When It Comes to Vaccines, Govt Tells Us One Thing, Supreme Court Another

On May 13, the government told us that between August and December this year, the covid vaccine availability/production will be ramped to around 216 crore doses. Tweets were published by several government handles. (You can take a look here and here).

Many media reports were also published regarding the same. As the Mumbai edition of The Times of India reported on May 14: “Setting out its roadmap to vaccinate the around 95 crore 18-plus population, the Centre said on Thursday India should be able to access nearly 217 crore doses between August and December.”

The following table shows how the 216-crore number was arrived at.

Source: Ministry of Health and Family Welfare. In case you are unable to see the table, click here.

Several ministers reiterated this message. Prakash Javadekar, who holds multiple portfolios in the government, said: “India will get 216 crore new vaccines by December. India will be able to vaccinate more than 108 crore people with the help of these vaccines.” The health minister Dr Harsh Vardhan also made a similar statement.

The underlying message here was that the vaccine shortage, if any, would not be a problem in the months to come. Over the next few days, WhatsApp and other social media kept buzzing with this message. The above table was shared over and over again. The Be Positive crowd had a field day. So far so good.

The trouble is that the numbers in the table are just that, numbers. Allow me to explain.

75 crore doses of the Covishield vaccine are expected to become available between August and December, a period of five months. This implies a production capacity of 15 crore doses per month on an average.

In a submission to the Supreme Court on May 9, the government had said that the manufacturing capacity of the Serum Institute, the company which manufactures Covishield, is expected to go up from 5 crore doses per month to 6.5 crore doses by July 2021. Increasing production capacity from 6.5 crore doses per month to 15 crore doses per month is going to be some task.

Of course, the government always has the option of importing the Astra-Zeneca vaccine doses (which is locally manufactured as Covishield). But even if the government decides to import, the difference between the local production capacity and the projection of 15 crore doses per month on an average, is huge. Further, any imports will come at the expense of denting the atma nirbharta narrative.

When it comes to Covaxin, the estimated production between August and December has been assumed to be at 55 crore doses. This implies a production of 11 crore doses per month on an average.

The central government told the Supreme Court on May 9 that the manufacturing capacity of Bharat Biotech, the company which currently manufactures Covaxin, is expected to go up from 90 lakh doses per month to 2 crore doses per month, and further increase to 5.5 crore doses per month by July 2021. So, 5.5 crore doses a month is half of the 11 crore doses per month that is required as per the government’s calculation.

Of course, it needs to be remembered that the intellectual property for Covaxin is shared between Bharat Biotech and the Indian Council of Medical Research. Hence, Covaxin will also be manufactured by three public sector manufacturing facilities. These are Indian Immunologicals, Hyderabad, Haffkine Biopharmaceuticals, Mumbai, and Bharat Immunologicals and Biologicals, Bulandshar.

Based on this, the government told the Supreme Court: “This is projected to enhance Covaxin‟s current manufacturing of 1 crore doses/month to nearly 10 crore doses/month in the next 8-10 months.”

So, Covaxin’s production is expected to touch 10 crore doses per month only in 2022. At least, that’s what the central government told the Supreme Court. Nevertheless, that did not stop them from telling you and I, that 11 crore doses per month of Covaxin will be produced on an average between August and December. Given this, the vaccine production projections made by the government, don’t pass the basic smell test. 

And we aren’t done with this yet. A close look at the above table tells us that it also includes doses from vaccines which haven’t been cleared for production. In fact, this was precisely the point made by the two amici appointed by the Supreme Court ( Jaideep Gupta and Ms Meenakshi Arora) in the Suo Moto writ petition that the Court is currently hearing.

As Wikipedia points out: “An amicus curiae (literally, “friend of the court”; plural: amici curiae) is someone who is not a party to a case who assists a court by offering information, expertise, or insight that has a bearing on the issues in the case.”

As the Amici told the Supreme Court:

“The [central government] has claimed that it will be able to vaccinate a substantial number of persons (around 100 crore persons requiring 200 crore doses) by December 2021. However, no projections have been shared with this Court regarding how this target would be achieved. Based on reports, it appears that the [central government] has factored a number of vaccines that are currently in their development stages to reach its projected number of 200 crore doses. This approach would be misguided as the success and efficacy of vaccines that are currently in the stage of clinical trials is uncertain and cannot be guaranteed.”

The interesting thing is that the central government hasn’t presented any projections of vaccine availability to the Supreme Court and in an affidavit submitted to the Court on May 9, it said: “It is difficult to predict the projections for vaccines given that it depends on variable factors such as introduction of new foreign vaccines, capability of increased production by existing manufacturers, among others.”

Of course, the variable factors did not stop the government in confidently telling us that 216 crore vaccine doses would become available between August and December, later this year. Something, it didn’t have the confidence to tell the Supreme Court on May 9, it told the country on May 13, four days later, and has been saying it over and over again since then.

What this tells us is that the submissions to the Supreme Court are clearly not good WhatsApp material and hence, things can be said as the way they are.

Nevertheless, the Solicitor General, during the course of his oral submissions to the Supreme Court, did say: “He is in a position to address these concerns of this Court and that the UoI aims to vaccinate approximately 100 crore persons by the end of December 2021.”

Nonetheless, there is a huge difference between an aim, a plan, and a projection, as we have seen in the calculations earlier in this piece. Numbers are just numbers and can easily be tortured to arrive at what one wants to say. The table accompanying this piece is an excellent example of this phenomenon.  

But then on WhatsApp who is bothered about the details and the nuance. So, the main aim of the government was to project a confident be positive narrative and it did just that.

To conclude, it is safe to say that there is one truth out there for the Supreme Court and another for the country at large.

On Being Positive – Do You Have Your Bullshit Receptors On?

Be positive.

My friends have told me to be positive.

My extended family has asked me to be positive.

Unknown people on the social media have suggested the same.

Because in their heads they feel that being positive will drive us out of the rut and all the troubles that we currently find ourselves in.

Of course, it’s not as simple as that. It never is. 

