The Peninsula Foundation

Category: Healthcare & Public Health

  • Indian Economy at 75: Trapped in a Borrowed Development Strategy

    Indian Economy at 75: Trapped in a Borrowed Development Strategy

    In 1947, at the time of Independence, India’s socio-economic parameters were similar to those in countries of South East Asia and China. The level of poverty, illiteracy, and inadequacy of health infrastructure was all similar. Since then, these other countries have progressed rapidly leaving India behind in all parameters. ‘Why is it so?’ should be the big question for every Indian citizen in this time of our 75th anniversary celebrations.

     

    Introduction

    India at 75 is a mixed bag of development and missed opportunities. The country has achieved much since Independence but a lot remains to be done to become a developed society. The pandemic has exposed India’s deficiencies in stark terms. The uncivilized conditions of living of a vast majority of the citizens became apparent. According to a report by Azim Premji University, 90% of the workers said during the lockdown that they did not have enough savings to buy one week of essentials. This led to the mass migration of millions of people, in trying conditions from cities to the villages, in the hope of access to food and survival.

    Generally, technology-related sectors, pharmaceuticals and some producing essentials in the organized sectors have done well in spite of the pandemic. So, a part of the economy is doing well in spite of adversity but incomes of at least 60% of people at the bottom of the income ladder have declined (PRICE Survey, 2022). The great divide between the unorganized and organized parts of the economy is growing. The backdrop to these developments is briefly presented below.

    Structure and Growth of the Economy

    In 1947, at the time of Independence, India’s socio-economic parameters were similar to those in countries of South East Asia and China. The level of poverty, illiteracy, and inadequacy of health infrastructure was all similar. Since then, these other countries have progressed rapidly leaving India behind in all parameters. So, India has fallen behind relatively in spite of improvements in health services and education, diversification of the economy and development of the industry.

    In 1950, agriculture was the dominant sector with a 55% share of GDP which has now dwindled to about 14%. The share of the services sector has grown rapidly and by 1980 it surpassed the share of agriculture and now it is about 55% of GDP. The Indian economy has diversified production `from pins to space ships’.

    Agriculture grows at a trend rate of a maximum of 4% per annum while the services sector can grow at even 12% per annum. So, there has been a shift in the economy’s composition from agriculture to services, accelerating the growth rate. The average growth rate of the economy between the 1950s and the 1970s was around 3.5%. In the 1980s and 1990s, it increased to 5.4% due to the shift in the composition. There was no acceleration in the growth rate of the economy in the 1990s compared to the 1980s. This rate again increased in the period after 2003 only to decline in 2008-09 due to the global financial crisis. Subsequently, the rate of growth has fluctuated wildly both due to global events and the policy conundrums in India.

    There was the taper tantrum in 2012-13 which cut short the post-global financial crisis recovery. Demonetization in November 2016 adversely impacted growth. That was followed by the structurally flawed GST. These policies administered shocks to the economy. Then came the pandemic in 2020. The economy’s quarterly growth rate had already fallen from 8% in Q4 2017-18 to 3.1% in Q4 2019-20, just before the pandemic hit.

    1980-81 marked a turning point. Prior to that, a drought would lead to a negative rate of growth in agriculture and of the economy as a whole. For instance, due to the drought in 1979-80, the economy declined by 6%. But, that was the last one. After that, a decline in agriculture has not resulted in a negative growth rate for the economy. The big drought of 1987-88 saw the economy grow at 3.4%. After 1980-81, the economy experienced a negative growth rate only during the pandemic which severely impacted the services sector, especially the contact services.

    Employment and Technology Related Issues

    Agriculture employs 45% of the workforce though its share in the economy (14%) has now become marginal. It has been undergoing mechanisation with increased use of tractors, harvester combines, etc., leading to the displacement of labour. Similar is the case in non-agriculture. So, surplus labour is stuck in agriculture leading to massive disguised unemployment.

    India is characterized by disguised unemployment and underemployment.Recent data points to growing unemployment among the educated youth. They wait for suitable work. The result is a low labour force participation rate (LFPR) in India (in the mid-40s) compared to similar other countries (60% plus).The gender dimension of unemployment and the low LFPR is worrying with women the worst sufferers.

    India’s employment data is suspect. The reason is that in the absence of unemployment allowance, people who lose work have to do some alternative work otherwise they would starve. They drive a rickshaw, push a cart, carry a head load or sell something at the roadside. This gets counted as employment even though they have only a few hours of work and are underemployed. So, India is characterized by disguised unemployment and underemployment.

    Recent data points to growing unemployment among the educated youth. They wait for suitable work. The result is a low labour force participation rate (LFPR) in India (in the mid-40s) compared to similar other countries (60% plus). It implies that in India maybe 20% of those who could work have stopped looking for work. No wonder for a few hundred low-grade government jobs, millions of young apply. The gender dimension of unemployment and the low LFPR is worrying with women the worst sufferers.
    These aspects of inadequate employment generation are linked to automation and the investment pattern in the economy. New technologies that are now being used in the modern sectors are labour displacing. For instance, earlier in big infrastructure projects like the construction of roads, one could see hundreds of people working but now big machines are used along with a few workers.

    Further, the organized sectors get most of the investment so little is left for the unorganized sector. This is especially true for agriculture. Thus, neither the organized sector nor agriculture is generating more work. Consequently, entrants to the job market are mostly forced to join the non-agriculture unorganized sector, which in a sense is the residual sector, where the wages are a fraction of the wages in the organized sector. The unorganized sector also acts as a reserve army of labour keeping organized sector wages in check

    Lack of a Living Wage

    To boost profits, the organized sector is increasingly, employing contract labour rather than permanent employees. This is true in both the public and private sectors. So, not only the workers in the unorganized sector, even the workers in the organised sector do not earn a living wage. Thus, most workers have little savings to deal with any crisis. They are unable to give their children a proper education and cannot afford proper health facilities. Most of the children drop out of school and can only do menial jobs requiring physical labour. They cannot obtain a better-paying job and will remain poor for the rest of their lives.

    The Delhi socio-economic survey of 2018 pointed to the low purchasing power of the majority of Indians. It showed that in Delhi, 90% of households spent less than Rs. 25,000 per month, and 98% spent less than Rs. 50,000 per month. Since Delhi’s per capita income is 2.5 times the all India average, deflating the Delhi figures by this factor will approximately yield all India figures. So, 98 per cent of the families would have spent less than Rs.20,000 per month, and 90 per cent less than Rs.10,000 per month. This effectively implies that 90 per cent of families were poor in 2018, if not extremely poor (implied by the poverty line). During the pandemic, many of them lost incomes and were pauperized and forced to further reduce their consumption.

    Unorganized Sector Invisibilized

    In the unorganized sector, labour is not organized as a trade union and therefore, is unable to bargain for higher wages, when prices rise. It constitutes 94% of the workforce and has little social security. No other major world economy has such a huge unorganized sector. No wonder when such a large section of the population faces a crisis in their lives, the economy declines, as witnessed during the pandemic. India’s official rate of growth fell more sharply than that of any other G20 country.

    The micro sector has 99% of the units and 97.5% of the employment of MSME and is unlike the small and medium sectors. The benefits of policies made for the MSME sector do not accrue to the micro units.

    Policymakers largely ignore the unorganized sector. The sudden implementation of the lockdown which put this sector in a deep existential crisis points to that. The micro sector has 99% of the units and 97.5% of the employment of MSME and is unlike the small and medium sectors. The benefits of policies made for the MSME sector do not accrue to the micro units.

    Invisibilization of the unorganized sector in the data is at the root of the problem. Data on this sector become available periodically, called the reference years. In between, it is assumed that this sector can be proxied by the organized sector. This could be taken to be correct when there is no shock to the economy and its parameters remain unchanged.

    Demonetization and the flawed GST administered big shocks to the economy and undermined the unorganized sector. Its link with the organized sector got disrupted. Thus, the methodology of calculating national income announced in 2015 became invalid.

    The implication is that the unorganized sector’s decline since 2016 is not captured in the data. Worse, the growth of the organized sector has been at the expense of the unorganized sector because demand shifted from the latter to the former. It suited the policymakers to continue using the faulty data since that presented a rosy picture of the economy. This also lulled them into believing that they did not need to do anything special to check the decline of the unorganized sector.

    Policy Paradigm Shift in 1947

    Growing unemployment, weak socio-economic conditions, etc., are not sudden developments. Their root lies in the policy paradigm adopted since independence.
    In 1947, the leadership, influenced by the national movement understood that people were not to blame for their problems of poverty, illiteracy and ill-health and could not resolve them on their own. So, it was accepted that in independent India these issues would be dealt with collectively. Therefore, the government was given the responsibility of tackling these issues and given a key role in the economy.

    Simultaneously, the leadership, largely belonging to the country’s elite, was enamoured of Western modernity and wanted to copy it to make India an ’advanced country’. The two paths of Western development then available were the free market and Soviet-style central planning. India adopted a mix of the two with the leading role given to the public sector. This path was chosen also for strategic reasons and access to technology which the West was reluctant to supply. But, this choice also led to a dilemma for the Indian elite. It had to ally with the Soviet Union for reasons of defence and access to technology but wanted to be like Western Europe.

    Both the chosen paths were based on a top-down approach. The assumption was that there would be a trickle down to those at the bottom. People accepted this proposition believing in the wider good of all. Resources were mobilized and investments were made in the creation of big dams and factories (called temples of modern India) that generated few jobs. They not only displaced many people trickle down was minimal. For instance, education spread but mostly benefitted the well-off.

    The Indian economy diversified and grew rapidly. An economy that for 50 years had been growing at about 0.75% grew at about 4% in the 1950s. But, the decline in the death rate led to a spurt in the rate of population growth. So, the per capita income did not show commensurate growth, and poverty persisted. Problems got magnified due to the shortage of food following the drought of 1965-67 and the Wars in 1962 and 1965. The Naxalite movement started in 1967, there was BOP crisis and high inflation in 1972-74 due to the growing energy dependence and the Yom Kippur war. Soon thereafter there was political instability and the imposition of an Emergency in 1975. The country went from crisis to crisis.

    Planning failed due to crony capitalism. The prevailing political economy enabled the business community to systematically undermine policies for their narrow ends by fueling the growth of the black economy.

    The failure of trickle-down and the cornering of the gains of development by a narrow section of people led to growing inequality and people losing faith in the development process. Different sections of the population realized that they needed a share in power to deliver to their group. Every division in society — caste, region, community, etc. — was exploited. The leadership became short-termist and indulged in competitive populism by promising immediate gains.

    The consensus on policies that existed at independence dissipated quickly. Election time promises to get votes were not fulfilled. For instance, PM Morarji Desai said that promises in the Janata Dal manifesto in 1977 were the party’s programme and not the government’s. Such undermining of accountability of the political process has undermined democracy and trust and aggravated alienation.

