A medical worker prepares to dilute a vial of Pfizer-BioNTech vaccine at a COVID-19 vaccination centre in Singapore, March 8, 2021. Photo: Reuters/Edgar Su/File Photo
It was a hot day in March, a few weeks ago, at a COVID-19 vaccine point of dispensing (POD) in Arizona. I, a PhD student from India who hadn’t travelled home for over a year, found fitting catharsis in public health community service in a state that has been my home away from home for almost three years now.
The day was coming to an end for our tired team of volunteers; we had been working under the relentless Arizona sun to administer vaccines and facilitate vaccination, now open to all in the state. The POD I had volunteered in was to operate until 5 pm.
Until about 3 pm, the site was so packed with cars – vaccinations in Arizona are being administered primarily in drive-throughs – that the volunteers just about managed to scarf down some food and inhale sips of water between their duties. Around 3 pm, the rush died down abruptly. We the volunteers, who had been frantically working until then, began ambling around the site unsure of what we were supposed to do next.
As a strange lull set in on the POD, volunteers began huddling in a tent to chit-chat in the absence of activity. The POD manager stepped out of the main building to talk to us. “Today is so weird,” he said. “Just an hour ago, we had so many people! We asked to turn away those without appointments because we thought we would run out of doses. Now, we are afraid the vaccines will go to waste.”
Upon hearing this, a fellow volunteer asked, “How many extras do we have?” “About 75 vaccines are ready to be administered,” replied the manager. “Spread the word among your friends if they want to come and get vaccinated with the extras.”
We waited for another hour but not many cars showed up in this time. On the way back to the main building, where our volunteering kits were, a volunteering nurse who I’d been talking to expressed concern. “I guess people are just not showing up for their appointments.”
Nationalism and hesitancy
Such a sudden reversal of fortunes at a vaccination site in a state in the US that was until recently a COVID-19 ‘hotspot’ is indicative of the complexities bound to arise in the management of a pandemic at local and global levels both.
Given the brutal implications of the novel coronavirus’s spread across the world – social, economic, collective – countries have been scrambling for vaccines to immunise entire populations. It’s now evident that the richer, economically developed countries have won the race in vaccine nationalism. Some, like the US, have bought vaccines for many multiples of its adult population.
Nevertheless, a critical public discourse has emerged around the injustice of richer countries hoarding vaccines, leaving the rest with shortages. What must be further emphasised in this discourse is how vaccine nationalism builds on existing inequalities in the political economy of global health.
The development of pharmaceuticals, including vaccines, has long banked on the vulnerability of marginalised bodies in the ‘global south’. So it should come as no surprise that the strategies to manage the pandemic have employed exclusionary ideas of nationalism for vaccine acquisition rather than leading to globally concerted efforts.
Equally predictable are the instances of vaccine wastage that my first-hand experience as a COVID vaccination volunteer also reflects. Vaccine hesitancy is a palpable reality in the US even as structural inequality has meant that minority communities, such as the African-American community and communities of colour, have been worst hit.
Earlier this year, during a cab ride on the way to receive my first COVID-19 vaccine shot, a conversation with the driver, an African American man in his 50s, about his reluctance to getting vaccinated revealed to me a deep-seated fear of medical experimentation among American minority communities.
The friendly fellow reminded me of the Tuskegee experiments of the 1930s, in which doctors conducted unethical and uninformed trials on Black Americans with syphilis. Vaccine skepticism in the US is also intertwined with colonialism and racism. The US political will of biologically defending its entire population is therefore confronted with the collective memory of racial and structural abuses in the US, along with conspiratorial suspicions directed at the scientific establishment.
The problem of vaccine wastage isn’t confined to the US. Just last month, this issue stirred public opinion in India and drew sharp criticism. Vaccine hesitancy leading to low turnouts at vaccination sites is the major cause of vaccine wastage in India. This hesitancy has been the result of loss of public trust in the vaccines due to the summary approval for Covaxin in January, ethical questions raised about clinical trials and reports of side-effects of the AstraZeneca shot.
Addressing vaccine hesitancy in India therefore requires transparent public engagement by experts on questions of the probabilities of side effects weighed against the protections conferred by the vaccine.
‘Pharmacy of the poor’
India is currently experiencing a second, more virulent outbreak of COVID-19 infections. State governments are rolling out statutory notifications for a second round of lockdowns. In the wake of these events, India’s inverse vaccine nationalism, which was focused on distributing India-made vaccines to the rest of the developing world, has been partly halted. India has decided to curtail the export of vaccines, an act that is likely to impact how the pandemic is managed in the rest of the developing world.
These concerns have prompted the Government of India to make reassurances about the continuous supply of COVID vaccines from India to other countries, but only with a view to the domestic situation. However, any attempts at maintaining a continuous export of vaccines will only be successful if the second wave is successfully managed within the country.
In a welcome move, the Indian government expanded the vaccine eligibility criteria to people older than 45 years from April 1. But there also exists considerable confusion regarding the procedure for registering to receive the vaccine, particularly in rural areas. Media reports have suggested that registration may require navigating a digital interface, which in turn requires devices and familiarity with using them. There is also no definitive information in the public domain on whether registrations are to be made through an app called CoWIN, through the Aarogya Setu app or by walking into vaccination centres.
Definitive public directives are essential for any public health initiative to succeed. At the same time, COVID-19 management strategies were not a major point in the election manifestos of political parties in the states where assembly elections are currently underway.
The future of India as a pharmaceutical provider for the developing world is therefore precariously hinged on tensions between vaccine nationalism and domestic vaccine hesitancy. In the coming months, how the Indian state manages these tensions will determine how well India continues to play the role of a pharmacy of the poor.
Sanghamitra Das is an Indian PhD scholar at Arizona State University. Her research lies at the intersections of medical anthropology, science studies and South Asian studies.