Dear Reader, have you ever wondered why the be positive messages started going around on WhatsApp, Twitter, Instagram, LinkedIn and what not, last month, right in the middle of the worst phase of the second wave of the covid pandemic? People were dying. People were not getting oxygen, beds or medicines for that matter, and in the middle of all this man made chaos, friends and family, were sending WhatsApp messages promoting the idea of being positive. 

Well, if you are like the people who have been asking me and others to be positive, you clearly didn’t think about it. This is simply because you were busy being positive and didn’t bother to figure out why this bullshit of being positive came up right when it did and not before or after.

The Nobel Prize winning psychologist Daniel Kahneman along with Olivier Sibony and Cass Sunstein, have got a possible answer for this in the book Noise—A Flaw in Human Judgement.

As they write:

“Sure enough, some people are more receptive than others to bullshit. They can be impressed by “seemingly impressive assertions that are presented as true and meaningful but are actually vacuous.””

The word vacuous means empty or mindless. From religious gurus to corporate gurus to religious gurus morphing as corporate gurus (yes there is a category like that as well), follow this formula with great success. Doing this involves use of phrases and sentences which sound profound when heard, but mean nothing, if you sit and think about it.

As Kahneman, Sibony and Sunstein write:

“Gordon Pennycook and colleagues have conducted many studies of people’s reactions to meaningless, pseudo-profound statements generated by assembling randomly selected nouns and verbs from the sayings of popular gurus into grammatically correct sentences, such as “Wholeness quiets infinite phenomena” or “Hidden meaning transforms unparalleled abstract beauty.” The propensity to agree with such statements is a trait known as bullshit receptivity.”

In order to make the population at large receptive of bullshit, it is important that they are in a good mood. While  doing this would have been very difficult earlier, now with cheap internet and rock-bottom mobile phone rates, and many smart phones going around, people can be bombarded endlessly with messages of being positive. It doesn’t cost anything except a few message writers, who are available dime a dozen.

As the authors point out:

“Inducing good moods makes people more receptive to bullshit and more gullible in general; they are less apt to detect deception or identify misleading information.”

And this is where the entire idea of being positive which has been promoted so extensively over the last one month, comes in.

The idea is to make sure that people are in a good mood and hence, more receptive to misleading explanations around why there is shortage of vaccines, why the government was caught totally unprepared for the second wave and why the government is not be blamed for all this. And it needs to be given the benefit of doubt.

Recently I was told by someone that the vaccine shortage is primarily because of journalists (yes, journalists). They wrote columns questioning the efficacy of the vaccines. This led to a situation where many people did not vaccinate between January and March, before the second wave broke out, as they thought the vaccines are not safe.

Given that enough people were not getting themselves vaccinated, the government ended up exporting six crore doses. Hence, now there is a shortage, and the government can’t be blamed for it, because journalists questioned vaccine efficacy. This is one argument going around among the be positive crowd.

There are many ways of puncturing this argument but let me use the simplest one. The current government has no interest in listening to journalists or anyone else who does not conform to their way of things. So why would they listen to them on just this issue? The more important question is why the government did not bother to order enough vaccines in advance, like governments of so many countries did.

The government didn’t do this simply because it got caught in its own rhetoric of India having successfully beaten the covid pandemic. The trouble with government propaganda is that sometimes the governments end up believing in it and the citizens have to bear its cost, which they currently clearly are, though many of them are busy being positive. 

It is important to keep in mind what Carl Bergstrom and Jevin West write in Calling Bullshit – The Art of Scepticism in a Data Driven World:

“Human language is immensely expressive, in the sense that we can combine words in a vast number of ways to convey different ideas… This is a good skill to have when trying to communicate efficiently—and it’s equally useful when using communication to manipulate another person’s beliefs or actions. That’s the thing about communication. It’s a two-edged sword.”

The entire be positive campaign (can’t think of a better word to describe it), is what the American philosopher Harry Frankfurt called a deliberate misrepresentation in his book On Bullshit.  And this deliberate misrepresentation has been carried out to ensure that there are no scratches on the teflon coating surrounding the government. 

To conclude, be positive in 2021 is basically what acche din aane waale hain was in 2014. They are two sides of the same coin. They were both designed to mislead. 

The Real Story Behind India’s Covid Vaccine Exports

Chintan Patel and Vivek Kaul

India began administering covid vaccines on 16 January 2021. Within a week, the Indian government had sent almost 50 lakh free doses to Bangladesh, Bhutan, Nepal, Myanmar and other countries. The Modi government calculated that it could raise India’s global stature by pursuing a covid vaccine diplomacy strategy – dubbed vaccine maitry.

By the end of March, India had exported more vaccines than administered to its own population. In fact, India’s ambassador to the United Nations (UN) wore this fact as a badge of honour. In an UN general assembly meeting on March 26, Ambassador Nagaraj Naidu claimed: “In fact, as of today we have supplied more vaccines globally than have vaccinated our own people.” (The statement clearly hasn’t aged well).

Of course, as we know, India was hit by a massive second wave of covid in early April, which has caused widespread loss of life, health and wealth.

As India continues to grapple with the devastation, the government’s export strategy has come under scrutiny. Even the Serum Institute of India (SII), manufacturer of the Covishield vaccine, has been criticised for vaccine exports. Taking note of this criticism, SII came out with a statement defending the vaccine roll-out in India, including the rationale behind exporting vaccines before the second wave set in.

Let’s look at the underlying data to examine the public discourse on this issue, including some of Poonawalla’s claims. 


Source: Summary of a larger table available at https://www.mea.gov.in/vaccine-supply.htm.

The above table presents the data for the total covid vaccines exported – both by month, and by category. Vaccines sent abroad are divided into three categories: a) grants made by the Indian government, b) purchases made by the foreign governments (under commercial), and c) SII vaccines sent to COVAX – the international consortium that is coordinating the distribution of covid vaccines to low-income countries.

Central to the vaccine export debate, is this simple question: Did the government’s vaccine diplomacy effort contribute to India’s vaccine supply crisis?

The data presented in the above table provides some clues. Let’s look at them point wise.