    Black Economy and Policy Failure

    The black economy has grown rapidly since the 1950s with political, social and economic ramifications. Even though it is at the root of the major problems confronting the country, most analysts ignore it.

    So, the black economy controls politics and to retain power it undermines accountability and weakens democracy.

    It undermines elections and strengthens the hold of vested interests on political parties. The compromised leadership of political parties is open to blackmail both by foreign interests and those in power. When in power it is willing to do the bidding of the vested interests. So, the black economy controls politics and to retain power it undermines accountability and weakens democracy.

    The black economy controls politics and corrupts it to perpetuate itself. The honest and the idealist soon are corrupted as happened with the leadership that emerged from the anti-corruption JP movement in the mid-1970s. Many of them who gained power in the 1990s was accused of corruption and even prosecuted. Proposals for state funding of elections will only provide additional funds but not help clean up politics.

    The black economy can be characterized as ’digging holes and filling them’. It results in two incomes but zero output. There is activity without productivity with investment going to waste. Consequently, the economy grows less than its potential. It has been shown that the economy has been losing 5% growth since the mid-1970s. So, if the black economy had not existed, today the economy could have been 8 times larger and each person would have been that much better off. Thus, development is set back. In 1988, PM Rajiv Gandhi lamented that out of every rupee sent only 15 paisa reaches the ground. P Chidambaram as FM said, `expenditures don’t lead to outcomes’.

    The black economy leads to the twin problem of development. First, black incomes being outside the tax net reduce resource availability to the government. If the black incomes currently estimated at above 60% of GDP could be brought into the tax net, the tax/GDP ratio could rise by 24%. This ratio is around 17% now and is one of the lowest in the world. Further, as direct tax collections rise, the regressive indirect taxes could be reduced, lowering inflation.

    India’s fiscal crisis would also get resolved. The current public sector deficit of about 14% would become a surplus of 10%. This would eliminate borrowings and reduce the massive interest payments (the largest single item in the revenue budget). It would enable an increase in allocations to public education and health to international levels and to infrastructure and employment generation.

    In brief, curbing the black economy would take care of India’s various developmental problems, whether it be lack of trickle-down, poverty, inequality, policy failure, employment generation, inflation and so on. It causes delays in decision-making and a breakdown of trust in society.

    Due to various misconceptions about the black economy, many of the steps taken to curb it have been counterproductive, like demonetization. Dozens of committees and commissions have analysed the issues and suggested hundreds of steps to tackle the problem. Many of them have been implemented, like reduction in tax rates and elimination of most controls but the size of the black economy has grown because of a lack of political will.

    Policy Paradigm Shift in 1991

    Failure of policies led to crisis after crisis in the period leading up to 1990. The blame was put on the policies themselves and not the crony capitalism and black economy that led to their failure. The policies prior to 1990 have been often labelled as socialist. Actually, the mixed economy model was designed to promote capitalism. At best the policies may be labelled as state capitalist and they succeeded in their goal. Private capital accumulated rapidly pre-1990. The Iraq crisis of 1989-90 led to India’s BOP crisis and became the trigger for a paradigm change in policies in favour of capital. The earlier more humane and less unequal path of development was discarded.

    Marketization has led to the ’marginalization of the marginals’, greater inequality and a rise in unemployment.

    In 1991, a new policy paradigm was ushered in. Namely, ’individuals are responsible for their problems and not the collective’. Under this regime, the government’s role in the economy was scaled back and individuals were expected to go to the market for resolving their problems. This may be characterized as ’marketization’. This brought about a philosophical shift in the thinking of individuals and society.

    Marketization has led to the ’marginalization of the marginals’, greater inequality and a rise in unemployment. These policies have promoted ’growth at any cost’ with the cost falling on the marginalized sections and the environment, both of which make poverty more entrenched. So, the pre-existing problems of Indian society have got aggravated in a changed form.

    Poverty is defined in terms of the ’social minimum necessary consumption’ which changes with space and time. Marketization has changed the minimum due to the promotion of consumerism and environmental decay imposing heavy health costs.
    The highly iniquitous NEP is leading to an unstable development environment. The base of growth has been getting narrower leading to periodic crises. Additionally, policy-induced challenges like demonetization, GST, pandemic and now the war in Ukraine have aggravated the situation. These social and political challenges can only grow over time as divisions in society become sharper.

    Weakness in Knowledge Generation

    Why does the obvious not happen in India? No one disagrees that poverty, illiteracy and ill health need to be eliminated. In addition to the problems due to the black economy and top-down approach, India has lagged behind in generating socially relevant knowledge to tackle its problems and make society dynamic.

    Technology has rapidly changed since the end of the Second World War. It is a moving frontier since newer technologies emerge leading to constant change and the inability of the citizens to cope with it. The advanced technology of the 1950s is intermediate or low technology today.

    Literacy needs to be redefined as the ability to absorb the current technology so as to get a decent job. Many routine jobs are likely to disappear soon, like, driver’s jobs as autonomous (self-driving) vehicles appear on the scene. Most banking is already possible through net banking and machines, like, ATMs. Banks themselves are under threat from digital currency.

    So, education is no more about the joy of learning and expanding one’s horizon. No wonder, the scientific temper is missing among a large number of the citizens.

    India’s weakness in knowledge generation is linked to the low priority given to education and R&D. Learning is based substantially on `rote learning’ which does not enable absorption of knowledge and its further development. So, education is no more about the joy of learning and expanding one’s horizon. No wonder, the scientific temper is missing among a large number of the citizens. Dogmas, misconceptions and irrationalities rule the minds of many and they are easily misled. This is politically, socially and economically a recipe for persisting backwardness.

    In spite of policy initiatives regarding education, like, the national education policy in 1968 and 1986, there is deterioration. This is because the milieu of education is all wrong. Policy is in the hands of bureaucrats, politicians or academics with bureaucratized mindsets. So, policies are mechanically framed. Like the idea that ’standards can be achieved via standardization’.

    Learning requires democratization. So, institutions need to be freed from the present feudal and bureaucratic control. Presently, institutions treat dissent as a malaise to be eliminated rather than celebrated. Courses are sought to be copied from foreign universities. JNU is told to be like Harvard or Cambridge. This is a contradiction in terms; originality cannot be copied. Courses copied from abroad tend to be based on the societal conditions there and not Indian conditions. Gandhi had said that the Indian education system is alienating and for many it still is.

    The best minds mostly go abroad and even if they return, they bring with them an alien framework not suited to India. So, as a society, we need to value ideas, prioritize education and R&D and generate socially relevant knowledge.

    Learning is given low priority because ideas are sought to be borrowed from abroad. So, the rulers have little value for institutions that could generate new ideas and inadequate funds are allotted to them. The best minds mostly go abroad and even if they return, they bring with them an alien framework not suited to India. So, as a society, we need to value ideas, prioritize education and R&D and generate socially relevant knowledge.

    Conclusion

    The growth at any cost strategy has been at the expense of the workers and the environment. This has narrowed the base of growth and led to instability in society — politically, socially and economically.

    India is a diverse society and the Indian economy is more complex than any other in the world. This has posed serious challenges to development in the last 75 years but undeniably things are not what they were. The big mistake has been to choose trickle-down policies that have not delivered to a vast number of people who live in uncivilized conditions. Poverty has changed its form and the elite imply that the poor should be grateful for what they have got. They should not focus on growing inequality, especially after 1991, when globalization entered the marketization phase which marginalizes the marginals.

    The growth at any cost strategy has been at the expense of the workers and the environment. This has narrowed the base of growth and led to instability in society — politically, socially and economically. The situation has been aggravated by the recent policy mistakes — demonetization, flawed GST and sudden lockdown. The current war in Ukraine is likely to lead to a new global order which will add to the challenges. The answer to ’why does the obvious not happen’ in India is not just economic but societal. Unless that challenge is met, portents are not bright for India at 75.

    This paper is based substantially on, `Indian Economy since Independence: Persisting Colonial Disruption’, Vision Books, 2013 and `Indian Economy’s Greatest Crisis: Impact of Coronavirus and the Road Ahead’, Penguin Random House, 2020.

    This article was published earlier in Mainstream Weekly.

    Feature Image Credit: Financial Express

    Other Images: DNA India, news18.com,  economictimes, rvcj.com

  • Roe overturned: What you need to know about the American Supreme Court abortion decision

    Roe overturned: What you need to know about the American Supreme Court abortion decision

    Despite the terminal decline of the American Empire or the Deep State, the American Republic still remains an inspiration for people across the world, for reasons of its vibrant democracy and peoples’ liberty ensured through robust institutions, law and order, and the strong constitutional process. To paraphrase Johan Galtung – ‘the US is a fabulous Republic but a terrible empire’. But even that seems to be changing as society’s democratic values, ethics, and morals are in serious decline.  The rise of right wing politics has led to a decline in the standards and values, and in the independence of institutions most notably the Judiciary. Separation of the Church and the State is a core tenet of the American Constitution and governance. That seems to be compromised as many judges bring their personal and religious beliefs in to their work. This was in demonstration in the American Supreme Court’s judgement that ends one of the most critical fundamental rights of women to their bodies and their choices for abortion. 

    After half a century, Americans’ constitutional right to get an abortion has been overturned by the Supreme Court.The ruling in Dobbs v. Jackson Women’s Health Organization – handed down on June 24, 2022 – has far-reaching consequences. There is a strong religious influence to this judgement. This could influence many other countries, particularly in an environment where right wing politics, influenced by narrow religious overtones,  is on the upswing in many countries across the world, including the world’s largest Democracy, India. Fortunately, India’s abortion laws are governed by medical advice and womens’ safety (and so it is termed MTP – Medical termination of Pregnancy). The MTP Act of 1971 was further liberalised through an Amendment Act of 2021 wherein the gestation limit for abortions is raised from 20 to 24 weeks. While India’s laws are considerate by supporting abortion decision to rape and incest survivors, the American judgement will deny this freedom or choice to the victim women.

     Nicole Huberfeld and Linda C. McClain, health law and constitutional law experts at Boston University, explain what just happened, and what happens next. This article was published earlier in The Conversation. TPF is happy to republish this article under the Creative Commons Attribution-No Derivatives 4.0-International (CC BY-ND 4.0).

    – TPF Editorial Team

    What did the Supreme Court rule?

    The Supreme Court decided by a 6-3 majority to uphold Mississippi’s ban on abortion after 15 weeks of pregnancy. In doing so, the justices overturned two key decisions protecting access to abortion: 1973’s Roe v. Wade and Planned Parenthood v. Casey, decided in 1992.

    The court’s opinion, written by Justice Samuel Alito, said that the Constitution does not mention abortion. Nor does the Constitution guarantee abortion rights via another right, the right to liberty.

