India: The Next Billion Jabs
A multi-disciplinary analysis of the journey that India must undertake to defeat the Coronavirus.
The overwhelming consensus is that vaccination is a more effective way than lockdown to beat the pandemic. So then, what makes this vaccination journey so hard? In one word: SCALE.
In this article, I present an analysis of the sheer magnitude of the challenge, where we are today, and how might we end this pragmatically, drawing insights and learnings from multiple disciplines.
The background:
The Covid-19 battle rages on. Reams of articles have been written — and millions of WhatsApps forwarded — about the pandemic and India’s fight against Corona.
More variants are being discovered and a third wave is inevitable.
The current thinking on what it might look like, how long it might last, and what damage and suffering it might inflict is the same severity as the second wave, lower mortality if the health infrastructure improves. This report is from the same research group at the State Bank of India that had projected the duration and severity of the second wave.
First things first. Let’s get our numbers in order.
India is in sync with the rest of the world numerically when it comes to units, tens, hundreds, and thousands. However, we then take a detour into lakh and crore before rejoining at a billion. So,
In the International system:
- 1000 K → 1 Million
- 1000 Million → 1 Billion
In India:
- 100 K → 1 Lakh
- 100 Lakh → 1 Crore
- 100 Crores → 1 Billion.
In other words, a Million is 10 Lakhs, and a Crore is 10 Million. For example, India’s population is 1.37 Billion or 137 Crores. Easy enough, yes?
So how are we doing right now?
The following table summarizes the vaccination efforts at a state and national level as of 5th June. The last national census was in 2011, so projected population estimates are used from the UIDAI (Unique Identification Authority of India, the government authority that issues Aadhaar cards and runs the Aadhaar ecosystem — this will be important later in the article. For vaccination target, I’ve used 70% of the population as a target and a 2-dose vaccine regimen.
Now, unless you are particularly blessed, this table above actually does not tell you much. Largely because, well, these are humongous numbers. But also, because we, as a species, are just plain terrible at grasping giant numbers.
Let’s try this another way, break it down piece-by-piece.
Starting with the states.
Administratively, India comprises states and union territories. The map below compares these states with countries of the equivalent total population. Almost immediately, the size of the challenge becomes obvious — even if you’ve never visited or heard of some of these countries. For instance,
- Karnataka has roughly the same population as France.
- Delhi is largely Sweden and Switzerland combined.
- Uttar Pradesh is essentially equivalent to Brazil!
Imagine that!!
The rate of vaccination and progress made so far:
Now that we have an idea of the magnitude, let’s evaluate the progress made so far. Table 1 above showed how far along each of the states are as of 5th June. The plot below puts all of these on a single chart. Immediately, the magnitude again becomes apparent — the x-axis below (Total doses), is logarithmic. India as a whole has completed 23 crores (230 million) doses and yet between 1st April and 5th June, the needle only moved from 3.59 % to 12.06 %. Another aspect to notice is the size of the circles— they represent the number of doses per lakh (100K) population.
While those numbers are a decent abstraction from an absolute perspective, the reality every state, every region, every district is different. Some are densely populated, some are remote and inaccessible. Demographics, religion, dominant languages, population gender-ratio, level of education are all different. The figure below plots the same progress data on a map and the differences between even adjacent states show up. This time, hover or click on each state.
Was there enough vaccine?
During April and May, there were numerous complaints of the unavailability of slots or even vaccines. Some of this led to overcrowding and long waits — especially at the Jumbo centers in the large metros. The following chart shows the number of available centers by day for these two months. Periods, where very few centers were open, are evident.
When would we finish?
Two months' worth of data, especially within the gamut of wave 2, and lower vaccine availability allow us to project forward. If we were to continue at the same average rate, when would we finish? What if we DOUBLED the rate? How much sooner would we finish?
From the chart below we see that some states would benefit by doubling the current rate of daily jabs, but for most of the others, a different technique will need to be applied. Intuitively also, India needs about 1 Crore (10 million) jabs daily, more than 3x to 4x the current rates.
If vaccines were available, can we do this in 180 days?
The current vaccines in India are effective for 6 months. Let’s see what it would take to finish all vaccinations within those 6 months and achieve herd immunity. Again, this varies widely by state.