1) A total of 1.07 crore vaccines were sent as donations to other countries. Of this, most of the vaccines were sent before April, when the second wave started. This category comes with nuance attached to it. The government of India purchased the covid vaccines from vaccine makers (almost exclusively from SII) and decided to send over 1 crore doses to other countries instead of making them available to Indian citizens.

Helping other countries who are also in need is a noble idea and can earn valuable diplomatic capital and goodwill. But it also comes at a cost. Clearly, the government thought that the benefits accrued by this act of benevolence outweighed the potential cost.

Making judgment calls on future events is an intrinsic part of leadership. Deciding to donate over one crore vaccines while most of the country was still not vaccinated was one such judgment call made by PM Narendra Modi and his government. The obvious alternate use of the vaccines that were given away to other countries – or what economists call ‘opportunity cost’ – was to inoculate Indian citizens.

Of course, one can always argue that one crore doses wouldn’t have made much of a difference in the overall scheme of things, given that India needs to vaccinate a total of 94.3 crore adults (people aged 18 and above). 

Nevertheless, the opportunity cost of the one crore vaccines was the increased immunity of many Indian citizens. Or as the old cliché goes, something is better than nothing.

Given both the severity of the infections and the lack of supply that has slowed down the vaccination drive since early May, there can be no doubt that the decision to give away vaccines wasn’t a great judgment call.

While one can argue (like Poonawalla does) that the intensity of the second wave of covid blindsided many, any government’s primary responsibility is to keep its citizens safe. If it fails to prepare for an event that leads to mass death and destruction, it has failed in discharging its primary duty.

As we had explained in a previous piece, the Indian government was caught napping, while other countries were stocking up on vaccine doses through the second half of 2020 and early 2021. (You can see the table here). The government got caught believing its own rhetoric. Using the surprise element of covid as an excuse would have worked at the point when the first wave struck. It doesn’t really hold when talking about the second wave. 

In many ways, the covid pandemic is a war-type scenario. Donating life-saving vaccines when our own population is still vulnerable is comparable to giving away body armour that could protect soldiers on a battlefield. That the enemy struck with more ferocity than expected, is not an acceptable excuse.



2)
Nevertheless, there is much more to this story. A total of 3.58 crore doses were exported from January to March as part of purchase agreements between vaccine makers and foreign governments. The Serum Institute of India (SII) was the main player here, with Bharat Biotech (BB) having exported only 3.25 lakh doses abroad.

3) Another 1.99 crore doses were sent to the COVAX consortium by SII. COVAX is the global effort to procure vaccines for low-income countries led by Gavi, the Vaccine Alliance, Coalition for Epidemic Preparedness Innovations (CEPI) and the World Health Organization (WHO). Over 1.70 crore of these doses were sent in March alone. SII has contractual obligations to deliver vaccines to COVAX as part of its licensing agreement with Astra Zeneca and collaboration with Gavi.

Given that over 5.5 crore doses (3.58 crore plus 1.99 crore) sent abroad were a part of private contracts and licensing agreements between SII and foreign entities, can the Modi government really be held responsible for allowing the export of these vaccines? Supporters of the government will say no, while detractors will say yes. We, on the other hand, can only offer some nuance.

1) It is incorrect to group the vaccines which the government gave out as grants in the same category as the vaccines that were sent as part of commercial/COVAX agreements. The government is directly responsible for the former being sent abroad, and only tangentially responsible for the latter. Across all categories, vaccine manufactures (SII or BB) should not be targeted for exporting vaccines.

They were either selling to the Indian government, who then decided to share its stocks with the world, or fulfilling their contractual obligations – both perfectly reasonable and legitimate actions.

That said, in February and March, when the Covid situation seemed under control in India, the Modi government was happy to claim credit for all exported vaccines, including the ones being sent as part of private contracts. Hence, by their own logic, the administration should be held accountable for all 6.6 crore vaccines exported. But their logic was flawed when they claimed credit, and it would be flawed to pin equal responsibility to all export categories.

2) The 3.58 crore vaccines that foreign entities could buy from SII and BB was only made possible because the Indian government had not been proactive in placing vaccine orders. The government could have placed much larger advance orders, like other countries did. It could have done so especially with SII, to ensure that it got the lion’s share of the company’s production capacity, outside of its obligations to COVAX.

The government gave the first order for vaccines in January 2021 when it procured one crore shots from SII and 55 lakh shots from BB. After this initial order, the government has been ordering vaccines in a piece-meal manner.

An order of 12 crore doses (10 crore from SII and 2 crore from BB) was placed in March. The exact dates for other intermediate orders is not in the public domain, but around 16.5 crores doses were ordered before April 28. In early May, the government issued a statement clarifying that a new order of 16 crore doses (11 crore from SII and 5 crore from BB) was placed on April 28. The timing and quantity of these orders meant that vaccine makers were not given the fillip to prioritise maximum production with an assurance that their supplies will be purchased by the Indian government.

Prioritising your own citizens in a time of crisis is not selfish. In fact, it is the right thing for an elected government to do. The United States (US) which has the most robust vaccination drive in the world has been doing that, and justifiably so. The US chose not to export any of its vaccines, including ones that were not even authorised for domestic use till its vaccine supply exceeded local demand.  

3) Lastly, it is not entirely correct to claim that the government is in no position to interfere with vaccine manufacturers’ contract commitments to foreign countries or agencies. India has placed a restriction on vaccine exports since late March – so the provision exists to take such an action. Of course, placing such a restriction before the second wave hit, would have been difficult to justify.

These export restrictions bring up an interesting dilemma of vaccine exports vis a vis the role that the government has in the execution of private contracts. As mentioned earlier, SII has contractual obligations to other countries and COVAX to deliver a certain quantity of vaccines. In fact, SII may have already received advanced funding as part of those contracts. So, it seems only fair that the SII should be able to deliver on those contract terms.

However, SII needs export permission from the government to be able to ship vaccines out of the country. The government has temporarily halted all exports of covid vaccines given the domestic lack of supply and severity of need. In fact, last week it again denied SII’s request to export 50 lakh doses to the United Kingdom.