    The opinion rejected Roe’s and Casey’s argument that the constitutional right to liberty included an individual’s right to privacy in choosing to have an abortion, in the same way that it protects other decisions concerning intimate sexual conduct, such as contraception and marriage. According to the opinion, abortion is “fundamentally different” because it destroys fetal life.

    The court’s narrow approach to the concept of constitutional liberty is at odds with the broader position it took in the earlier Casey ruling, as well as in a landmark marriage equality case, 2015’s Obergefell v. Hodges. But the majority said that nothing in their opinion should affect the right of same-sex couples to marry.

    Alito’s opinion also rejected the legal principle of “stare decisis,” or adhering to precedent. Supporters of the right to abortion argue that the Casey and Roe rulings should have been left in place as, in the words of the Casey ruling, reproductive rights allow women to “participate equally in the economic and social life of the Nation.”

    The ruling does not mean that abortion is banned throughout the U.S. Rather, arguments about the legality of abortion will now play out in state legislatures, where, Alito noted, women “are not without electoral or political power.”

    States will be allowed to regulate or prohibit abortion subject only to what is known as “rational basis” review – this is a weaker standard than Casey’s “undue burden” test. Under Casey’s undue burden test, states were prevented from enacting restrictions that placed substantial obstacles in the path of those seeking abortion. Now, abortion bans will be presumed to be legal as long as there is a “rational basis” for the legislature to believe the law serves legitimate state interests.

    In a strenuous dissent, Justices Stephen Breyer, Elena Kagan and Sonia Sotomayor faulted the court’s narrow approach to liberty and challenged its disregard both for stare decisis and for the impact of overruling Roe and Casey on the lives of women in the United States. The dissenters said the impact of the decision would be “the curtailment of women’s rights, and of their status as free and equal citizens.” They also expressed deep concern over the ruling’s effect on poor women’s ability to access abortion services in the U.S.

    Where does this decision fit into the history of reproductive rights in the U.S.?

    This is a huge moment. The court’s ruling has done what reproductive rights advocates feared for decades: It has taken away the constitutional right to privacy that protected access to abortion.

    This decision was decades in the making. Thirty years ago when Casey was being argued, many legal experts thought the court was poised to overrule Roe. Then, the court had eight justices appointed by Republican presidents, several of whom indicated readiness to overrule in dissenting opinions.

    Instead, Republican appointees Anthony Kennedy, Sandra Day O’Connor and David Souter upheld Roe. They revised its framework to allow more state regulation throughout pregnancy and weakened the test for evaluating those laws. Under Roe’s “strict scrutiny” test, any restriction on the right to privacy to access an abortion had to be “narrowly tailored” to further a “compelling” state interest. But Casey’s “undue burden” test gave states wider latitude to regulate abortion.

    Even before the Casey decision, abortion opponents in Congress had restricted access for poor women and members of the military greatly by limiting the use of federal funds to pay for abortion services.

    In recent years, states have adopted numerous restrictions on abortion that would not have survived Roe’s tougher “strict scrutiny” test. Even so, many state restrictions have been struck down in federal courts under the undue burden test, including bans on abortions prior to fetal viability and so-called “TRAP” – targeted regulation of abortion provider – laws that made it harder to keep clinics open.

    President Donald Trump’s pledge to appoint “pro-life” justices to federal courts – and his appointment of three conservative Supreme Court justices – finally made possible the goal of opponents of legal abortion: overruling Roe and Casey.

    What happens next?

    Even before Dobbs, the ability to access abortion was limited by a patchwork of laws across the United States. Republican states have more restrictive laws than Democratic ones, with people living in the Midwest and South subject to the strongest limits.

    Thirteen states have so-called “trigger laws,” which greatly restrict access to abortion. These will soon go into effect now that the Supreme Court has overturned Roe and Casey, requiring only state attorney general certification or other action by a state official.

    Nine states have pre-Roe laws never taken off the books that significantly restrict or ban access to abortion. Altogether, nearly half of states will restrict access to abortion through a variety of measures like banning abortion from six weeks of pregnancy – before many women know they are pregnant – and limiting the reasons abortions may be obtained, such as forbidding abortion in the case of fetal anomalies.

    Meanwhile, 16 states and the District of Columbia protect access to abortion in a variety of ways, such as state statutes, constitutional amendments or state Supreme Court decisions.

    None of the states that limit abortion access currently criminalize the pregnant person’s action. Rather, they threaten health care providers with civil or criminal actions, including loss of their license to practice medicine.

    Some states are creating “safe havens” where people can travel to access an abortion legally. People have already been traveling to states like Massachusetts from highly restrictive states.

    The court’s decision may drive federal action, too.

    The House of Representatives passed the Women’s Health Protection Act, which protects health care providers and pregnant people seeking abortion, but Senate Republicans have blocked the bill from coming up for a vote. Congress could also reconsider providing limited Medicaid payment for abortion, but such federal legislation also seems unlikely to succeed.

    President Joe Biden could use executive power to instruct federal agencies to review existing regulations to ensure that access to abortion continues to occur in as many places as possible. Congressional Republicans could test the water on nationwide abortion bans. While such efforts are likely to fail, these efforts could cause confusion for people who are already vulnerable.

    The Supreme Court’s rolling back a right that has been recognized for 50 years puts the U.S. in the minority of nations, most of which are moving toward liberalization.

    What does this mean for people in America seeking an abortion?

    Unintended pregnancies and abortions are more common among poor women and women of color, both in the U.S. and around the world.

    Research shows that people have abortions whether lawful or not, but in nations where access to abortion is limited or outlawed, women are more likely to suffer negative health outcomes, such as infection, excessive bleeding and uterine perforation. Those who must carry a pregnancy to full term are more likely to suffer pregnancy-related deaths.

    The state-by-state access to abortion resulting from this decision means many people will have to travel farther to obtain an abortion. And distance will mean fewer people will get abortions, especially lower-income women – a fact the Supreme Court itself recognized in 2016.

    But since 2020, medication abortion – a two-pill regimen of mifepristone and misoprostol – has been the most common method of ending pregnancy in the U.S. The coronavirus pandemic accelerated this shift, as it drove the Food and Drug Administration to make medication abortions more available by allowing doctors to prescribe the pills through telemedicine and permitting medication to be mailed without in-person consultation.

    Many states that restrict access to abortion also are trying to prevent medication abortion. But stopping telehealth providers from mailing pills will be a challenge. Further, because the FDA approved this regimen, states will be contradicting federal law, setting up conflict that may lead to more litigation.

    The Supreme Court’s rolling back a right that has been recognized for 50 years puts the U.S. in the minority of nations, most of which are moving toward liberalization. Nevertheless, even though abortion is seen by many as essential health care, the cultural fight will surely continue.

    Featured Image Credit: Evening Standard

  • “Aapada mein Avasar”: Examining India’s Engagement with the International Community Amidst the Pandemic

    “Aapada mein Avasar”: Examining India’s Engagement with the International Community Amidst the Pandemic

    [powerkit_button size=”lg” style=”info” block=”true” url=”https://admin.thepeninsula.org.in/wp-content/uploads/2022/05/TPF-Issue-Brief-Aapada-mein-Avasar-1_compressed-2.pdf” target=”_blank” nofollow=”false”]
    Download PDF
    [/powerkit_button]

    Abstract

    Health security has often been considered an issue of “low politics”. However, in the past two years, the global economy has suffered the most since the Great Depression and global supply chains have been hampered. The developed countries were caught off-guard at par with the rest of the world with global resource inequities at display. As the developed world resorted to “medicine nationalism” and “vaccine nationalism,” their credibility as “global leaders” was sharply questioned. Amidst this, the allegations of the pandemic’s origins generated reactions from an emergent China which stopped concealing its geopolitical ambitions and adopted an unapologetically aggressive posture. Moreover, the credibility of a prominent international organization, the World Health Organization, in terms of its inability in notifying and managing the pandemic was heavily criticised. Each of these occurrences having emerged from a global health crisis has unexpectedly altered the prioritization of matters in the international order, and thereby international diplomacy.

    With the developing and least developed countries deprived of critical medical supplies due to hoarding by developed countries – India’s active engagement in medical diplomacy in the initial phase garnered international appreciation. While it cannot be looked at in a transactional sense, it visibly helped India push for its geopolitical interests in the middle of a global crisis – finding the adequate avasar (possibilities) in the ongoing aapada (crisis). Although flaws on the domestic front existed during the first wave, their impact on India’s medical diplomacy was limited. However, a domestic crisis during the second wave turned out to be an eye-opener and prominently impacted foreign policy initiatives. Considering the lessons so learnt and applied in managing the third wave, this paper examines the tremendous domestic potential of India, while also looking at its historical legacy. In doing so, it emphasises the relevance of domestic affairs as a determinant of successful medical diplomacy outreach – thereby impacting the larger foreign policy objectives.

    Introduction

    While health security has often been relegated as a low-priority issue in the geopolitical landscape, the last two years have unprecedentedly changed everything. A majority of developed nations have appeared helpless in managing the human catastrophe thereby resorting to vaccine and medicine protectionism. To put this on record, over six million people worldwide have lost their lives (COVID Live – Coronavirus Statistics, 2022) during these two years – with the maximum number of lives lost in the United States of America. The global economy has suffered the most since the Great Depression as a fallout of extended total lockdowns that hampered global supply chains. Moreover, an unexpected, unrealised over-dependency of global supply chains on a single country’s economy – China – caught the international community unprepared. Gradually, newer possibilities and threats have emerged through a changing character of the global economy, society, as well as politics and warfare – each of these shifting to the virtual domain.

    [powerkit_button size=”lg” style=”info” block=”true” url=”https://admin.thepeninsula.org.in/wp-content/uploads/2022/05/TPF-Issue-Brief-Aapada-mein-Avasar-1_compressed-2.pdf” target=”_blank” nofollow=”false”]
    Read More
    [/powerkit_button]

    Feature Image Credits: ABC

  • Responsible Decision-making in the Face of Corona – A Need for a Metric

    Responsible Decision-making in the Face of Corona – A Need for a Metric

    [powerkit_button size=”lg” style=”info” block=”false” url=”https://admin.thepeninsula.org.in/wp-content/uploads/2022/02/Issue-Brief-TPF_Corona-Metric-2_compressed-1-12-1.pdf” target=”_blank” nofollow=”false”]
    DOWNLOAD PDF
    [/powerkit_button]

     

    Abstract

    The asymmetry of the human mind in treating the information that is currently available and the information we do not have is remarkable. During the Covid-19 pandemic, many people have been conscious to take precautions to prevent contracting the virus oneself or their family members. However, the consequences of a person infecting another are not consciously considered by everyone while going on about their ‘new normal’ life making daily transactions that involve the labour of a multitude of people. Nobody pauses to wonder whether anyone in the supply chain of the product or service consumed by an individual has contracted the virus or died due to the virus in the process of its production. This is because that information is unavailable to us in a tangible form for our minds to perceive and hence it chooses to ignore it. Although the number of cases increases with every wave, people have started accepting it or rather have become desensitised to the number of lives lost to Covid-19, mainly because these deaths are unseen. This article explores whether such a pondering – number of people infected and consequently lives compromised – would be a consideration in the decision-making in the production and consumption of products and services. If so, is there a need to develop a metric to inform us of this number? Would it be feasible to have such a metric? This article attempts to quantify these unseen deaths, so as to sensitise people to the consequences of a person getting infected.

