy redundant. India has a number of other hurdles when it comes to distribution. The two most effective vaccines, from Moderna and Pfizer, require very low sub-zero temperatures to store and transport. It requires a cold chain infrastructure which India does not have. The health ministry is trying to address the problem and the same press release noted: ‘Current cold chain system, consisting of 85,634 equipment for storage of vaccine at about 28,947 cold chain points across the country, is capable of storing additional quantity of Covid-19 vaccine required for the first 3 Crore, i.e., Health Care Workers and Front Line Workers. The Health Ministry in consultation with States/UTs has assessed the additional requirement for Cold Chain storage (Walk in Coolers, Walk in Freezers, Deep Freezers, Ice lined refrigerators etc.). Additional supplies would be available to States/UTs beginning December 10, 2020.’

Yet, the creation of enough cold chain facilities to cater to the entire population is impossible within months or even years. The Moderna and Pfizer vaccines will be, even if available to India, only the rich man’s option. That would not be a problem if other vaccines that India is banking on to distribute in large quantities, like the one by Oxford-AstraZeneca or Bharat Biotech, are found to be equally effective. But if they are not, then it becomes a political question whether the wealthy should have exclusive access to better ones while the poor have to wait and get infected, meanwhile. It is not easily answered. Price controls could impede the financial health of the sector without really achieving anything. Writing in Mint, former Deputy Chairman of Planning Commission Montek S Ahluwalia wrote, ‘Denying high-income individuals access to state-of-the-art vaccines available abroad will lead them to go abroad to get vaccinated. In fact, some of our private hospitals may be tempted to set up vaccination clinics in Nepal or Sri Lanka to offer these vaccines with much lower costs even after accounting for airfare,’ he wrote.

Meanwhile, other infrastructure are also being propped up. Like bolstering the cargo capacity of airports. The airport in Mumbai, according to a Quartz India article, ‘plans to create a dedicated task force to facilitate vaccine transportation. This team will undertake advance planning and collaborate with all stakeholders such as other airports, airline customers, supply chain partners, regulatory and governmental bodies, and vaccine distributors.’ Airlines and railways will be instrumental in transportation and distribution across the country. Private hospitals, too, are getting ready. Apollo Hospitals, which has 70 hospitals under its chain, was getting ready to give as many as one million doses per day. It was training 10,000 healthcare workers to administer the vaccine. A Moneycontrol report said, ‘The healthcare workers will be given four month training and certification, using Apollo’s nursing schools and online education platform. Apollo said the company has been investing on expanding and strengthening its cold chain and transportation, to facilitate storage and distribution of the vaccine.’

The challenge is gargantuan. If 30 crore people are in the first line, then that needs more than 60 crore doses. No single vaccine manufacturer can deliver anywhere close to that. There would need to be a combination of suppliers. An article in The Print asked where the scope is for choice when demand outstrips supply by so much. It said: ‘So, the question of choice of vaccine arises — does a recipient or even a state get to choose which vaccines he/it wants, or would the choice of which state gets what vaccine be made by the central government?’ After that, there are the remaining 100 crore Indians who also need to get their doses.

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