The situation in India may not improve in the months to come, and there is also the warning of a third wave that needs to be taken into account. A recent report suggests that this restriction may now last till October.  On the other hand, Gavi, the vaccine alliance, has made it clear that it views the agreement with SII as a legally binding contract that has to be enforced. Astra-Zeneca has also sent legal notices to SII for delay in shipments. The international community has bet heavily on India’s vaccine manufacturers and extended import restrictions may not be taken too kindly.

Given this backdrop, a potential international legal wrangle looms ahead. A vaccine initiative that promised friendship may end in acrimony.

But How Do You Hide the Dead…

The idea for this piece came from a May 13 tweet by G Raghuram. In this tweet Raghuram talked about the Goodhart’s law in the context of the way Covid numbers are being reported.

In a 1975 article, the British economist Charles Goodhart had stated: “Any observed statistical regularity will tend to collapse once pressure is placed upon it for control purposes.” This came to be known as the Goodhart’s law. Of course, like many other laws in economics, the Goodhart’s law has also not been stated in simple English.

As Carl T Bergstrom and Jevin D West write in Calling Bullshit—The Art of Scepticism in a Data-Driven World: “While Goodhart’s original formulation is a bit opaque, anthropologist Marilyn Strathern rephrased it clearly and concisely: When a measure becomes a target, it ceases to be a good measure.”

As Bergstrom and West further explain: “If sufficient rewards are attached to some measure, people will find ways to increase their scores one way or another, and in doing so will undercut the value of the measure for assessing what it was originally designed to assess.”

Examples of this phenomenon can be seen across different facets of life. A business school I used to work for had started dozens of journals and magazines, without much quality control, to drive up its rankings and it briefly did succeed. This was because business school rankings gave some weightage to research carried out by the faculty of a business school and by having its own magazines and journals, it was easier to publish. This helped in driving up the ranking. 

Now what does the Goodhart’s law have to do with the covid pandemic? As the covid pandemic struck and spread, different measures have been used to get an idea of its strength (for the lack of a better term). These include daily increase in covid cases, the total number of tests carried out in a district and a state, the total number of covid deaths, etc.

As per Goodhart’s law, these different measures have become targets. And that has led to different state governments  trying to game these measures, in order to make themselves look good and tell the world at large that they have the covid pandemic under control.

Before I get into data and news reports, let me explain this through a very simple example. For a while, the daily increase in the number of covid cases in Nagpur in Maharashtra was much more than the increase in the entire state of Madhya Pradesh.

Anyone who knows Indian geography would know that Nagpur is right on the border that Maharashtra shares with Madhya Pradesh. It is not an island. People can move between the states. This anomaly wasn’t really explainable unless one looked at the Madhya Pradesh numbers from the lens of the Goodhart’s law.

One parameter that has been managed (or should I say fudged) by different states is the number of people dying of covid. The idea as I explained earlier is to tell the world at large that they have the situation under control. The trouble is that the governments may be able to manage the data, but they can’t always hide the dead bodies.

Crematoriums across the country have been working overtime. Public health expert Ashish Jha, offered a straightforward argument in a Twitter thread on May 9. As he wrote: “During [the] non-pandemic year 2019, about 27,000 Indians died on [a] typical day. Crematoriums handle that level of deaths every day. Additional 4,000 deaths won’t knock them off their feet. Crematoriums across the country [are] reporting 2-4X normal business.”

He further writes: “So best estimate [of] 55,000 to 80,000 people dying daily in India, If you assume baseline deaths of 25,000-30,000, Covid [is] likely causing additional 25,000 to 50,000 deaths daily, not 4,000.” As Anirban Mahapatra writes in Covid-19 – Separating Fact from Fiction: “During the pandemic many of these excess deaths are due to COVID-19.”

Many journalists and newspapers have found ways of going beyond the official numbers. Let’s take the case of Gujarat. The Divya Bhaskar newspaper has reported that the state has issued 1.23 lakh death certificates between March 1 and May 10 this year. It had issued around 58,000 death certificates during the same period last year. So, the number of deaths has more than doubled this year. As per Gujarat government’s data only 4,218 deaths happened due to covid during the period. This suggests massive underreporting. The Gujarat government has called this report inaccurate.

It would be unfair to suggest that this trend of underreporting covid deaths is prevalent only in Gujarat. An April 15 report on NDTV, during the early days of the second wave, said that for Lucknow, the “cumulative official covid death count released by the government in the last seven days is 124.” Nevertheless, as “per the records maintained by the city’s crematoriums, over 400 people who died because of the virus had been cremated,” during the period. The government explained away this difference by saying that those dying in neighbouring districts and states were also being cremated in the city.

A similar thing happened in Bhopal as well. Over a period of 13 days in April, the official covid death count stood at 41. Nevertheless, a survey carried out by The New York Times of the main covid-19 cremation and burial grounds in the city, revealed that more than 1,000 deaths had been handled under strict protocols. There was a similar newsreport on Kanpur as well.  

In fact, the Financial Times, collected news reports across seven districts and found that the number of covid victims who had been cremated are ten times larger than the official covid numbers in the same districts. (Click on the above link to look at the graph).

Of course, other than such news stories, there have been a spate of photographs and videos lately, showing bodies washing up and then later buried on the shores of the Ganga river, flowing through Uttar Pradesh and Bihar. A Dainik Bhaskar news report puts the number at more than 2,000 bodies, with Kanpur, Unnao, Ghazipur and Ballia being worst hit. (Those who can read Hindi, I suggest please read this report).  

Journalists have also been counting paid obituaries being published in newspapers, again suggesting a huge difference between the reported numbers and the actual state of things.

As Bhramar Mukherjee, an epidemiologist at the University of Michigan told the New York Times: “It’s a complete massacre of data… From all the modeling we’ve done, we believe the true number of deaths is two to five times what is being reported.”

As per the Institute for Health Metrics and Evaluation, which is based in Seattle, United States, the total covid deaths in India as of May 6, stood at 6.54 lakh, around three times the official figure.