    Introduction:

    Now, two years after the onset of the Covid-19 pandemic, most people reading this would have lost one or more relatives, friends, colleagues or an acquaintance due to the infection. I am no exception. But the trigger for this article is the death of a couple, Razia and Nasir (names changed) that happened in the summer of 2021. Their small fruits and vegetable outlet, by a synergic arrangement, was situated within the spacious premises of another outlet – a cold storage that dispenses meat, poultry and fish for the upwardly mobile residents living in a posh locality of Bangalore. 

    [powerkit_button size=”lg” style=”info” block=”true” url=”https://admin.thepeninsula.org.in/wp-content/uploads/2022/02/Issue-Brief-TPF_Corona-Metric-2_compressed-1-12-1.pdf” target=”_blank” nofollow=”false”]
    READ MORE
    [/powerkit_button]

    Featured Image Credit: OSORIOartist

  • Viability of Universal Healthcare in India: Case Study of Sonipat

    Viability of Universal Healthcare in India: Case Study of Sonipat

    The Covid-19 pandemic is a global catastrophe that has disrupted the economies and national health of countries and the livelihood millions across the world. In India, the impact in 2020 was presumably well controlled, and the beginning of 2021 saw the Indian government projecting prematurely the return of normalcy. This sense of normalcy led to a lowering of the precautions, and the month of April saw the rise of the second wave. The second wave was vicious, crippling the healthcare system and resulting in a huge number of deaths, primarily attributed to the shortage of oxygen supply in most states. This crisis exposed the shortcomings of the Indian healthcare system and the wide disparities that exist in access to healthcare between different sections of the society, a result of the shockingly low investment in healthcare and human resources. The catastrophe has led many to question the efficacy of the healthcare system and the level of expenditure incurred on it, and whether universal healthcare would have allowed the country to tackle these events. Analysis of the impact of universal healthcare requires insight into the structure and efficacy of healthcare in India, given our history and experiences.

    The principle behind universal healthcare states that every individual who is a citizen of the country must have access to essential health services, without the obstruction of financial hardship. Among the most efficient methods of ensuring that this principle is adhered to is bringing it under the constitutional mandate. Although the Supreme court has, in its various judgements, recognized health as a fundamental right, it is not yet recognized in the constitution. Article 21 of the constitution reiterates the right to life, with the landmark judgment of Maneka Gandhi v The Union of India specifying that the article also includes the right to live a dignified life and access to all basic amenities to ensure the same. This statement has been given a new context in light of the recent crisis, in which most of the fatalities caused were due to respiratory problems caused by the virus where providing oxygen availability became an essential requirement for the cure. In such a scenario, the oxygen availability constitutes part of basic amenities, which the government failed to supply in adequate quantity. The government fulfils its obligation towards healthcare in the form of government hospitals and healthcare centres, but their situation was synonymous with the private sector. The government claims that the hospitals under their control are sufficient, but the recent predicament has proven that the aforementioned claim is not true. The healthcare services provided by the government will be meaningful only if access to such hospitals is convenient for the common people and the hospitals are well-endowed with investment and human resources. An analysis of our constitution, especially Article 21, which guarantees protection of life and personal liberty, makes it evident that the principles on which our democracy is founded dictate that healthcare is one of the most important obligations of the government, and the most efficient method for fulfilling said obligation is the introduction of Universal healthcare in India.

    An attempt at examining the applicability of universal healthcare was made by the Planning Commission through the 12th Five-Year plan. The first-ever framework for universal health coverage was developed by a High-Level Expert Group, which planned to develop a system that was in accordance with the nation’s financial capabilities. The primary objective of these reforms was to reduce the out-of-pocket expenditures incurred by lower-income groups on healthcare services and increase the number of people covered under the Rashtriya Swasthya Bima Yojana. Around this time the Rashtriya Swasthya Bima Yojana was scrutinized by many due to its low enrolment rates, high transaction costs due to insurance intermediaries, and allegations that the government was using it as a pathway to hand over public funds to the private sector. The objective of reducing out-of-pocket expenditure even though expressly mentioned did not come to fruition because of the lack of extensively funded facilities, especially in rural areas which were covered by RSBY. These facilities were lacking not only in medical infrastructure but also the medicines required for treatment, which compelled the patient to bear the expenses of medicines on their own. The 12th Five-year Plan also proposed an increase in Budget allocation for health from 1.58% to 2.1% of the GDP, which was again criticized because it was very low in relation to the global median of 5%, despite the population size of the country. The healthcare reforms also failed to take note of the important role played by nutrition and the Public Distribution System in aiding the advancement of healthcare. The 12th five-year plan is not considered successful due to the poor implementation of the reforms introduced and provides valuable lessons for the implementation of universal healthcare coverage in the future.

    The need for implementation of universal healthcare coverage can be made evident through a case study of the town of Sonipat, which is near Delhi and is a rural area. The case study is done through the observation of a survey conducted by the Institute of Economic Growth in 2017. The table below shows the data that became available as a result of the last survey conducted.

    CDMO Office, Sonipat District (2017)

    CDMO Office, Sonipat District (2017)

    An analysis of the data portrays that even though the resources and infrastructure are adequate to the population of Sonipat, the facilities are lacking in human resources. The data shows that 6 posts for the Medical Officers (MO) were sanctioned, but only 3 were filled. Despite the high number of deliveries, there was no sanctioned post of a gynaecologist, which can probably be a reason behind the high number of maternal deaths in the area. It was also found that the Non-Communicable Disease (NCD) program was not functioning in the district for the past 2 years. O.P. Jindal University, which is in the heart of Sonipat, houses a total of 7482 individuals, and has an adequate number of facilities, with 5 in-house doctors and 10 nurses. It has an isolation facility ward for cases of communicable diseases. It has an ambulance and referral service to hospitals in the NCR. These facts show that there is an acute shortage of human resources for healthcare in the area. Even though an adequate number of posts were sanctioned, there was no qualified personnel to fill them, and there were no sanctions for important positions. The case of O.P. Jindal university shows that good healthcare requires good investment and incentive for the staff, which the Sonipat administration has failed to provide to the staff of healthcare centres owned by the state.

    The arguments mentioned above portray the acute necessity of universal healthcare in India. The ideals of our constitution implore for the right to health to be established, which gives universal healthcare constitutional support. The failure of the 12th Five-year Plan showcases the failures that can happen if the framework for such a plan is not well-thought-out or well-invested. The example of Sonipat further portrays the need for increased investment in healthcare, which can be achieved by the utilization of universal healthcare. Although there is no concrete data available for the crisis which the nation recently endured, it can be concluded that the approach of universal healthcare could have allowed us to endure this crisis better, as there would have been lesser chances of shortage of supplies like oxygen because of the increased investment. The first step towards the policy of universal healthcare should be to strengthen existing institutions of insurance and learn from the mistakes in the implementation of the RSBY.

     

    References

    1.http://iegindia.org/upload/uploadfiles/Sonipat%20Haryana%202017.pdf

    2.http://ijariie.com/AdminUploadPdf/RIGHT_TO_HEALTH__A_CONSTITUTIONAL_MANDATE_IN_INDIA_ijariie5596.pdf

    3.http://jsslawcollege.in/wp-content/uploads/2013/12/RIGHT-TO-HEALTH-AS-A-CONSTITUTIONAL-MANDATE-IN-INDIA.pdf

    4.http://nhsrcindia.org/sites/default/files/Twelfth%20Five%20Year%20Plan%20Health%202012-17.pdf

    5.https://www.hindustantimes.com/health/why-india-s-national-health-insurance-scheme-has-failed-its-poor/story-6TIXYO0A8CyxTfGYPRdkYK.html

     

    Image Credit: www.financialexpress.com

  • Fighting the Invisible Enemy with Vaccines: Beginning of the End of the COVID-19 Pandemic

    Fighting the Invisible Enemy with Vaccines: Beginning of the End of the COVID-19 Pandemic

    Fighting the Invisible Enemy with Vaccines Beginning of the End of the COVID-19 Pandemic [powerkit_button size=”lg” style=”info” block=”false” url=”https://admin.thepeninsula.org.in/wp-content/uploads/2021/06/Fighting-the-Invisible-Enemy-with-Vaccines-Beginning-of-the-End-of-the-COVID-19-Pandemic-8-1.pdf” target=”_blank” nofollow=”false”]
    Download
    [/powerkit_button]

    Authors:  Avanti A Srinivasan (1st-year Biology Honors College Student, New Jersey, USA); Keerthika Gnanasegaran (MBBS, Puducherry, India); Vishu Priya (MBBS, Puducherry, India).

    Keywords:

    COVID, Coronavirus disease; COVID-19, SARS-CoV-2, Severe Acute Respiratory Syndrome Corona Virus 2 identified in 2019 that causes COVID; Flattening the curve, The longer it takes for the coronavirus to spread through the population, the more time the health care systems (hospitals) have to prepare and treat patients, but not be overwhelmed by the pandemic; Herd immunity, when most of a population (70-80%) becomes immune to COVID-19, they provide indirect protection to those who are not immune to the disease; Immunity, protection from an infectious disease. If a person is immune to COVID that person can be exposed to the virus without becoming infected; Immunization, the process by which a person becomes protected against an infectious disease by vaccination; Vaccine, a biological preparation or substance (also known as antigen) that is used to stimulate the production of antibodies and provide immunity against COVID-19, without inducing the disease. Vaccines are usually administered by needle injections; Vaccination, the process of introducing a vaccine (prepared from the COVID, its products such as protein or DNA, or a synthetic substitute such as mRNA) to act as an antigen, into the body to induce immunity against COVID-19 disease.

    COVID-19 Pandemic

    Corona Virus disease (COVID-19) was first identified in Wuhan, China, in December 2019. It is caused by Severe Acute Respiratory Syndrome Corona Virus 2 (SARS-CoV-2). The highly contagious coronavirus has spread rapidly around the world exponentially, causing a pandemic.