The map below shows a projection of how many doses DAILY would be needed to be administered by states over180 days. The size of the bubbles represents the number of vaccination centers that need to be set up in each state.
This sounds impossible? Here’s the reality of the situation though.
India is no stranger to large volumes, massive vaccination drives, or rapid country-wide mobilizations. Therein lies the opportunity to defeat Corona.
Here’s a quick sampling of some relevant, humongous numbers in India
#1: 110 million polio doses in 3 days
In January 2021 — yes, right in the middle of the pandemic — India managed to vaccinate over 110 million children under five years of age against polio in just three days as part of the Polio National Immunisation Day (NID) on 31 January 2021. And these were all infants, toddlers, kids below 5 years of age. This means between 70 to 100 million adults and households were also mobilized. And we do this every year!
#2: 600 million votes in 7 phases over 5 weeks.
As the world’s largest democracy, India holds general elections every 5 years. This is a mind-boggling exercise in logistics. In the last one held in 2019, about 910 million citizens were eligible to vote, and turnout at 67 percent, was the highest ever, as well as the highest ever participation by women voters.
#3: 8 billion passengers, 1.4 million employees
The Indian Railways is the 8th largest employer in the world, transporting an average of 22 million passengers daily. Densely populated cities account for a large chunk of these, for instance, the local trains in Mumbai handle over 2 billion commuters annually, or about 7.5 million a day. Delhi Metro handles about 2.2 million daily. Other urban rail transits have similar figures relative to their populations. When extended beyond railways to other modes of transport, the size just explodes. Not counting ride-sharing services such as Uber and Ola, Mumbai has buses, taxis, and auto-rickshaws; buses alone handle 5 million commuters daily.
#4: 250 million students in 1.5 million schools
Not counting colleges and professional institutions, India has 25 crore students attending 15 Lakh schools. 13 Lakh of these schools are in rural areas and 74 % of these schools have electricity (we’ll see why that matters shortly). Also, half of India’s population is under the age of 25 (at 2016 estimates, this number was 47.5 percent, so around 600 million at the time).
What does all this mean?
It boils down to this — India does have the capacity to carry out massive, planet-scale vaccinations and mobilizations, even with all of the strict COVID-19 protocols in place, including those for social distancing, for lockdowns and containment zones, for registration, and adverse events following immunization (AEFIs).
In fact, with sufficient vaccine availability, we can even get this done safer and sooner! We just need to look at the successes from the past, from our other fields and rearrange a few things.
First the logistics — where could we do this?
The map below plots the schools by state. With wide distribution in the rural areas, pre-existing infrastructure, and local knowledge and semantics, and 75% electrification, the schools could serve as possible vaccination centers, reducing load and crowding at hospitals, clinics, health centers, and other areas. Also, in many regions, there are fixed school routes and buses, rickshaws, or other local transport already mechanisms in place — boosting the local economy. The reason you need a school or a fixed structure, in the first place, is because of AEFI protocol, viz., once you receive a jab, you need to be under observation for 30 minutes.
Next, who could do this?
The polio vaccination mentioned above was largely possible because of the ease of administration (it is an oral dose) and also because of the large army of ASHAs (Accredited Social Health Activists) Anganwadi Workers(AWW) and Anganwadi Helpers (AWHs). To wit:
- There are 1.3million AWWs and 1.2 million AWHs and about 1million ASHAs in India.
- Additionally, with 1.2 Lakh seats available for admission in medical colleges in India, over 4 years, there are about 4.5 Lakh students currently training to be doctors and dentists.
- There are also 3.2 Lakh seats for admission in nursing colleges, which, over 3 years means 9 Lakh students are training to be Nurses.
- Finally, India has about 21 Lakh Nurses, 9 Lakh ANMs (Auxiliary Nurse-cum-Midwives), and 56 K Lady Health Visitors (LHVs).
Understandably, Covid-19 plays by a different set of rules than, say Polio, Measles-Rubella (MR), or Diphtheria. However, the combination above could deliver the all-important knock-out punch in the fight against Corona. Here’s how and why.
- ASHAs are by definition female, locals, young (25–45 years), literate, and chosen after a rigorous selection process. More importantly, they are highly visible in the community, and able to reach through to women, and have a high trustworthy factor — which is crucial to overcome some of the hesitancy associated with Covid-19 vaccination.