There are several ways in which the undercounting happens. In Uttar Pradesh, in order to get admitted into a hospital, the patient required a reference letter from the Chief Medical Officer “who heads the Integrated Command and Control Centres set up by the government in all districts”. Due to this rule, patients were turned away from hospitals. And if such a patient died he or she wouldn’t be counted in the covid deaths.

A medical officer in Krishnagiri in Tamil Nadu told The Hindu: “We have been told orally in the meeting that only deaths within 10 days of admissions will be taken as covid-19 deaths.” MK Stalin, the new Tamil Nadu chief minister, has asked the state government officers not to fudge data.

The number of deaths also depends on how the counting is carried out. Take the case of West Bengal, where in May 2020, the “official’ coronavirus death toll… doubled in the five days since the state virtually shelved its Covid-19 death audit committee.”

Then there are cases where an individual dying of covid had not tested positive (hence, it was a case of a false negative). There are examples of such cases not being counted as well.

There are also cases of covid deaths being attributed to other health complications that individuals had when they got infected by the virus. These include diabetes, hypertension, cancer etc., which increase the risk of severe covid.  

A news report on BMJ.com published in July 2020, pointed out that in Vadodra “death audit committees attributed nearly 75% of deaths in covid-19 positive cases to other causes such as complications from diabetes or following organ transplants.”  All this is happening against the prevailing guidelines of the Indian Council of Medical Research.

People who die outside hospitals or on their way to one, aren’t counted in the covid deaths. Two thirds of registered deaths in India happen at home. In all around 86% of deaths in India are registered.

Even here there is a great deal of variation across states. In Bihar and Uttar Pradesh, only 34.6% and 60.8% of the deaths, respectively, are registered. As the disease spreads across rural Bihar and rural Uttar Pradesh, massive undercounting of both active covid cases and deaths, is happening.

The reluctance of politicians notwithstanding, the system itself is not geared up to count the dead, from covid or otherwise, in these states.

The biggest evidence of undercounting comes from the fact that the Prime Minister Narendra Modi recently said that the “states should be encouraged to report their numbers transparently without any pressure of high numbers showing adversely on their efforts”.

There are several reasons why the governments need to count the number of people dying because of covid, correctly.

First and foremost, people have a right to know what is happening in the country. It tells us clearly how the disease is progressing  and helps us prepare accordingly, mentally, physically and financially.

Second, as I have often said in the past, if we don’t recognise a problem how do we work towards solving and/or containing it. With regard to this, Bhupinder Singh Hooda, a former chief minister of Haryana, made an important point in a recent column in The Indian Express, where he said:

“The Union government is allocating oxygen on the basis of the severity of the second wave in the state. If the state government underreports the numbers or fudges the data, it will harm, rather than help, the state as it will get a lower allocation of oxygen and more deaths will follow.”

Third, counting covid death numbers as accurately as possible is important for the overall health security of the world. No herd immunity can be achieved if the disease keeps spreading across India.

Fourth, the correct data helps epidemiologists run their models properly and then make projections that should help policy.

It also needs to be said here that historically during a pandemic, data is not always accurately collected. As  Chinmay Tumbe writes in Age Of Pandemics (1817-1920):

“Death figures are collected on the basis of ‘registration’, which is a process that usually breaks down in a period of crisis, as observed by the health officials of those times. It leads to serious underestimation of the number of deaths, especially in poorer countries with weak data collection systems. In India, the Census of 1921 noted that due to ‘the complete breakdown of the reporting staff, the registration of vital statistics was in many cases suspended during the progress of the epidemic in 1918’.”

The mortality statistics of those who died in the pandemic that happened between 1918 and 1921, have been updated through various studies over the years.

Having said that, when it comes to data and data collection, things have improved by leaps and bounds over the last 100 years. Hence, even with the pandemic being on, data collection and management, needs to be carried out in a much better way.

Of course, all this is lost on a central government, which is primarily interested in narrative management. It is currently busy spreading the narrative that it had warned the states of a second wave.

But then it did nothing about it… Didn’t order enough vaccines… Didn’t make sure that there was enough stock of oxygen… Exported the vaccines being produced… Continued with the kumbh mela and the elections, both big super spreader events… And also told the world that India had managed to defeat covid.

In between all this we were also asked to bang utensils and eat dark chocolate. 

India’s Vaccination Mess and How to Sort It

Chintan Patel and Vivek Kaul

The second wave of coronavirus continues to unleash its horror in India. This crisis has brought in focus the significance of mass vaccinations being carried out at a very quick pace. Without vaccinating a vast majority of our population against Covid-19, there is no pathway to normalcy and achieving herd immunity.

Policy-makers in India have finally awakened to this reality or at least that is what we hope. That they have been found so lacking – in planning, preparation, and priorities – speaks volumes of the caliber of our political and bureaucratic class.

As a piece in The Times of India, dated May 10, points out, at the current rate of vaccination, it will take around 1,000 days to vaccinate the adult population of 94 crore (around 94.3 crore to be precise). But assigning blame will not solve this crisis. Timely, considered action and policies might.

In this article, we try to assess the logistical readiness of a mass vaccination plan by looking at the capabilities and capacities at each step of the vaccination process. Specifically, we look at current and future vaccine supplies and discuss key issues related to vaccine administration.

Vaccine Supply

There are two vaccines available in India currently – Covishield manufactured by the Serum Institute of India (SII) and Covaxin manufactured by Bharat Biotech. In addition, we will be importing Sputnik V from Russia starting this month, with a small amount already having come in, and are likely to receive shipments of Astra-Zeneca vaccines from the United States. Also, Zydus Cadilla has announced that it expects to get emergency authorisation for its 3-dose vaccine shortly.

The table below lists the different vaccine sources and their estimated/committed doses for the next six months. Projections beyond October are subject to too many assumptions which can lead to wide variations in estimates. For now, a six-month planning and estimate window seems appropriate. Even then, these are estimates that may prove to be incorrect.