    As of June 04, 2021, there were over 172,231,339 confirmed cases and 3,703,522 deaths globally according to Johns Hopkins University (JHU) COVID-19 Dashboard. The USA alone has accounted for over 33,327,112 confirmed cases with over 596,444 fatalities reflecting the heavy toll inflicted by the pandemic. India has reported over 28,574,350 confirmed cases and 340,702 deaths, which is likely a low estimate.

    The US Government at the beginning of the pandemic embarked on the “Operation Warp Speed” program to accelerate testing, supply, development, and distribution of safe and effective vaccines, therapeutics, and diagnostics for COVID-19 by January 2021. The program has led to the development of several effective vaccines against COVID-19 by commercial enterprises. The new US administration has focused all its efforts to vaccinate the US population starting January 2021 with the goal of reaching herd immunity by July 4, 2021; it is on its way to successful completion by the target date.

    Initially, the number of confirmed COVID-19 cases reported by India was less, which was probably due to the quick action taken by the Indian Government to implement a total lockdown of the country to control the community spread of the virus. This was a very successful strategy for the short term and helped to flatten the curve and slowed the infection rate (Fig. 1). However, without an effective vaccine, with the Indian economy stagnating, with a population of 1.3 billion most of whom are poor, and a highly mutating virus, mitigation efforts alone proved to be grossly inadequate over the long term.

     

    Fig 1: USA Center for Disease Control (CDC) graphic on flattening the curve

    Over the past two months, India’s coronavirus daily infections have averaged over 400,000 and 4,000 deaths. They have come down recently, averaging daily infections of less than 200,000 and 2,800 deaths. Vaccinating the Indian population and reaching herd immunity, may be the only option left to fight the invisible enemy and to successfully put an end to the pandemic. India so far has inoculated only about 3% of its 1.3 billion people. India has a long way to go to get 70-80% of its population vaccinated and reach herd immunity.

    What is immunity?

    Humans are constantly exposed to disease-causing pathogens such as viruses, bacteria, fungi, and parasitic worms. Our body has two lines of defence against these threats: innate immunity and adaptive immunity, which together constitute the immune system. Their collective defence against pathogens makes up the immune response. The two components of the immune system interconnect and communicate at chemical and cellular levels to provide powerful protection against pathogens.

    Innate immunity provides an immediate, nonspecific response against any invading pathogen and has no memory of prior exposure to the pathogen. Innate immunity relies on the recognition of certain foreign molecules to stimulate inflammatory responses and phagocytosis. Innate immunity is the first line of defence against pathogens, representing a critical systemic response to prevent infection and maintain homeostasis. It also contributes to the activation of an adaptive immune response. It does not adapt to a specific external stimulus or a prior infection but relies on genetically encoded recognition of molecular patterns.

    The innate immune system recognizes pathogen-associated molecular patterns that are associated with pathogenic organisms but are absent in the host. The patterns are recognized by pattern recognition receptors of phagocytic cells such as toll-like receptor that are found on the cell surface and within the cell on various membrane-bound compartments. Cell surface receptors on macrophages (white blood cells) recognize and bind to surface molecules on the pathogen, activating the macrophage to phagocytize (engulf) the pathogens. Activated macrophages secrete cytokines, which bind to receptors on other host cells to trigger a successful immune response.

    Adaptive (or acquired) immunity is specific; it recognizes individual pathogens and mounts an attack that directly neutralizes or eliminates them and retains a cellular memory of a pathogen; it reacts quickly upon second exposure to the same pathogen. The innate immune system provides some immediate protection against invading pathogens while the more powerful, specific, adaptive response system is mobilized that can take several days. Adaptive immunity, also known as acquired immunity, is a host immune response that is mediated by antigen-specific lymphocytes. Unlike innate immunity, the acquired immunity is highly specific to a particular pathogen, including the development of immunological memory. Like the innate system, the acquired system includes both humoral immunity components and cell-mediated immunity components. T cells differentiate from stem cells in the bone marrow and are carried in the blood to the thymus to generate two types of T cells (helper T cells and cytotoxic T cells) that are involved in adaptive immunity. Humoral immunity arises from B cells that differentiate from stem cells in the bone marrow and are carried in the blood to capillary beds serving the tissues and organs of the lymphatic system. In antibody (humoral)-mediated immunity, B-cell derivatives called plasma cells to secrete antibodies – highly specific protein molecules – that circulate in the blood and lymph recognizing and binding to antigens and clearing them from the body. In cell-mediated immunity, a particular type of T cell becomes activated and, in conjunction with other cells of the immune system, attacks foreign cells directly and kills them. Specific receptors on the plasma membrane of one B cell or T cell (B-cell receptors or T-cell receptors) bind to one specific antigen structure, also known as epitopes (Fig. 2).

    Fig. 2: Structure of B-cell and T-cell receptors

    The adaptive immune response includes four key steps: 1) Antigen encounter and recognition: lymphocytes encounter and recognize an antigen; 2) Lymphocyte activation: lymphocytes are activated by binding to the antigen and divide to produce clones; 3) Antigen clearance: large clones of activated lymphocytes clear the antigen from the body; and 4) Development of immunological memory: memory cells circulate in blood and lymph, prepared for a rapid response in a future encounter of the same pathogen. The entire population of B cells and T cells in the body includes about 100 million different kinds of receptors – enough of a repertoire to recognize and destroy any type of antigen. Importantly, these cells are present even before the body has encountered the antigens.

    Adaptive immunity can be acquired either naturally by infection or by vaccination. Adaptive immunity can be active or passive. Active immunity is acquired through exposure to a pathogen, which triggers the production of antibodies by the immune system. Passive immunity is acquired through the transfer of antibodies or activated T cells derived from an immune host either artificially or through the placenta from the mother.

    What is a vaccine?                                                    

     In 1796, Edward Jenner infected healthy individuals with cowpox, which prompted their immune systems to protect them against smallpox, a more deadly viral disease. Jenner’s technique became the basis for worldwide vaccination against smallpox, which now has been eradicated from the human population. This forms the basis for vaccination against other deadly pathogens.

    An antigen is a foreign molecule that triggers an adaptive immune response. A vaccine is usually made from weakened or killed forms of the microbe, or typically contains an antigen from the disease-causing microorganism such as its toxins, or one of its surface proteins. The antigen stimulates the body’s immune system to recognize it as a threat and destroy it and to further recognize and destroy those microorganisms in a future encounter. Vaccines can be prophylactic (to prevent or ameliorate the effects of a future infection by a pathogen), or therapeutic to fight a disease that has already occurred. The administration of vaccines is called vaccination or inoculation. Vaccination is the most effective way to prevent infectious diseases. Widespread immunity due to vaccination is largely responsible for the worldwide eradication of smallpox and the restriction of diseases such as polio, measles, and tetanus.

    Molecular structure of SARS-CoV-2

    SARS-CoV-2 is a large, enveloped, spherical virus that contains a positive-sense, single-stranded RNA genome (30 kb in size), which is packed inside the nucleocapsid protein (N) and surrounded by an envelope. The RNA genome has a 5′ capped structure and a 3′ poly-A tail. The 5′ terminal two-thirds of the genome encodes a polyprotein, pp1ab, which is further cleaved into 16 non-structural proteins that are involved in genome transcription and replication. The 3′ terminus encodes 3 different structural proteins.

    Membrane proteins (M) and envelope proteins (E) are involved in virus assembly. The M protein (~30 KDa) is the most abundant structural protein in the virion. The E protein (~12 KDa) is found in small quantities within the virion.

    Spike protein (S1) that mediates virus entry into host cells, is the target of all COVID-19 vaccines. The spike protein forms large protrusions from the virus surface, giving it the appearance of having crowns (Fig. 3). Spike protein contains an S1 subunit that is a Receptor Binding Domain (RBD) and a membrane-fusing spike S2 subunit; The entry receptor utilized by SARS-CoV-2 is Angiotensin Converting Enzyme II (ACE II). Upon binding S1 is processed into S2, which induces fusion of the host and viral membranes.

    Fig. 3: Structure of the coronavirus, SARS-CoV-2 that causes COVID-19 [adapted from Centers for Disease Control (CDC) and Prevention, USA].

    COVID-19 viral vector vaccines

    Viral vector vaccines are a modified version of a different virus to deliver instructions to the cell to make the antigen against coronavirus spike protein. People vaccinated with viral vector vaccines gain protection without ever having to risk the serious consequences of getting sick with COVID-19. Several important characteristics of the viral vector need to be pointed out that include: 1) The vector is not the virus that causes COVID-19; it is a different harmless virus that is engineered to carry the gene coding for the spike protein, a harmless piece of the coronavirus. The modified version of the virus will be injected into the body and the cells will produce the spike protein that is found only on the surface of coronavirus. The cells display spike protein on their surface, triggering an immune response against the spike protein antigen. The immune cells produce antibodies and activate T cells to fight off the infection. The net result is the body has learned to recognize spike protein and to protect us against any future infection by the virus that causes COVID-19. The vaccine protects us, without ever having to risk the serious consequences of getting sick with COVID-19. Any temporary discomfort (side effects) experienced by us immediately after getting the vaccine is a natural part of the process and indicates that the vaccine is working to stimulate our immune system. Viral vector vaccines have been around for a while; they are safe and effective. COVID-19 viral vector vaccines were developed using adenoviral vector by two commercial entities, namely AstraZeneca and Johnson & Johnson (Appendix I).

    COVID-19 messenger RNA (mRNA) vaccines

    mRNA vaccines are a new type of vaccine to protect against infectious diseases. To trigger an immune response, most vaccines inject a weakened or inactivated pathogen into our bodies. mRNA vaccines, on the other hand, teach our cells how to make a protein antigen (or even a piece of a protein) within cells to induce an immune response in our bodies. The focus of the mRNA COVID-19 vaccine is to teach cells how to make spike protein, and thereby, trigger an immune response in our bodies. Like the viral vector vaccines, people vaccinated with mRNA COVID-19 vaccines gain protection without ever having to risk the serious consequences of getting sick with COVID-19. The mRNA vaccines are some of the first COVID-19 vaccines that were authorized for emergency use by the US Government. mRNA vaccines can be developed easily in a laboratory using readily available materials. Furthermore, the process of making mRNA vaccines can be readily standardized and scaled up, making vaccine development much faster than the traditional methods of making vaccines. As soon as the genome sequence of the virus that causes COVID-19 became available, scientists began designing the mRNA instructions for cells to build the unique spike protein into an mRNA vaccine. Effective COVID vaccines became available in less than a year to vaccinate the US population from two commercial enterprises, namely Moderna and Pfizer-BioNTech (Appendix II). The US Government has been very successful in administering the COVID-19 vaccines to its population. The USA is on the verge of reaching herd immunity by July 4, 2021. The success of the vaccination effort can be seen from the fact that several states in the USA have started lifting all mandatory mitigation efforts including the mask mandate.

