How Getting a Vaccine in India Is a ‘Privilege’ Especially For Those in Rural Areas

If the month of April was marked by images of endless rows of burning funeral pyres from major Indian cities, the images of floating bodies in the Ganges River near the north Indian states of Uttar Pradesh and Bihar in May were a grim reminder of the unchecked spread of the virus in rural India where a majority of Indians, without access to basic health care, vaccines or infrastructure, have been fighting the virus.

The second surge of the virus in India has wreaked havoc in the largely unconnected and inaccessible rural areas, and according to an analysis by Down to Earth, these areas have accounted for “more than half of India’s… COVID-19 deaths” in April. There is not only a lack of information and facilities provided by the government to the rural population on how to protect themselves against the virus but also a lack of access to medical facilities or even vaccines, which had led to the rural areas being left completely vulnerable to the virus.

In India, efforts to vaccinate enough people to create the much-needed herd immunity and manage the number of infections and deaths in the country during the second wave have been marked by confusion and a lack of planning by the government, especially the BJP-led government of Prime Minister Narendra Modi at the center that has mostly left it to the states to figure out how to vaccinate their residents. The result is that vaccinations have become a privilege that seems mostly unattainable by the poor and marginalized populations of the country. According to a doctor that I spoke with, Dr. Harjit Singh Bhatti, “it is mostly a privilege vaccine meant for the rich and influential… the system is anti-rural and anti-poor.”

The question those working on the ground in India are asking is how the vaccines will reach people, especially the poor—who in most cases have no access to the internet or do not have the digital know-how to book vaccine appointments. And even those with internet access and tech-savviness still face the difficulty of trying to register for a vaccine on the government’s CoWIN website, which is reported to be difficult to navigate and subject to technical glitches and long wait times.

The Privilege of Getting Vaccinated

Dr. Bhatti works in a private hospital in New Delhi where he has been responsible for treating COVID-19 patients. While treating them, one thing became clear to him: the system wasn’t set up to treat the poor and the marginalized. To help this section of society, he and some other doctors have started an initiative, DoctorsonRoad for rural India, to help create awareness about COVID-19 and vaccines and also provide basic facilities for rural Indians to fight the virus.

Bhatti says India’s vaccine rollout is mostly meant for the privileged and that “the system wasn’t set up for the poor people who have to walk 100 kilometers to access health care. The irony of the situation is that, even when they reach [health care facilities], there isn’t any help available because these centers in rural areas don’t have the requisite resources or manpower or are not operational,” says Bhatti, who is also the national president of Progressive Medicos and Scientists Forum. According to him, there is a lack of adequate testing taking place in rural areas, which contributes to the undercounting of cases. Furthermore, even if the tests do take place, the results can come seven to ten days later, and Bhatti says that by then a patient may have passed away from the virus—but these deaths are not included in the official COVID-19 death count due to the lag in test results.

“The vaccination policy wasn’t meant for the poor, underprivileged and those living in rural areas. Look at the government’s intention. There are two vaccine manufacturers [the Serum Institute of India and Bharat Biotech], and Sputnik V will be manufactured by Dr. Reddy’s Laboratories for about Rs 1,000 [almost $13], and we don’t know what price they will eventually sell it for and if the [state or central] governments who procure it will bear the entire cost for it. Can a middle-class or a poor family of five in India afford to pay so much for vaccinations when they don’t have a livelihood due to lockdowns? The system is anti-rural and anti-poor,” he says.

In an interview with the Economic Times published on May 15, Dr. Anurag Agarwal, the director of the Council of Scientific and Industrial Research’s Institute of Genomics and Integrative Biology and the Indian SARS-CoV-2 Consortium on Genomics, said, “Vaccination levels… [in rural areas] are not going to be good… I am not adequately informed to comment on the rural side, in terms of personal direct knowledge or insight or access to data. I know that India has very large hinterlands, I know that facilities there are very poor. Just like any other rational person, I would worry about rural India.”

Talking about the lack of awareness about how to treat the virus, Bhatti says, “There is no proper death registration in rural areas, and no proper diagnosis of the virus is taking place, so many of the deaths due to the virus are not counted into the figures.” He adds that many people living in rural areas and slums in urban centers don’t have access to masks and soap and don’t know how to isolate a person who has been infected. For most of them, isolation is a privilege they cannot afford, with many family members living together in a small room.

In Manipur, a hilly state in northeastern India, Sadam Hanjabam and his team from Ya All, a nonprofit organization working with the youth and the LGBTQI community, have been trying to organize medical aid for people there through crowdfunding. He talks about the difficulty in getting to a medical facility in the face of an emergency and the lack of clarity on vaccines. “The medical clinics—which in most cases are privately owned—are located in the city center, and to get there, people in rural areas have to take some sort of public transport. But during lockdowns, public transportation is not available, and getting medical help in such a scenario is increasingly becoming a challenge.” In India, while there is no national lockdown in place presently, various states have implemented lockdown measures.

Hanjabam talks of the stigma attached to getting sick with COVID-19, leading to many in rural areas hiding the fact that they are sick. “This is accounting for the rise in deaths.”

“I am not vaccinated. We were told that vaccinations for [people age] 18 and above would be available by May 17, but very few slots are available [in Imphal, Manipur]. I don’t think I will be vaccinated anytime this year,” he adds.

“The vaccination centers are also not properly managed. The crowding at these centers by people waiting to get vaccinated has led to fear of getting infected by the virus from visits to these vaccination centers,” says Hanjabam. According to him, since there are very few shots available per center, those in rural areas who don’t know how to book appointments have already lost hope of getting vaccinated.

