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Dispatches from India: Vaccine Inequity and the Pandemic Rages On

July 21, 2021
by Devina Buckshee

Devina Buckshee is a first-year M.P.H. student at the Yale School of Public Health. She is also a health journalist who has been monitoring the COVID-19 crisis daily from her home in Maharashtra, the second-most populous state in India. What follows is the second installment of Buckshee’s personal reports on the human toll of the coronavirus pandemic from the front lines of the crisis in India. She hopes that sharing firsthand accounts of the situation in India will encourage others to support relief efforts there. This report was compiled in June and early July.

On Vaccine Equity and the Myth that the Pandemic is Ending

If one country celebrates going maskless while another suffers through indelible despair, can we really say that the pandemic is ending?

As a student from India soon to be arriving in the United States, I feel like I’m being transported to a different world. In India, we barely survived a devastating second wave of COVID-19 this spring. While most states have either lifted or eased lockdown restrictions, fear of a third wave, a potent new variant (Delta Plus), and the trauma of the second wave still lingers in the air.

The crowds are back now in India. But masking is a public health mandate. Signs reminding people to “mask up” are omnipresent, and most abide. Scrolling through Instagram, I see pictures of friends in the U.S. enjoying a mask-free life. The New York Times reports that many in the U.S. believe the worst of the pandemic is over.

But as India stands on the cusp of a potential third wave, imagining a post-pandemic world still feels distant.

An Enormous Undertaking

India’s immunization program is one of the largest in the world. Yet, even with the best-laid-out plans, we must acknowledge that vaccinating everyone is an enormous undertaking, says Dr. Anant Bhan, adjunct professor and researcher in bioethics at Mangaluru’s Yenepoya University.

“India has many interregional variations, so public health delivery cannot be uniform across states, regions or marginalized communities”, said Dr. Sanghamitra Singh, a health scientist and senior manager at the Population Foundation of India.

These different levels of access to care have resulted in inequities across the system.

Cruelly Out of Reach

India’s vaccination program was launched on Jan. 16, 2021 for priority health workers and people ages 65 and older. On May 1, vaccine eligibility was extended to anyone 18 and older. The program is run through CoWin, a government-sponsored mobile app and website. But with an acute vaccine shortage, appointments for many remain cruelly out of reach.

Adding to this distress is the fact that making appointments through CoWin requires digital access and literacy, further marginalizing those who are economically disadvantaged and without such resources. “We shouldn’t be entirely dependent on [technology] for critical interventions in public health,” said Dr. Bhan. A digital divide exists between privileged individuals and families that have the necessary technology and those that don’t. As a result, the vaccination process has exposed systemic health care inequities that appear to favor the privileged over others who are less fortunate.

Mina Mahapurey, a 27-year-old domestic worker from Mumbai, said she didn’t understand the CoWin app, and her employer registered her instead.

Those who did access the CoWin website and who tried but failed to make an appointment, are vocalizing their frustrations through social media. But for those of lesser privilege, it is access to the system itself that is causing the most serious concern.

People with disabilities, the economically disadvantaged and daily wage earners have been particularly impacted. Mahapurey said she finally got her first dose - after a month of trying - at a local temple that organized a free vaccine drive.

We shouldn’t be entirely dependent on [technology] for critical interventions in public health.

Dr. Anant Bhan

“Any intervention should be designed to be bottom-up, to include rather than exclude,” said Rashi Vidyasagar, director of the mental health organization The Alternative Story, who recently got her shot after weeks of trying.

“Representation needs to be embedded into the vaccine delivery infrastructure,” Vidyasagar continued. “We have existing on-ground delivery systems [via Accredited Social Health Activists or ASHAs and other frontline workers]. We should involve them to ensure we are reaching everyone.”

Public health experts say the COVID-19 pandemic presents an opportunity to reimagine India’s overwhelmed health care systems, and to refocus on the country’s 1946 mission of accessible health care for all.

Mind the (Gender) Gap

Gendered restrictions toward women have added another layer of tension and distress during the pandemic and create a major barrier to care. In India, according to our fourth National Family Health Survey (2015-16), which was released in December 2017, only 40% of women reported they are allowed to go out alone, including to a health facility.

A gender disparity in vaccination rates, with 46% women vaccinated and 54% men, therefore, isn’t surprising, Dr. Singh said. “Restrictive social norms, gender inequality and a lack of agency naturally lead to limited health care access. The lower uptake in vaccination is a result of these societal issues. This is compounded in rural areas, where women face an increased lack of access and awareness,” she added.

Widely circulating vaccine myths that carry misinformation and encourage vaccine hesitancy among women only serve to exacerbate the problem. Ranju, a 35-year-old cook from Delhi who asked that her full name not be used, said she heard (through the WhatsApp social network) that the vaccine causes infertility. Only after a chance meeting with a health worker was she convinced enough to get her first shot of Covaxin.

Another factor that pushed her toward getting vaccinated, Ranju said, were the government health messages that came over her phone every time she tried to make a call. “Mask up! Wash your hands frequently! Get vaccinated!” the messages said.

Then, there are the further marginalized: transwomen. Dalit and transgender activist Grace Banu is among those fighting to improve vaccine equity in India.

On the systemic inequalities and trans-erasure in health care, Banu said, “You need government ID to get access to the vaccine portal, or even COVID-19 cash relief and ration kits.” But some transpeople who leave their homes and families abruptly due to transphobia, leave their documents behind, or worse, their family destroys their IDs, Banu said. Re-applying is a lengthy process slowed down by the pandemic, making their odds of getting a protective shot even more difficult.

The Way Forward

India’s staggered vaccination drive has many gaps, and it is clear greater equality needs to be woven throughout the health care system. But we, as a country, have conquered such challenges before. We eradicated polio and improved maternal mortality rates. So, a road map exists for improving public health and the infrastructure — from being the world’s largest vaccine manufacturer to having existing delivery systems in place — is there to once again allow us to succeed.

In a land of many Indias – where there is great diversity among political, geographical and cultural regions — context-specific, localized interventions that are inclusive and built up from the community level — are key to preventing another humanitarian crisis.

Submitted by Ivette Aquilino on July 21, 2021