    CDC (USA) Guidelines for Side Effects of COVID-19 Vaccines

    COVID-19 vaccines are highly effective, but they are also “reactogenic”, meaning that they are likely to cause a noticeable immune response or side effects. Side effects may vary with the type of COVID-19 vaccine. The most common side effects include soreness at the site of injection, fatigue, headache, muscle aches, chills, joint pain, and fever (Table 1). The side effects usually last 24 to 48 hours, and no more than a few days. Side effects were more frequent after the second dose in the vaccine trials. These side effects are typical of the inflammation induced by vaccines and are a sign of the body’s immune response to the vaccine. Some people have more severe reactions than others. Side effects have been less frequent and less severe in adults older than 55 years in the vaccine trials.

    The first dose by itself will not provide complete protection, and it will take about seven days after the second dose before one achieves a full protective level of immunity that develops in about 95% of vaccine recipients. If one is exposed to SARS-CoV-2 before this time, it is possible that the person could develop COVID-19. Even once a person has received both doses of the COVID-19 vaccine, it will still be important to continue practising public health mitigation strategies like masks and social distancing until the pandemic is under control and till we know more about how the vaccines prevent transmission. The side effects of the vaccine typically start within 12 to 24 hours of vaccination. If you experience side effects that last beyond 48 hours, you should contact your doctor or medical provider for advice.

    COVID-19 vaccination will help to protect you from getting COVID-19. You may have some side effects, which are normal signs that your body is building protection. Side effects may affect your ability to do daily activities, but they should go away in a few days.

    Common side effects:

    On the arm where you got the shot:

    • Pain
    • Swelling

    Throughout the rest of your body:

    • Fever
    • Chills
    • Fatigue & tiredness
    • Headache

    Helpful tips:

    If you have pain or discomfort, talk to your doctor about taking over-the-counter medications, such as ibuprofen or acetaminophen.

    To reduce pain and discomfort where you got the shot:

    • Apply a clean, cool, wet washcloth over the area.
    • Use or exercise your arm.

    To reduce discomfort from fever:

    • Drink plenty of fluids.
    • Dress lightly.

    When to contact a doctor:

    In most cases, discomfort from fever or pain is normal. Contact your doctor or healthcare provider:

    • If the redness or tenderness where you got the shot increases after 24 hours
    • If your side effects are worrying you or do not seem to be going away after a few days.

    Some things to remember:

    • Side effects may feel like flu and even affect your ability to do daily activities, but they should go away in a few days.
    • With most COVID-19 vaccines, you will need 2 shots for them to work effectively. Get the second shot even if you have side effects after the first shot unless a vaccination provider or your doctor tells you not to get a second shot.
    • It takes time for your body to build protection after any vaccination. COVID-19 vaccines that require 2 shots may not protect you until a week or two after your second shot.

    It is important for everyone to continue using all the tools available to help stop this pandemic as we learn more about how COVID-19 vaccines work in real-world conditions. Cover your mouth and nose with a mask when around others, stay at least 6 feet away from others, avoid crowds, and wash your hands often.​

    SARS-CoV-2 variants

    Viruses are constantly mutating and changing, that includes SARS-CoV-2, the virus that causes COVID-19. These genetic variations occur over time and can lead to the emergence of new variants that may have different properties. The SARS-CoV-2 genome encodes instructions organized as genes, to build the virus. Genomic sequencing allows scientists to identify SARS-CoV-2 and monitor how it changes over time into new variants, understand how these changes affect the characteristics of the virus, and use this information to better understand how it might impact health.

    It is important to monitor circulating viruses for key mutations that happen in important regions of the genome like the gene coding for spike protein. For instance, variants of the spike protein gene sequence can alter the amino acid sequence of the spike protein, which could alter the effectiveness of the antibody treatment and the immunity developed through vaccination. Many mutations do not affect the virus’s ability to spread or cause disease because they do not alter the major proteins involved in infection; eventually, these are outcompeted by variants with mutations that are more beneficial for the virus.

    As per CDC (USA), surveillance of emerging variants can help detect coronavirus variants with:

    • Ability to spread more quickly in people.
    • Ability to cause either milder or more severe disease in people.
    • Ability to evade detection by specific diagnostic tests. 
    • Decreased susceptibility to medical therapies that employ monoclonal antibodies. (Such therapy involves specifically designed antibodies that target regions of the virus to block infection. Because these treatments are more specific than natural immune response-generated antibodies, they may be less effective against variants that emerge).
    • Ability to evade natural or vaccine-induced immunity (Both natural infection with and vaccination against SARS-CoV-2 produces a polyclonal antibody response that targets several parts of the spike protein. The virus would need to accumulate significant mutations in the spike protein to evade immunity induced by vaccines or by natural infection).

    Among these, the ability to evade vaccine-induced immunity would be the most concerning. Several coronavirus variants have evolved mutations to spread more easily, make people sicker, escape immune responses, evade tests, or render treatments ineffective. These are called “variants of concern” by WHO. There are four coronavirus variants that experts around the world are particularly worried about. These variants were first identified in South Africa, the UK, Brazil, and India respectively (Table 2).

    COVID-19 variants of concern

    1) B.1.1.7, first found in the UK (WHO name: Alpha)

    B.1.1.7 was first detected in two people in South-East England. It has been identified in 123 countries worldwide, including the US. It became the most common variant in the US. Tennessee has the highest proportion of B.1.1.7 cases of any state, accounting for 73% of sequenced cases. B.1.1.7 is between 30% to 50% better at spreading from person to person than other coronavirus variants, according to UK scientists. B.1.1.7 could be more deadly. However, two studies published in the Lancet Infectious Diseases and the Lancet Public Health indicated that B.1.1.7 was more infectious, but didn’t cause worse illness in hospitalized patients. COVID-19 vaccines from Pfizer-BioNTech, Moderna, Jonson & Johnson and AstraZeneca all provide protection against B.1.1.7. all provide protection against B.1.1.7.

    2) B.1.351, first identified in South Africa (WHO name: Beta)

    B.1.351 was first detected in South Africa, in samples dating back to the beginning of October 2020. It has been found in 84 countries, including the US. B.1.351 is thought to be 50% more contagious than the original strain. Data suggests that the variant may evade the body’s immune response. Antibodies work best when they bind well to the virus and stop it from entering our cells. The B.1.351 variant has mutations called E484K and K417N at the site where antibodies bind. In lab tests, antibodies produced by Pfizer and Moderna’s COVID-19 vaccines could not bind well to B.1.351, compared to the original coronavirus. In a real-world study, Pfizer’s vaccine was 75% effective at preventing infection of varying severity caused by the variant first found in South Africa, called B.1.351, after two doses. Johnson & Johnson COVID-19 vaccine was 64% effective at preventing COVID-19 in trials in South Africa, where 95% infections are caused by B.1.351, and 72% effective in the US, where B.1.351 accounted for less than 1% of sequenced coronavirus tests. This suggests that vaccines will not become completely useless against variants. Existing vaccines could be updated and tailored to a new variant within weeks or months, or you may require a booster shot.

    3) P.1, first identified in Brazil (WHO name: Gamma)

    The variant found in Brazil was first detected in four people in Japan, who had travelled from Brazil on January 2,. It has been found in 45 countries worldwide, including the US. P.1 is twice as contagious as the original coronavirus. P.1 has similar E484K and K417T mutations as B.1.351, which means it can evade antibody responses. This could be the reason P.1 reinfects people who have already caught coronavirus. A recent study published on April 14 showed that previous coronavirus infection only offered between 54% and 79% of the protection for P.1 than for other virus strains. P.1’s mutations could also mean that vaccines work less well. COVID-19 vaccines from Pfizer and AstraZeneca work against P.1. Johnson & Johnson’s COVID-19 vaccine was 68% effective in trials in Brazil, where the variant is the most common strain, compared with its 72% efficacy in the US, where P.1 at the time accounted for 0.1% of sequenced coronavirus tests.

    4) B.1.617, first identified in India (WHO name: Delta)

    The variant first found in India, B.1.617, is in fact three distinct viruses. Collectively, they have spread to more than 17 countries. All three have been detected in the US. The WHO and UK have designated it a “variant of concern” because it is more infectious than the original virus. The mutations include: L452R, may make the virus more infectious or it may avoid the antibody response; P6814, may make it more infectious; and E848Q, may help the virus avoid the antibody response. Health officials in England recently reported that two doses of the COVID-19 vaccines made by Pfizer-BioNTech or AstraZeneca are highly protective against variants first detected in India and the United Kingdom. The data also underscored the need for two doses, as both vaccines were significantly less effective after only one shot. The vaccines were similarly effective at protecting against the UK variant. Moderna vaccine also appears to protect against COVID variants, B.1.617 and B.1.618 that were first identified in India.

    Moderna reported that its COVID-19 vaccine was 100% effective in a trial involving 3732 adolescents aged 12-17, with no major safety concerns. Among adolescents who received two doses, there were no cases of COVID-19 compared with four cases among those who received a placebo. After only one dose, the vaccine was 93% effective in the age group. Side effects were similar to first reported in earlier studies, including headache, fatigue, body ache, fever and chills. Rare cases of a few adolescents and older teenagers developing myocarditis (mild heart problems) after receiving the COVID-19 vaccines was reported. CDC is investigating whether this is a possible side effect of vaccination or if they are merely a coincidence. The relatively few cases seem to have occurred approximately four days after the second dose of mRNA vaccines made by either Pfizer-BioNTech or Moderna. Symptoms have been more common in males than females. Some rare cases of females developing blood clots after receiving the AstraZeneca vaccine has also been reported. Moreover, it appears that COVID-19 survivors with lingering symptoms can safely be vaccinated against the coronavirus.

    More recently, WHO has named the four variants of concern, known as the UK (B.1.1.7), South Africa (B.1.351), Brazil (P.1) and India (B.1.617.2) with Greek alphabets Alpha, Beta, Gamma, and Delta, respectively.

    “Breakthrough” infections after vaccinations

    Based on roughly 101 million Americans fully vaccinated against COVID-19, CDC reported that breakthrough infections occurred in 0.01% of them. Approximately, 27% of breakthrough infections were asymptomatic, while in 2% of the cases, patients died. The CDC sequence data for virus samples from 555 breakthrough infections indicated that mutated variants of the coronavirus, those were first seen in the UK and South Africa, accounted for 64% of the breakthroughs. Moderna and Pfizer are developing booster shots to combat COVID-19 variants.

    COVID-19 disease & black fungal infection

    A rare and potentially deadly infection by mucormycosis (also known as black fungus), has been observed in several coronavirus patients, or those who have recently recovered from COVID-19, whose immune systems have been weakened by the virus or who have underlying conditions, most notably diabetes. Over 6000 black fungus cases have been reported across India, with hundreds hospitalized and at least 100 dead.