Prime Minister Modi, meanwhile, issued a press release on May 15 and “asked for augmentation of healthcare resources in rural areas to focus on door to door testing and surveillance.”

According to Down to Earth, while more than “65 percent of India lives in rural districts, as per the World Bank… only 37 percent of beds in government hospitals are in rural India, according to the National Health Profile 2019.”

In urban India, the situation is no better. Ambalika Banerjjee, a senior lawyer who lives in Mumbai, has been trying to book an appointment to get vaccinated for most of May. “Why did the government open up the vaccinations for all adults if they didn’t have sufficient vaccinations?” Banerjjee says.

“I have been spending three to four hours to get an appointment without much success. The CoWIN website is hard to navigate because you can’t move away from your laptop for a moment, otherwise you have to start the login process again. The right to a vaccine is a right of every citizen; instead, it is being treated as a privilege. I am willing to pay up to Rs 900 ($12) for a shot [administered through a private hospital]. It’s not even like it is being provided for free,” says Banerjjee.

The pricing of the vaccines depends on many factors including a person’s age, the type of hospital it was administered by (whether public or private), and the way in which it was procured (whether it was purchased by the center, state, or private sector, and which vaccine manufacturer sold it).

The Reality of the Vaccine Rollout

India started its vaccination drive in mid-January, offering it to the priority groups of frontline and health care workers. The second phase saw the vaccination of people 60 years and over and those between 45 and 59 with underlying health conditions. By April 1, vaccination had opened up to all people 45 years and above, and by May 1, the country opened up registration for vaccinations to all adults over 18, in spite of facing vaccine shortages. In fact, many states have had to shut down vaccination centers in May with the shortage persisting.

Currently, the center is responsible for providing the states with 50 percent of all COVID-19 vaccine doses produced by two private Indian manufacturers: Bharat Biotech, which, along with the Indian Council of Medical Research and the National Institute of Virology, developed Covaxin; and the Serum Institute of India, the world’s largest vaccine manufacturer, which is producing Covishield (licensed from AstraZeneca). The center bought 50 percent of the vaccine supply to offer it to states for free, leaving the other 50 percent up to states and private hospitals to buy directly from the manufacturers. Out of the 25 percent of the vaccines being procured by private hospitals, however, “very little” is reaching the rural areas, according to an analysis by the Times of India.

The crippling shortage of vaccines, meanwhile, has forced state governments to float global tenders for the procurement of vaccines, resulting in states being pitched against one another to ensure that their citizens are inoculated. Delhi’s Chief Minister Arvind Kejriwal has pointed out in a tweet how this procurement strategy portrays a “bad image” of the country, saying that the process should be centralized instead.

If the global community of vaccine manufacturers and countries had been approached by a united “‘India’ rather than individual states, our bargaining power” would be much greater, he further tweeted, because the central government “has much more diplomatic space to negotiate with their countries.” Indeed, Pfizer and Moderna have reportedly refused to “deal with [the] Indian states for vaccines.”

India’s vaccination program is hamstrung by its lack of centralization twofold—not only by how successful the central, state, and private sector are in procuring the vaccines, but also in the pricing offered by manufacturers to each buyer. Manufacturers are quoting different prices for the vaccines to the central government, state government and private hospitals. India’s highest court has questioned the “rationale” behind this “differential vaccine pricing.” The center while responding to this has maintained that “the difference in the prices fixed for Central government, state governments and private market are because of the volumes sought by them,” Business Today reports.

While the majority of states have decided to provide free vaccines to adults, those getting a shot from a private hospital will most likely have to pay out of their own pocket, even as most countries have made vaccination free for their citizens. Talking about the implications of the differential pricing or the increase in prices for vaccines being provided to state governments and private hospitals, economist R. Ramakumar told Firstpost in an interview, “It will have major implications in the way that it will push and exclude millions of poor people in India out of access to this health measure.”

The central government, while facing pressure on vaccinations, has come up with a new plan where it claims that it will have 2 billion vaccines available between August and December to vaccinate the whole population by the end of 2021, which seems ambitious to say the very least.

How Lack of Action Has Cost Lives

As of June 1, 3.3 percent of India’s population was fully vaccinated as against 40.7 percent of the population in the U.S. or 10.5 percent of the population in Brazil.

India is reporting around 3,000 deaths per day and is second only to the U.S. in the total number of COVID-19 cases that have been reported from the country so far.

Despite this, the central government’s messaging has focused on controlling its image rather than on taking charge of the health crisis. It has denied its own failure and has made no effort to share useful information to prevent the spread of the virus, with India’s health minister, Dr. Harsh Vardhan, even telling people to eat “dark chocolate to beat COVID-19 stress.” More recently, he tweeted to support a rebuttal of a recent Lancet report criticizing the handling of the crisis by the government.

The misinformation and downplaying of COVID-19 by the right-wing Modi government is similar to that of America’s former President Donald Trump, who said that people should consume disinfectants to fight coronavirus, only to later say he was being “sarcastic.” Many other parallels can be drawn regarding the handling of the COVID-19 situation by Trump and the Modi government. The state governments in America were also left pleading with the federal government for basic medical facilities, as seen in India. Much like Trump, who was against calling for a national lockdown, Modi is now averse to the idea, even as experts feel it will help curb infection rates. This is mostly due to the criticism Modi faced of calling a lockdown on short notice during the first wave. Despite receiving a clear mandate, both the leaders squandered the faith of the people who voted them to power.

Meanwhile, India and its slow vaccination rollout have become a cautionary tale for the rest of the world. “The tragedy in India does not have to happen here in Africa, but we must all be on the highest possible alert,” said Matshidiso Moeti, the WHO regional director for Africa.