Covid vaccine: The seven principles of a successful immunisation programme

Or why there’s an opportunity in every crisis, since science has given us the means.

WrittenBy:Jammi N Rao
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Albert Einstein was once asked how it was possible that while man had the intelligence and ingenuity to “discover the structure of the atom”, he had not the ability “to devise the political means to keep the atom from destroying us”.

“That is simple,” Einstein said. “It is because politics is far more difficult than physics.”

Scientists have successfully harnessed the marvels of modern science to give us a huge choice of vaccines. The Covid Networked Meta-Analysis initiative is tracking and collating the results from the 100+ trials in progress. Sooner rather than later, India too will grant regulatory approval to one or two vaccines. The last thing we need now is for the politics of running an effective immunisation programme to suddenly become a stumbling block.

The pandemic has so far resulted in 82 million cases worldwide and 1.8 million deaths. In India, the toll has been 10.2 million infections and 150,000 deaths. But the real cost of the pandemic goes far beyond infections and deaths.

In her blog, International Monetary Fund chief economist Gita Gopinath says that coronavirus has pushed the world “into the worst economic crisis since the Great Depression”. India is projected to be among the worst-affected economies with output in 2020 forecast to be 10.3 percent down when compared to 2019. In most of the world, except China, economic activity is unlikely to return to 2019 levels, even in 2021.

In India, as indeed in almost all major economies across the world, the poor have become destitute, jobs have been lost on an unprecedented scale, the downward trend in the prevalence of hunger and undernutrition has been reversed, and inequalities in both health and economic status have widened.

An effective and successful immunisation programme is the only way out of this slump. It holds the promise of halting the transmission of the virus, allowing human interaction, travel and trade, and business and commerce to limp back to what was once normal. The scientist-entrepreneurs have done their bit both in India and abroad; there is the technology to manufacture the vaccines. All that remains is to make sure that we deploy the same ingenuity and innovation to deliver an effective immunisation programme that we showed in developing the vaccines.

Seven principles

I outline what I hold to be seven key principles. Not following them would amount to committing, so to speak, one or more of the seven deadly sins in public welfare.

Balance the compulsions of the individual versus the public

The public health priority is to get everyone in the population immunised. For an individual, however, the balance of benefit lies in everyone else around him receiving the vaccine (so that herd immunity kicks in) while he himself avoids the costs and risks of the vaccine. The only way to align these two divergent perspectives is to create the right incentives while dismantling the known disincentives.

Transparency and openness is vital

Open, honest and timely communication of the unvarnished truth is vital. The people must be treated as equal partners in an enterprise that can succeed only with their support.

Health journalist Priyanka Pulla is right to question the ethical stance of the sponsors of the Covishield trial when a trial participant suffered a serious adverse event. The honest and morally right thing for the Serum Institute of India to do would have been to acknowledge the adverse event suffered by the Chennai participant, admit that they cannot be certain that it was NOT vaccine-associated, and offer a no-fault compensation. Instead, they threatened to sue the man for the temerity to complain.

That was in the context of a trial. In a mass immunisation programme, it is vital — if we are to preserve public confidence — to set up a publicly funded insurance scheme that would pick up the healthcare costs of serious adverse events that might occur soon after the vaccine is administered or within a defined time interval.

Be prepared for setbacks

Every mass immunisation programme in every country has suffered unexpected setbacks due to adverse publicity, unanticipated mishaps, deliberate and malicious attacks from anti-vaxxers, and administrative cock-ups. The key is to be prepared, to plan and to have in place a strategy for rapid, authoritative, and truthful communication of the facts in each case.

When you give a vaccine to hundreds of millions of people, there will occur, by sheer statistical probability, apparently associated health-related problems within hours or days of vaccine administration. In Israel a man with a known history of heart disease died of a heart attack hours after receiving the vaccine. The right response is to acknowledge the loss, point out the likely coincidental nature of the two events, and make the argument that there will be scores more where someone got Covid-19 days or weeks before he was due to get the vaccine.

Logistics and planning is everything

Even in the United States, the richest country in the world, as Brown University’s professor of public health Ashish Jha pointed out in a tweet thread, the planning has been poor, last minute, and badly resourced. India’s vastly bigger problem must, at the very least, not be minimised. Even assuming for a minute that vaccine stock and supply is not constrained, the coronavirus immunisation programme in India will be the biggest public health mass immunisation programme ever undertaken. The smallpox and polio campaigns of the past are an inspiration, yes, but in terms of scale and pace, they will seem easy, undemanding and relaxed in comparison to the effort that will be needed against Covid.

Keep it simple, do not overcomplicate the task

KISS (Keep It Simple, Stupid) is a well-known acronym, attributed to a Lockheed engineer in the 1960s, that trips off the tongues of management consultants who then promptly go on to complicate matters in proportion to their fee. At heart, the idea is simple. Focus, laser-like, on the core objective, do the minimum necessary to achieve it, and avoid mission-creep — the adding of bells and whistles that multiply the cost and complexity without adding to the efficiency of the programme.

If the immediate objective is to immunise as many people as fast as vaccine supplies allow, in order to reach 70 percent of the population, then a central IT system that tracks recipients is clearly redundant. The Indian government’s proposal to use yet another app, Co-Win, for this purpose raises barriers to access, introduces an unnecessary level of complexity, and creates worries about data privacy. It is an excellent example of mission-creep.


Huge and complex public health programmes work best when responsibility for the delivery of each aspect of a complex programme is devolved downwards to the lowest administrative level at which it can most efficiently be executed. In India, clearly, top-level leadership, vision, procurement, budgetary resource allocation, and strategic planning must lie with the union government at the Centre. Everything else must be entrusted to the states who, in turn, should be free to devolve operational planning and final delivery — the last mile (as Ashish Jha calls it) to district and subdistrict levels.

We are all in it together

The “public” in public health is recognition of an inescapable set of axiomatic truths. One is that “no one is safe until everyone is safe”. Another is that famous American ideal e pluribus unum, “out of many, one”. A third is the well-known dictum, a corollary almost of the first statement: “nothing is in place until everything is in place”. And a final truism, “a chain is only as strong as the weakest link in it”.

Taken together, and interpreted in context, the “we-are-all-in-it-together” ethos should lead to the unarguable realisation that a coronavirus immunisation programme calls for a publicly funded, free-at-the-point-of-delivery primary health service where everyone is equal, where prince and pauper alike wait together for their turn according to an order of priority that is determined not by expediency but by principle and with the core objective in mind.

There have been calls by some for those who can afford it to pay for their vaccines. This would be a mistake; it would create a black market in vaccines and encourage hoarding and price gouging. Those who can afford to pay are the very people who can afford to keep out of circulation and work from home, waiting for their turn while herd immunity builds up. It would do little to restore the confidence everyone needs for normal life to return, and for people to start to rebuild shattered livelihoods.

As a space-exploring, 1.3 billion-strong power that aspires to a permanent seat at the United Nations Security Council as the world’s No. 3 economy behind China and the United States, India needs a world class public health system. The coronavirus pandemic, devastating as it may have been, presents a once in a lifetime opportunity to start to build just such a system.

India must not let the present crisis go to waste.

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