    Black fungus is caused by mould found in damp environments (like soil or compost) and can attack the respiratory tract. It is not contagious and does not spread from person to person. Black fungus commonly affects the sinuses or lungs after a person inhales fungal spores in the air and can also affect the skin following a surface injury like a cut or burn. Symptoms depend on where in the body the fungus is growing but can include facial swelling, fever, skin ulcers and black lesions in the mouth. Black fungus disease begins to manifest as skin infection in the air pockets located behind our forehead, nose, cheekbones, and in between the eyes and teeth. It can then spread to the eyes, lungs and can even spread to the brain. It leads to blackening or discolouration over the nose, blurred or double vision, chest pain, breathing difficulties and coughing of blood. If it is not controlled or treated, the mortality rate could be from 20% to 50%. The mortality rate also depends on which part of the body is affected; it is less deadly for people with sinus infections but more deadly for those with lung infections.

    Immunocompromised people are more susceptible to infection who include COVID-19 patients, diabetic patients, people who take steroids, and those with other comorbidities like cancer or organ transplants. COVID-19 patients are particularly susceptible because not only does the virus affect their immune system, drugs used to treat the disease can also suppress their immune response. Due to these factors, COVID-19 patients face a renewed risk of failing the battle against attacks mounted by the black fungus. This does not mean that every COVID-19 patient will get infected by the black fungus as it is uncommon among those without diabetes. The prevalence of diabetes in India is as high as 12% to 18% of the adult population, especially in urban areas.

    Black fungus is treated with antifungal medicines such as Amphotericin B that is given intravenously. Patients may need up to six weeks of anti-fungal medicine to recover. Their recovery depends on how early the disease was diagnosed and treated. Often, surgery is required to cut away dead or infected tissue. For some patients, this may mean loss of the upper jaw or sometimes even the eye. Black fungus is 70 times more prevalent in India, possibly due to several factors that include: 1) higher rate of “undiagnosed” and “uncontrolled” diabetes; 2) tropical humid climate that promotes fungal growth; and 3) delays in seeking medical attention and diagnosing the disease, and challenges in managing the advanced stage of infection. COVID-19 pandemic has worsened the situation in India, by promoting opportunistic infection by the black fungus.

    Authors personal experience with COVID-19 vaccine side effects

    Avanti Srinivasan (1st-year Biology Honors College Student and working a part-time summer job at Penn Medicine Princeton Health): It is evident that COVID-19 has turned the world upside down. After almost a year of quarantine, death and chaos, the pandemic has also now opened a new era in vaccine development with new technologies. As a college student, when I heard about the vaccine I was delighted as I was ready to return to normalcy and resume my life where I left off one year ago after finishing my senior year of high school. I received the Pfizer-BioNTech COVID-19 vaccine on April 18th, 2021. I was quite nervous before receiving the shot as my friends had warned me about various side effects they felt from the vaccine after getting their first dose. Luckily, unlike many others, I did not feel any side effects from the vaccine. One day after vaccination, I felt a slight pain at the injection site, but this is a common immune response to receiving any vaccine as it shows that our immune system is working properly. Three weeks later, I received my second dose of Pfizer-BioNTech COVID-19 vaccine on May 9th, 2021. Just like the first dose, I did not feel any harsh side effects. The usual pain near the injection site and tiredness were there, but it got better after 2-3 days. Overall, I would encourage everyone to get vaccinated as soon as possible. After receiving both doses of the vaccine, I feel more confident and protected and have resumed normal activities without fear of the coronavirus. I know that even if I do get infected with coronavirus, I will not become seriously ill, as the vaccine will provide me with a layer of protection from the deadly virus. After getting vaccinated I also feel that I am playing my role as a good citizen and community member in my state by helping to prevent the spread of COVID-19. I am also encouraging those around me to get vaccinated and by doing so, we will reach herd immunity at which point we can finally put the pandemic behind us and move forward with our lives.

    Dr Keerthika Gnanasegaran (currently working in a multi-speciality hospital in Pondicherry and an INICET aspirant): I got vaccinated with COVISHIELD at my hospital on March 10, 2021. At first, I was very scared about getting the COVID-19 vaccine. I surfed many websites and got advice from many health care professionals, which convinced me to change my mind about getting vaccinated. One day after vaccination of the first dose, I got injection site pain, severe headache, fever >102⁰ F, and fatigue. I consulted my Chief at the Hospital and he said not to worry and advised me to take a Paracetamol tablet once every 6 hours. The following day, I felt alright except for some mild injection site tenderness. Unfortunately, just before I was about to take my second dose of inoculation, I tested positive for COVID-19. I did not have any symptoms except mild body ache. My father, who is obese, diabetic, and suffers from hypertension, also tested positive for COVID-19 after the first dose of vaccination. He also had only mild body ache and we both were under home isolation. Finally, I realized, getting COVID-19 vaccination very likely prevented us from a serious illness. I plan to get my second dose of COVID-19 vaccination after six weeks. Based on my personal experience, I request and encourage everyone to go ahead, shed their inhibition about getting COVID-19 vaccination.

    Dr Vishnu Priyaa Radjassegarane (a medical student doing her postgraduate studies in Pediatrics in Pondicherry): As a medical student, I came to know about the seriousness of the COVID-19 disease at the hospital. During the early phase of the COVID-19 pandemic, I became infected with the virus, and thankfully I recovered from the infection after treatment. Initially, like many others, I had many doubts regarding the COVID-19 vaccine and was afraid of its side effects. But upon reflecting some more, I decided to get the COVID-19 vaccination done. I reasoned that even if I get reinfected again with the coronavirus, I could avoid a severe illness like getting admitted to ICU or being on a ventilator. I got my first dose of COVISHIELD inoculation on March 15, 2021. With the information that I gathered from my fellow postgraduates regarding the side effects of the vaccine, I took my pain killers prophylactically even before the symptoms could appear. After vaccination, I had some side effects: low-grade fever, injection site pain, myalgia and difficulty in lifting my arm. But these lasted for only 2 days and then subsided. After 6 weeks, I got my second dose of the COVISHIELD vaccine on April 24, 2021. But luckily, I did not experience any side effects after the second dose like the first. After getting the two doses of the COVID-19 vaccine, I feel very confident and safe to go back to work at my hospital, even looking after patients with COVID-19. I will never say that I will not be reinfected with the coronavirus again, but with the COVID-19 vaccination, I feel that I will not get a severe form of the COVID-19 disease that requires oxygen supply or ventilator support. In my opinion, I believe that most of the Pondicherry and Tamil Nadu citizens and the Indian population should be vaccinated as soon as possible to reach herd immunity when we can together put an end to this deadly pandemic and return to our normal life and walk outside confidently without masks.

    Summary

    COVID-19 vaccines offer the best way to fight the invisible enemy and overcome the COVID-19 pandemic. US President Biden has focused all his efforts to get at least 65-70% of the US population vaccinated in the first 180 days of his administration with at least one dose to reach herd immunity. The US is well on its way to successfully achieve this goal by July 4, 2021. Vaccinating the Indian population and reaching herd immunity, may be the only option left for the Indian Government to fight the invisible enemy and to successfully end the deadly COVID-19 pandemic. India so far has inoculated only about 3% of its 1.3 billion people, has a long way to vaccinate 70-80% of its population to reach herd immunity. COVID-19 variants could pose a problem by reducing the effectiveness of the vaccines. This could be addressed by giving booster shots against new COVID-19 variants.

    Acknowledgement

    This article was put together using the information from the Center for Disease Control and Prevention (CDC, USA), World Health Organization (WHO), CNN and from various news articles (too numerous to list them all here). As a disclaimer, we must emphasize that this article is meant to serve solely as an informational resource for the readership. People affected by the coronavirus should consult with their physician for advice and treatment as well as for information about COVID-19 vaccination.

    Table 1: COVID-19 vaccines and their side effects

    Vaccine Status Dosing Efficacy Potential Side Effects
    Pfizer Vaccine has been authorized for emergency use Two doses, delivered three weeks apart 95% effective at preventing serious illness Injection site pain, fatigue, 

    headaches, chills
    Moderna Vaccine has been authorized for emergency use Two doses, delivered four weeks apart 94% effective at preventing serious illness Injection site pain, fatigue, 

    muscle aches, joint pain, 

    headaches, chills
    Johnson & Johnson Awaiting emergency use authorization by the FDA One Dose 72% effective at preventing severe illness Injection site pain, fatigue, 

    headache, muscle pain, joint pain
    Novavax Vaccine trials are ongoing Two doses, delivered three weeks apart – Injection site pain, rash, 

    headaches, muscle pain, fever
    Covishield (AstraZeneca/Serum Institute of India) Central Drug Standard Control Organization (CDSCO) India granted Emergency Use Authorization (EUA)  Two doses, delivered 12 to 16 weeks apart 63% effectiveLonger dose intervals with 12 weeks range associated with greater vaccine efficacy Injection site pain, headache, 

    fatigue, myalgia, fever rarely 

    one-sided facial nerve palsies, 

    demyelinating disorders
    Covaxin (Bharat Biotech) Central Drug Standard Control Organization (CDSCO) India granted Emergency Use Authorization (EUA) Two doses, delivered four to six weeks apart 78% effective in preventing serious illness Injection site pain, headache, 

    fatigue, myalgia, fever, body ache, 

    tremors, giddiness, cold, cough

     

     Table 2: SARS-CoV-2 variants
     

     

    Name

     

    		 Spike Protein Substitutions First Detected
    B.1.525  

    Spike: A67V, 69del, 70del, 144del, E484K, D614G, Q677H, F888L

    		  

    United Kingdom/Nigeria – December 2020
    B.1.526  

    Spike: (L5F*), T95I, D253G, (S477N*), (E484K*), D614G, (A701V*)

    		  

    United States (New York) – November 2020
    B.1.526.1  

    Spike: D80G, 144del, F157S, L452R, D614G, (T791I*), (T859N*), D950H

    		  

    United States (New York) – October 2020
     

    B.1.617

    		  

    Spike: L452R, E484Q, D614G

    		  

    India – February 2021
    B.1.617.1  

    Spike: (T95I), G142D, E154K, L452R, E484Q, D614G, P681R, Q1071H

    		  

    India – December 2020
    B.1.617.2  

     

    Spike: T19R, (G142D), 156del, 157del, R158G, L452R, T478K, D614G, P681R, D950N

    		  

     

    India – December 2020
    B.1.617.3  

    Spike: T19R, G142D, L452R, E484Q, D614G, P681R, D950N

    		  

    India – October 2020
     

    P.2

    		  

    Spike: E484K, (F565L*), D614G, V1176F

    		  

    Brazil – April 2020

     

    (*) = detected in some sequences but not all

     Appendix I

     

    Appendix II

     

    Editors’ comments

    While it is difficult for any government to be fully prepared for a pandemic that occurs once every hundred years, it is important for a task force to review and put policies in place for future preparedness to deal with such a deadly pandemic. While India had successfully contained the coronavirus infection rate in the short term by mitigation efforts and complete lockdown, it failed to prepare for all possible contingencies, such as the emergence of a deadlier and more contagious COVID-19 variant. Furthermore, failure to curtail large gatherings for religious festivals and election-related activities may also have contributed to the rapid spread of the virus all over the Indian subcontinent. Consequently, the rate of infection soared; the Indian health care system was overwhelmed, leading to increased Indian mortality and morbidity. In hindsight, the Indian Government should have mobilized to vaccinate its population as soon as effective vaccines became available in early January 2021, to reach herd immunity and to make the Indian population immune to COVID-19. Overseas export of vaccines should have been curtailed immediately as the US Government did unilaterally with the export of raw materials (supply chains) needed to make the vaccines.  India, though late and after catastrophic deaths, has ramped up its vaccination program. Vaccine shortages are gradually being addressed. Currently, 20 crores (200 million) people have been vaccinated at least with one shot, which is second only to the US. In terms of percentages, it is low because of the huge Indian population. The Indian government is increasing its efforts to ramp up vaccination to 30 crores (300 million) people a month by August 2021.