Expected vaccine Supply (in crore)

Source:

  1. Covishield : SII CEO statement reported by Reuters on April 21. India’s Serum Institute to raise output to 100 mln AstraZeneca doses by July, not end-May | Reuters
  2. Covaxin: Bharat Biotech statement reported by NDTV on April 21. Bharat Biotech Scales Up Covaxin Production To 700 Million Doses Annually (ndtv.com)
  3. Sputnik: India Today report on May 1. First batch of Russia’s Sputnik V Covid vaccine arrives in Hyderabad, to be sent for regulatory approval – Coronavirus Outbreak News (indiatoday.in) and Sputnik V, Covishield, Covaxin: What we know about India’s Covid-19 (BBC). 
  4. Astra Zeneca: Press statement by White House, reported by CBS News on April 26. COVID vaccine: U.S. aims to share up to 60 million AstraZeneca doses with other countries after FDA review – CBS News
  5. Zydus Cadilla: Press report. Zydus Cadila Likely To Seek Approval For Its COVID-19 Vaccine This Month (moneycontrol.com)

Let’s discus the above table in a little more detail. 

These are broad estimates derived from publicly available information as on May 7, 2021. The intent behind this exercise is to consolidate information emerging from various sources to provide a coherent and a reasonable picture of the vaccine supply scenario.

There might be major changes in either direction, that is, actual supply might increase due to new production or distribution agreements or actual supply might decrease if manufacturers are not able to deliver to their committed/planned volume. As we said earlier, this is a broad estimate.

1) The estimates for Covishield are based on their total production capacity projections given by Adar Poonawalla, the CEO of Serum Institute of India (SII). SII’s current production capacity is between 6 to 7 crore per month. We have assumed it to be at 6.5 crore per month. By July, SII expects to raise its production to 10 crore, as reflected in our estimates starting August. We assume that an increase in production will start hitting the market in the next month. 

On April 28, 2021, the government of India placed an order with SII for 11 crore doses for May, June and July. Over and above this, SII has announced that it has a separate order of 11 crore doses from state governments and private hospitals. But the delivery schedule for those orders is not publicly known.  

To add another layer of ambiguity on the demand side, SII is also obliged to export 20 crore vaccine doses in 2021 as part of its agreement with Astra-Zeneca and World Health Organization. Currently, vaccine exports have been halted due to the domestic crisis in India. It is possible that export of Covishield doses will resume once the crisis abates. In fact, 5 million doses of the Covishield vaccine which were to be exported to the United Kingdom have now been made available for inoculating those in the 18-44 age group.

Thus, our estimates allocate the entire production of Covishield for domestic use. Please note that if export of Covishield vaccines resumes, the actual supply numbers for India will be lower than estimated numbers.

Currently India faces a supply problem. In May, the supply of vaccine doses is expected to be around 8-9 crore. As one of us had earlier estimated, the total number of vaccine doses needed to vaccinate the remaining part of India’s adult population, stands at around 178-190 crore doses. The gap between what is available as of now and what is needed, explains the prevailing chaos when it comes to vaccines.

2) For Covaxin, once again, our estimates reflect the total monthly capacity. Bharat Biotech, the makers of Covaxin, have announced that they will be able to ramp up their annual production capacity to 70-80 crore vaccine doses by July. In an interview given in late April, Krishan Ella, the CEO of Bharat Biotech had remarked:

“Last month we produced 1.5 crore doses, this month we are reaching 2 crore doses, next month we will be making around 3 crore doses followed by 7 to 7.5 crore doses. We are ramping up the production and by July-August we will be able to reach 70 to 80 crore doses production capacity per annum.”

Using this as a guideline, we have budgeted 2 crore Covaxin doses for May, which ramps up to 3 crore in  June, rising to 6 crore doses per month starting in July (6 crore per month x 12 = 72 crore per year).

3) The first pilot batch of 1,50,000 doses of the Russian Sputnik V vaccine, was shipped to the Hyderabad based Dr Reddy’s Laboratories in early May. We have not counted those since the number is too small for this estimation exercise. As per the agreement between Russian Direct Investment Fund which is marketing the vaccine and Dr Reddy’s, 12.5 crore doses are to be imported to India between April and June 2021 .

We have split that number up from June to September (12.5 crore/4 = 3.13 crore), given that a bulk of these vaccines have not been delivered as yet . For October, we have kept the number at 3.13 crore. It is likely that the Sputnik V dose availability might go up after a few months since six local manufacturers are supposed to manufacture 75 crore doses of the vaccine after the initial batch of imports. The timing of the locally manufactured Sputnik V is difficult to predict. So, as a rough estimate we have retained the 3.13 crore figure for October as well.

4) It is likely that the US might begin to share some of the stockpile it has of the Astra-Zeneca vaccine, with India. We have estimated that to be 1 crore doses a month, starting in June.

5) Zydus Cadilla is expecting to get an approval for its three dose Covid vaccine in May. Their initial production capacity is slated to be 1 crore doses per month, which is expected to rise to two crore doses per month. Given that the vaccine has not yet been approved we stick with the initial capacity of one crore doses.

This vaccine is a three dose vaccine, hence, the “value” of a single dose is two-thirds of the other vaccines – all of which are two dose vaccines. Thus, the equivalent monthly supply estimate for Zydus Cadilla is 0.67 crore (two-thirds of one crore).

6) Another indigenous vaccine made by Biological E based in Hyderabad may become available in August. Since the vaccine hasn’t been approved yet, we have not included it in our supply estimates.

7) During any vaccination drive, some amount of vaccines get wasted due to improper handling, theft and human errors. The following chart shows the rate of vaccine wastage in a few states as of May 10.

Source: Ministry of Health and Family Welfare.

We have not included wastage in our analysis to keep things slightly simple. Having said that, doses lost due to wastage will decrease the available supply for inoculation. 

Finally, with these caveats, we can say that there will be a supply around 102 crore additional vaccine doses between May and October 2021. What this means is that vaccines will continue to be in short supply in the short-term.

The efforts highlighted above to get the various vaccines available in India are all positive steps. But as the numbers indicate, the supply pipeline is not adequate to meet our vaccination needs of close to 180 crore vaccine doses.

The primary reason for this shortage is that the government of India waited too long to place vaccine orders and when it did, it didn’t order enough doses.  This can be seen in the chart below that compares the vaccination order timelines for different countries.

