Ethical Issues Concerning Ongoing Mass Vaccination in India
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India, acclaimed the world’s largest noble coronavirus vaccine manufacturer, found struggling with social, legal and moral issues with the ongoing coronavirus vaccination program. The greatest challenge for protection of its citizens against serious infectious disease through vaccination remains access to vaccines and associated inequity in access. Besides, improving infrastructure, developing novel delivery platforms that eliminate the need for a cold chain, continuing education and enhancing community engagement will be essential. There is a notable subset of the population who are skeptical about vaccination; and this requires a response from the scientific community to provide transparency about the existing knowledge gaps and strategies to overcome these. This paper, through integrative review of articles, published reports and interviews attempts to briefly discuss some unprecedented ethical issues raised regarding the vaccination programme against novel coronavirus spread in India. The study observed that systematic methodical rigor to improve coverage with all antigens in the diverse country has been wanting; and for the same efforts are needed to generate evidence for planning to (or not to) introduce new antigens in the programme and to prove the impact of vaccine introduction on disease.
Keywords: Ethics, Infectious disease, Vaccination, Strategy
Ethics, is a diverse field in the history of health and medical science, and its norms like science, are shaped by new data . Ethics norms are developed over time rather than being codified. Every progress in medicine carries with it a new set of ethical conundrums.
India, as of December 4,2021, administered coronavirus vaccines to 1.27 billion individuals - of whom 474 million people received double doses, which account for 34.4% of India’s adult population coverage. Even though India has recently hit a record with over 8 million vaccines engineered on a single day, it could complete administering just 58% of adult population with one dose vaccination . In the context of emerging ethical issues concerning the current vaccination programme, the Belmont report in 1979  laid down the principles of respect for persons, beneficence and justice, particularly in relation to vulnerable groups. Ethical values and legal principles are usually closely related, but ethical responsibilities usually exceed legal duties. In India, activists also contributed to the growth of bioethics by raising questions about research that was not done. Again, for any country its vaccination strategy needs to tackle two key-questions: what is required to achieve herd immunity and who to prioritize for vaccination. On both these counts, Government of India did attempt for a more ambitiously open decision-making process. But somewhere down the line effectively engaging the civil society groups and members did not materialize as expected.
The COVID-19 pandemic was preceded by a chain of public health emergencies, including epidemics in 2002, 2009, 2012 and 2014. They offered opportunities to learn how to plan for future outbreaks, and reflection by governments and multilateral agencies. However, there is today a tired acknowledgment that lack of ethical and moral vision impacted the right management required. Also, social activists attributed the management non-success to the policy refusal to think in terms of Gandhi’s talisman that asks us to weigh every action in terms of how it would benefit the weakest, the most vulnerable. They argued on ethics of most visible response to the pandemic i.e., imposition of prolonged lockdown. Critiques asserted that broadly Indian government’s response appeared to have been guided by politics of visibility and nationwide project of virtue signaling rather than wellbeing of general masses . Social activists pointed out that it was enforced contravened the Siracusa principles, a covenant drafted in 1985 by the International Council of Jurists which state that restrictions on human rights under the ICCPR must meet standards of legality, evidence-based necessity, proportionality, and gradualism . It details how states need to weigh human rights considerations when they impose restrictions to deal with public health emergencies.
For India the number of trained people in vaccinology and immunology is less than what country of this size requires. Thus, the greatest challenge in India for protection of the human population against serious infectious disease through vaccination remains access to vaccines and the huge associated inequity in access. Access to vaccines is currently limited, to varying degrees in different regions, by the absence of a health infrastructure to deliver vaccines, the lack of convenient vaccine provision for families, the lack of financial resources to purchase available vaccines (at a national, local or individual level) and the marginalization of communities in need. This is perhaps the most pressing issue for public health . Access to vaccines is one of the greatest obstacles, and improving infrastructure, continuing education and enhancing community engagement will be essential to improve this, and novel delivery platforms that eliminate the need for a cold chain could have great implications. There is a notable subset of the population who are skeptical about vaccination; and this requires a response from the scientific community to provide transparency about the existing knowledge gaps and strategies to overcome these. This paper, through integrative review of articles, published reports and interviews attempts to briefly discuss some unprecedented ethical issues raised regarding the vaccination programme against novel coronavirus spread in India. The emerged major ethical issues, can be summed up as follows:
The Epidemic Disease Act 1897 is a colonial era legislation that is still used as the primary law to control a mass epidemic. Despite recent amendments, the Act has major limitation in the era of changing dynamics in public health emergency management. Communicable diseases and their spread have changed over the years. Novel viral diseases, which are more virulent and potent in form, pose constant challenges for us. The Law that focuses on social policing did not help manage modern day pandemic with right-based approaches.
Public Health Experts asserted that there has been misjudgment regarding vaccination with lack of prioritizing before the second wave, rushed choice to open the vaccination plan to all age groups and not considering for rural population the online accessibility of vaccination program with limited internet and smart phone access. India's digital divide is hampering vaccine access.
In spite of the facts that India stand being the world’s largest vaccine manufacturer, a well-planned strategy that was needed in advance with public health expertise to maintain the equitable and fair distribution of vaccines got missed.
Over dependency on privatized healthcare in the country due to Government of India below par spending on public healthcare holds negative bearing on community health, especially for rural area inhabitants where private health infrastructure does not exist.
During the second wave of Covid-19 infections and the acute shortage of vaccines had led to considerable public anger. Union government announced a series of new measures that essentially liberalized vaccine sales and deregulate vaccine prices. The vaccine costs are found a burden for an average Indian family if they do not want to wait in the long queue of government hospitals. This is increasing divisions in social classes as education, travel, and job are now dependent on the vaccination status.
The history of vaccination efforts suggests that the systematic methodological rigor is required to improve coverage with all antigens in a diverse country like India, with health being state subject. The systematic efforts are needed to generate evidence for planning to (or not to) introduce new antigens in the programme and to prove the impact of vaccine introduction on disease, once the vaccine is introduced. The COVID-19 pandemic has shown that many parties with different incentives can come together to ensure that vaccines are being developed at unprecedented speed but has also highlighted some of the challenges of national and commercial interests.
- World Health Organization (2015) Global Health Ethics. Available online at: https://apps.who.int/iris
- Our World in Data (2021) Coronavirus COVID-19 Vaccinations. Available online at: https://ourworldindata.org/covid-vaccinations
- Belmont Report (2016) National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. Available online at: https://www.hhs.gov/ohrp/regulations-and-policy/belmont-report
- Science The Wire (2020) Where in India’s COVID-19 Response Is the Moral Compass That Guides Governance. Available online at: https://science.thewire.in/the-sciences/covid-19-india-epidemic-ethics-communities/
- Ray D, Subramanian S (2020) India’s lockdown an interim report. Indian Econ Rev 55: 31-79.
- Lahariya C (2014) A brief history of vaccines & vaccination in India. Indian J Med Res 139: 491-511.