- The geographical distribution of nurses and doctors is not uniform across India, but with ASHA, AWW, and other PHC (primary health care) combined, the ratio locally is better than 1 per thousand. In addition to ground-level mobilization, these folks can also assist in logistics, cold-chain, and registration.
- Students in Medical, dental, and nursing colleges could be given advanced practical training on administering vaccines (a 3–4 week intensive workshop would render them extremely useful at the vaccination centers-even if they don’t administer themselves.)
- Globally, the role of nurses in immunization efforts has been widely recognized. In the United States, due to staff shortages, nurses came out of retirement to help administer vaccines.
Finally, how do we mobilize?
- The key thread in all of the examples of the previous section was massive publicity, awareness, and preparation; sometimes months of prep.
If you had an infant, you knew when Immunization Day was coming. If you were voting, you knew your polling center, you knew which date, which voting phase applied to you. If you commute, you know exactly where and when you are commuting, traffic patterns, peak hours.
- The second key was an existing infrastructure.
You knew there would be a polio dose. You knew there would be a ballot box. You knew there would be a metro, bus, train, or even a school bus. You just had to show up!
- The third factor was that technology was an enabler, not a barrier.
You didn’t need a smartphone; you didn’t have to book slots. As an adult, you received an ink mark on your finger. As an infant, it was a permanent marker.
We could use this exact knowledge to prep for massive campaigns. Right now, vaccine availability isn’t great, but both production and procurement are being ramped up. This interim — even if it were five to six weeks out — could be used to prepare.
Urban cities could run transportation drills to avoid over-crowding. Rural areas could mobilize and spread awareness. Dates could be proclaimed in advance.
All this sounds nice. But how exactly?
Let’s take an urban scenario. Densely populated.
- Imagine veritable armies of bus drivers and conductors showing up at bus stops to fetch citizens to take them to the schools. Only, they are coming for you, not for the kids.
- You can only board if you have a physical Aadhaar card. That is the only check.
- You show up at the pick-up point, only on a designated date and time, known to you well in advance. No pre-booking.
- Only a certain number of folks are allowed to board — social distancing.
- Only a fixed number are allowed to wait at the point — and that’s fine because you know your turn will come.
- Once you get dropped off at the school, your temperature is checked, and you immediately get your vaccination. There is another army of doctors, nurses, medical students dishing out jabs with no wait time.
- Simultaneously, another volunteer applies indelible ink to one of your fingers.
But wait, what about the CoWin registration?
That is the best part!! The Covid-19 vaccination protocol mandates that you have to stick around for 30 minutes. And this is the weak link that ties it all together.
- Continuing the urban scenario above, at the same school; you’ve just received your jab, your ink mark and are now walking to a classroom.
- You wait there for 30 minutes, as instructed — during which time another set of volunteers show up.
- One of these volunteers, likely a tech-savvy youth, comes up to you, looks up your Aadhaar, marks you as done on the CoWin, registering you, if necessary.
- You get a second dab of indelible ink on another finger, same hand! If you are wondering, the Election Commission of India has already allowed this for home quarantines.
This simple step, of inverting the CoWin registration process guarantees local benefits, while still preserving a centralized view on the outcomes and counts. As a benefit, it neutralizes the divide between digital India and those who are not tech-savvy.
It’s also clear that this scenario could be played out in rural areas. Key differences, possibly being:
- You probably won’t be catching a train, but going to school, nonetheless.
- You may not have an app or a smartphone, but it won’t matter.
- You’ll not have situations where centers are open but no one shows up.
The same scenarios could be played in suburban and tier-2 railway stations, bus stands, places of worship, any place that is covered, accessible, has refrigeration, and places for folks to sit. There are other details and inter-disciplinary logistics that I’m happy to discuss. For instance:
- In urban areas, the fleet of taxis and metros could be used to ferry doctors and nurses — exactly like the polling agents on election day; you know where you will work; someone will come to pick you up.
- Traffic control rooms could be repurposed to direct and mitigate staff, supplies, and logistics. Like a nationwide assembly line that doesn’t halt.
A billion jabs, sure! We can do it! You just have to visualize it first!!