Source: https://epaper.telegraphindia.com/imageview_359302_24528134_4_undefined_19-04-2021_1_i_1_sf.html.

In fact, as Satyajit Rath, a veteran biologist formerly associated with the National Institute of Immunology, Delhi, told the Deccan Herald, regarding the government barely stocking up on vaccines: “This was part of a pattern of treating the epidemic as a short-term crisis, somewhat like natural disasters such as an earthquake.”

Now let’s take a look at the possible steps that can be taken to augment the vaccine supply.

A supply of more than 100 crore doses of different vaccines by October, if achieved, will be no mean feat. But even that is not fast enough given our vast population. The following steps can be taken to increase the supply of vaccines. These are medium term solutions and will likely yield results over the 6-12 month horizon. This means that the supply of vaccines will continue to be an issue over the next few months. 

1) The central government should work closely with both SII and Bharat Biotech to enable them to hit maximum production capacity. Additionally, both manufacturers should be asked to furnish a weekly supply schedule for better planning and coordination, if that is not already happening. With multiple buyers in the mix now (with state governments and private hospitals) such a supply schedule assumes even greater significance.

2) India is the vaccine manufacturing headquarters of the world. According to Central Drugs Standard Control Organisation, there are 18 private and three public sector vaccine manufacturers in the country. One potential route to increase vaccine supplies is to leverage spare local vaccination manufacturing capacity to increase supply of Covaxin using licensing and/or royalty agreements with Bharat Biotech.

The intellectual property for Covaxin is jointly owned by Bharat Biotech and the Indian Council of Medical Research (ICMR), a government body. In fact, an arrangement along this line is already in motion where the Mumbai based Haffkine Institute, one of the oldest biomedical research institutes in the country, has been granted permission by the central government and funding by the Maharashtra government to start production of Covaxin.

Vaccines production from this plant is expected to take atleast one year. Other efforts, similar to this could be spawned with other vaccine makers after an assessment of technological and supply chain feasibility. However, based on the Haffkine timeline, it is clear that such efforts will not help in the short term. Having said that, we don’t know if the current wave is the last wave of Covid. 

3) India can import additional vaccines from the United States. The United States has a contract with Astra Zeneca for 30 crore doses of which six crore doses are either in stockpile or will be shortly available. Since the Astra Zeneca vaccine has not been approved in the US, India can apply a concerted effort – both diplomatically and/or financially- to receive a substantive portion of the stockpile.

India should also look at importing additional vaccines directly from vaccine makers. The Municipal Corporation of Greater Mumbai has such plans.

Among the major vaccines approved and in use elsewhere, the Johnson and Johnson (J&J) vaccine is the most attractive given that it is a single-shot vaccine and it does not need extreme cold storage. The J&J vaccine may not be the best use of taxpayer money, but one that private companies could pursue and make available to the general public at a higher cost. 

Vaccine Administration

Vaccine supplies are no good if they don’t translate into inoculation. En-masse administration of vaccines depends on several factors including number of vaccination sites, available personnel, location of sites, and public willingness to get vaccinated. Let’s look at this in some detail. 

The following chart shows weekly vaccination rates in India.

Source: dashboard.cowin.gov.in.

Here are some observations from the above graph.

1) The vaccination rate was quite low till early March. The spread of the second wave of covid clearly catalysed the public into action and the vaccination numbers rose steadily till the first week of April, barring a small dip towards the end of March.

From just over 4 lakh vaccinations in the week of February 27 to March 5, numbers jumped to almost 2.5 crore in the week of April 3 to April 9. After hitting that peak, numbers have dropped down to around 1.15 crore vaccines for first week of May. This is a drop of around 54% over just one month. As covid has spread, our vaccination rates have been dropping.   Vaccine supply shortages are mainly responsible for this drop in inoculation in recent weeks, and the lockdown imposed across large parts of the country may also have contributed to this.

2) The peak rate of around 2.5 crore weekly vaccines is an important statistic. It translates to a monthly rate of 10 crore vaccines – more than the projected supplies for May but about 30% short of the projections for June. What this tells us is that the distribution capacity can handle the imminent vaccination volume, but will need to start ramping up soon to keep up with the projected supply.

3) According to the Cowin dashbord, as of May 7, there were 58,214 vaccination sites (55,822 government sites and 2,292 private sites). Along with using government hospitals in the urban centres, the government has wisely activated the rural healthcare system for vaccine delivery as well. 

The rural healthcare delivery system in India is a three-tier system. The smallest unit, called sub-centres, are health outposts which are meant to be the first contact point between the community and the healthcare system. A group of sub-centres are served by a single primary health centre which has a doctor (medical officer) and nurses on staff. A group of primary health centres feed into a community health centre– which is akin to small hospital with specialist doctors and diagnostic equipment.

A study of the vaccination sites in different states on the Cowin dashboard reveals that many states are using sub-centres, primary health centres and community health centres, as vaccination sites. The rural population is being targeted here.

However, as is often the case, enterprising citizens often outthink policy makers, resulting in unanticipated policy outcomes. In this case, there are reports that urban Mumbaikars, who are digitally more savvy than the rural folks, are showing up in rural areas to get vaccinated. This phenomenon highlights the need to make the registration process more accessible to all.

Now let’s look at state wise vaccination data.  As of May 7, 2021, around 16.75 crore vaccine doses had been given. How do different states compare in this vaccine drive?  The table below provides some insights.

Vaccination Rates (in %)

Source: Author calculations based on data from Cowin dashboard and Unique Identification Authority of India. 

In the above table, we show the five states that are performing the best and five that are performing the worst when it comes to vaccination rates, among states which have a population of over 1 crore. 

Uttar Pradesh has the worst vaccination rate, where only 4.6 % of the population has gotten at least one dose of the Covid vaccine, and just above 1% has been fully vaccinated. It appears that the energy spent by state leadership in image management, has come at the expense of an effective vaccine roll-out strategy.

Bihar, Assam, Tamil Nadu and Jharkand, are the other laggards with no state having fully vaccinated over 2% of their population (except Tamil Nadu which is marginally over 2%). In case of Assam and Tamil Nadu, among other things, the recent state assembly elections may have been responsible for low vaccination rates.

Among states that are doing well, Kerala and Gujarat – with their oft-cited competing models of development – are doing remarkably similar when it comes to vaccinating their people.  Uttarakhand, Jammu and Kashmir, and Rajasthan, are the other vaccination leaders.

The ratio of folks fully vaccinated is not starkly different between the leaders and the laggards – 4.83% for Gujarat vs 1.17% for UP – but the figures for people with one shot taken does show a significant difference (17.28% for Kerala vs 4.59% for UP).

Till the end of April, states were dependent on the centre for getting vaccines. So, the discrepancy in vaccination rates is likely to have been a function of the centre’s distribution decisions, as well. The central government has not released the criteria used for vaccine distribution to the states, something that they should be doing for transparency and efficacy auditing.

Having said that, Gujarat has clearly been a beneficiary of the allotment mechanism, receiving the highest quota of vaccines from the centre after taking its population into account. As an April 19 newsreport on moneycontrol.com points out:

“As on April 8, the supplies to Maharashtra covered just about 8.5 percent of the population. For Delhi, it was 10.4 percent. On the other hand, Gujarat, which can’t be regarded as the most impacted state if one goes by official numbers, had got enough vaccines for 16.4 percent of its population – the highest.”

It appears that when it comes to competition between states, Prime Minister Narendra Modi continues to root for his home state.

Starting  May 1, the state governments can procure vaccines directly from the manufacturers. Having states compete for what is essentially a fixed supply isn’t a great idea since it will not increase the total vaccines available nationwide. Instead, the states and private corporations will fight over the 50% pool that has been de-regulated.

So states that have more leverage with vaccine makers or more financial clout/headroom stand a better chance of pulling ahead in the vaccination race. It will be interesting to see the trajectory of vaccination rates of different states as they begin to place their vaccine orders in the coming weeks and months. Also, this is clearly creating an access problem for the poor.

Vaccine Logistics 

As the supply of vaccines increases in the coming months, the question is do we have enough health care workers and vaccination sites to keep up with supply. 

First, let’s look at the manpower question. As per the Fifteenth Finance Commission Report tabled in February 2021, there were a total of around 27 lakh healthcare workers in India in December 2017. These include registered nurses (RN), registered midwives(RM), lady health visitors (LHV) and auxiliary nurse midwives (ANM). Specifically, there were 20,48,979 RNs and RMs, 56,469 LHVs and 8,60,927 ANMs, serving in the country. All these healthcare workers are capable of administering a vaccine.

Now, consider a full-throttle vaccination campaign with 1 crore doses/day. Assuming that a healthcare worker administers 50 doses a day, we would need 2 lakh healthcare workers which is less than 8% of the total available personnel. Thus, it is evident that labour won’t be a bottle-neck to ramp up the vaccine drive. 

Next, let us look at how many potential vaccination sites are available. Recall that currently, around 61,000 sites are being used. As per the Rural Health Survey of 2019, there are 1,57,411 sub-centres, 24,855  primary healthcare centres and 5,335 community health centres, across the country.

Thus, even without counting government hospitals and private clinics, there are over 1,87,000 potential vaccination sites, almost three times than are being currently used. Thus, vaccination sites also are not limiting factors in scaling up vaccine delivery.

One potential hindrance in getting maximum number of people to sign up for the vaccines is the current vaccination registration process. A huge rush for vaccines has made the signing up process a bit of a lottery. In fact, techies have resorted to writing scripts to alert them when an elusive spot opens up. For everyone else, the process consists of repeated tries on loop.

One major problem experienced by folks trying to sign-up for a vaccine is the non-receipt of a one-time password (OTP). The OTP is a pre-requisite to move ahead in the registration process, and many folks have been unable get past the OTP step. Technical glitches in the early stages of an app/website roll-out are not unheard of, but given the importance of this issue, one would have expected the “routine” bugs to have been ironed out before mass adoption.

That such glitches are so widespread indicates that the en-masse registration was not planned with adequate lead time. Here too, like most aspects of the Covid response, the government’s lack of readiness is being exposed.

The online registration will likely smoothen out over time, but currently it only caters to the internet-savvy comfortable in English. Online sign-ups may not totally work for all folks, both rural and urban. Systems that allow a registration method that is appropriate and accessible for those not comfortable with the current digital setup, need to be created. .As a start, the Cowin registration website needs to become multi-lingual.

The language barrier automatically excludes the majority of the country. As per the 2011 Census, only around 13 crore people identified English as first, second, or a third language. It is mind-boggling that the government decided to offer the registration process only in a language that the vast majority does not understand. That the registration process cannot support the major Indian languages, is again a sign of a system put together in haste.

Vaccine Hesitancy 

Vaccine hesitancy can also potentially derail the entire vaccination drive. If too many adults choose not to sign up for the vaccine, it won’t be possible to reach herd immunity quickly. In some ways, the severity of the second wave makes the most compelling argument for the need to vaccinate. Yet, for a variety of reasons, people tend to be hesitant.

Safety concerns, efficacy concerns, and ignorance (wilful or genuine) about the seriousness of Covid-19, are prime reasons that drive this hesitancy. WhatsApp messages and fake news exacerbate the psyche of suspicion and distrust. The best anti-dote to that is positive messaging and increased awareness about the benefits of vaccination. Given this administration’s core competence of narrative management, mass communication to encourage vaccine enlistment should not be a big hurdle.

As a more directed policy step to incentivise vaccinations, especially in rural areas, the central government could consider linking a Public Distribution Service (PDS)-based benefit with a vaccination dose. For example, for each vaccine dose a voucher for a few kgs of rice/wheat, which can be redeemed at the local ration shop, can be given.

This should not cost the central government much (other than perhaps transport and administration) since the Food Corporation of India storehouses are overflowing with way more grain than the strategic and operational buffer that needs to be maintained.

The pathway to a fully vaccinated Covid free India is not easy and won’t happen overnight. But, with proper planning and execution, we can make significant progress over the next several months. We all need to do our bit to succeed in this effort.

All, including Nero.