    One bright spot that has emerged out of the misery of the pandemic is that it has helped us to recognize and laud the “real” heroes. They are many among us worldwide: doctors, nurses, first responders who risk their own lives to take care of the COVID-19 patients. The young authors of this article are representative of such real heroes worldwide.

     

    Edited by S Chandrasegaran PhD and M Matheswaran PhD.

    Dr S Chandrasegaran is Professor Emeritus at the Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA.

    Air Marshal M Matheswaran (Retd) is the President of The Peninsula Foundation. 

  • (Part-II) Proposing a Legal Framework for Distribution of the COVID-19 Vaccination

    (Part-II) Proposing a Legal Framework for Distribution of the COVID-19 Vaccination

    I.   Reassessing Vulnerabilities During a Pandemic

    A general problem across all conventional models is their failure to understand that vulnerabilities during a pandemic are created and compounded by socio-economic factors too. Therefore, there is a need to adopt approaches that holistically assess the correlation between socioeconomic factors and vulnerability during a pandemic.[1]

    The Syndemics Approach

    Under this approach, pandemics are understood as an interaction of that disease with other diseases and the socio-economic and political factors that increase the risk of vulnerability.[2] All these factors synergistically interact to impact the health of individuals and society. Through these risk factors, it identifies the overlapping health and socio-economic problems that increase vulnerability (‘syndemic vulnerabilities’). The socio-economic risk factors are influenced by social determinants of health, i.e., the conditions of housing, food, employment, healthcare, and education.[3] Therefore, the utility of this approach lies in its holistic conception of socio-economic factors that impact the formation, clustering, and progression of diseases.[4] Using this approach, I argue that the COVID-19 pandemic has synergistically interacted and exacerbated the existing diseases and socio-economic conditions of marginalized groups across countries.

    Higher Risks of Infection, Transmission, and Mortality: Typically, due to historic discrimination and denial, marginalized communities have a greater number of pre-existing diseases like diabetes and asthma,[5] which in turn elevates their risk of infection and mortality. Moreover, there is unequal access to healthcare among marginalized communities due to the high costs of medical care and the absence of health insurance.[6] Marginalized communities are also disproportionately poor,[7] which affects their ability to mitigate the impact of the pandemic.

    Typically, marginalized communities are housed in crowded neighbourhoods with smaller houses that lack outside space.[8] They also have higher population densities, especially in urban areas, and lower access to communal green space.[9]Due to historic discrimination, marginalized communities are over-represented in essential services, including low-wage healthcare sectors and sanitation jobs.[10] This reduces their ability to work from home, and thus increases their risk of infection and transmission. Marginalized communities are more likely to take public transportation,[11] which further increases their risk of infection and transmission.

    These syndemic vulnerabilities have increased the risk of mortality among these marginalized communities. For instance, in America, the mortality rate of African-Americans and Indigenous/Latino communities is 3.4 times and 3.3 times higher than a non-Hispanic White person.[12] Evidence from past epidemics/pandemics shows that the rates of infection and mortality are always disproportionately higher among marginalized communities.[13]

    Greater Socio-Economic Disruption: Due to a lack of quality education, members of marginalized communities tend to work in lower-wage jobs in the informal sector, which has been worst hit by the pandemic.[14] The percentage fall in employment for marginalized communities has been far greater, indicating that education was a protective factor in the first wave of job losses.[15] Consequently, there has also been greater housing evictions among these communities.[16]The access to quality education for children in marginalized communities has also been severely impacted because they lack access to the internet,[17] affecting their ability to access education. Moreover, low literacy among adults in marginalized communities indicates their inability to assist their children with any form of home learning.[18]

    Therefore, the increased syndemic vulnerabilities of marginalized communities and the consequent disproportionate socio-economic disruptions of the pandemic on them necessitate a greater strive for their inclusion in distributing the vaccine. Early access to such vaccines allows these groups the opportunity to proportionately mitigate these vulnerabilities and disruptions.

    Intersectionality

    Presently, vulnerabilities among individuals are dominantly viewed from a single-axis framework. This ignores the multiple layers and experiences of vulnerability, resulting from an interplay of power structures and different social identities, held by one individual. This ignorance is avoided when using intersectionality, which is an analytical framework that explains how different social, economic, and political identities overlap to create different modes of discrimination and privilege.[19] Thus, it explains how certain individuals in the population are relatively more disadvantaged than others.[20] Intersectionality not only provides a multi-layered understanding of vulnerabilities during a pandemic but also helps prioritize distribution within an identified category, given the scarcity of vaccines.

     

    II.   Proposing a Multi-Value Ethical Framework

    Given its rational criteria, incorporating utilitarianism’s clinical risk factors is quite valuable. However, as argued, vulnerability during a pandemic is also determined by socioeconomic risk factors. Therefore, there is a need to adopt a multi-value approach that incorporates both clinical and socio-economic risk factors. I propose to do so by simultaneously prioritizing the values of ‘collective wellbeing’ and ‘justice’.

    Borrowed from utilitarianism is the value of ‘collective wellbeing’, which aims at maximizing benefits and minimizing harms. Flowing from a syndemic conception of COVID-19 is the value of ‘justice’, which aims at reducing health inequities and treats like people alike. These values are not necessarily always distinct, but their overlap over one parameter indicates a stronger justification. They can be operationalized using an ‘intersectional multi-parameter weighted framework’.

    Operationalizing Values

    The framework is constructed through three layers: (1) for each risk parameter, there is (2) a value-based justification, along with (3) its extent of weightage. The risk parameters are viewed from an intersectional power axis, with value justifications sourced from clinical and syndemic vulnerabilities. The weightage typically connotes a three-point scale, where 3 indicates the highest priority, and 1 indicates the lowest. The priority order is based on the greatness of one’s total score. The lottery method should only be used as a tie-breaker when the score is the same, and no more doses are presently available.

    Age:    Older people are at a significantly higher risk of infection and severe morbidity or mortality due to physiological changes associated with ageing. Globally, more than 95% of COVID-19 deaths were among individuals aged 60 and above. Even among older people, more than half of all deaths occurred in people aged 80 and above.[21]

    Therefore, in descending order, weightage must be given to individuals above 80 years, individuals between 60-80 years, and individuals between 40-59 years.

    Comorbidities:          Depending on the country, between 48-75% of COVD-19 deaths are associated with existing comorbidities. Those with comorbidities are also at moderately higher risk of infection.[22]

    The prioritization has to be categorized based on the severity of the comorbidity, in contracting the infection and causing death. Therefore, in descending order, higher weightage must be given to severe comorbidities, moderate comorbidities, and mild comorbidities. The severity in infection and mortality is different for countries due to distinct socio-economic realities and evolutionary biology. Therefore, this identification and classification need to be uniquely undertaken. However, as a general rule, it is almost universal for HIV, cancer, and most cardiovascular diseases to be severe comorbidities.[23]

    Profession:     Prioritizing frontline healthcare, sanitation, and defence workers are justified because they engage in services, whose absence has the greatest negative societal impact- whether on health, safety/security, or economy. They are also in constant contact with areas and people having the greatest risk of infection. Therefore, protecting them has a multiplier effect, in that their ability to remain uninfected protects the health of others and minimizes societal and economic disruption. Since the state obligates these workers to work in risk conditions, while everyone else is working from home, it is further obligated to protect them.

    Therefore, in descending order, priority must be given to frontline workers, workers in other essential sectors, and workers in non-essential sectors.

    Income:          One’s economic status affects their ability to access healthcare, thus results in higher rates of mortality and severe morbidity.[24] The syndemic approach reveals that poverty compounds one’s syndemic vulnerability.

    Therefore, in descending order, priority must be given to individuals with low-income, middle-income, and high-income.

    Ethnic Identity:         The syndemic approach reveals that marginalized communities are at a greater risk of infection, transmission, and mortality. They are also worst affected by the pandemic, which further compounds their vulnerability. Given these vulnerabilities, prioritized vaccine access to marginalized communities also helps reduce all three risks among the general population.

    The prioritization criteria would depend on the marginalized communities within a country and the extent of their syndemic vulnerabilities. For instance, in America, the syndemic vulnerabilities are greatest for African-Americans, followed by the Indigenous/Latinos communities, and then Pacific Islanders.

    Conclusion

    The conventional models of vaccine distribution are unethical towards disadvantaged groups. While neoliberalism completely ignores the distributive function of law, utilitarianism, lottery, and FCFS at least acknowledge this. However, their criterion of distribution ignores socio-economic vulnerabilities. This ignorance can be addressed using a syndemics approach and intersectionality.

    The syndemics approach explains the socio-economic risk factors that disproportionately disadvantage marginalized communities, both medically and socio-economically. Intersectionality provides a layered understanding of how vulnerabilities affect people, even those in the same group, differently. Using these approaches, I propose a multi-value ethical framework that balances the pragmatic considerations of medical utilitarianism with greater social inclusion. It operationalizes the values of these ethical systems through the priority order generated under an ‘intersectional multi-parameter weighted framework’.

     

    Notes:

    [1] While each country has different marginalized groups, the patterns of vulnerability explored are similar. Thus, marginalized groups have been generally analyzed hereinafter.

    [2] Merrill Singer, Nicola Bulled, et al, ‘Syndemics and the biosocial conception of health’ (2017) 389 Lancet 941, 941-943.

    [3] Clare Bambra, Ryan Riordan, et al, ‘The COVID-19 pandemic and health inequalities’ (2020) 1 J Epidemiol Community Health 964, 965.

    [4] Singer (n 23) 948.

    [5] Harleen Kaur, ‘Indirect racial discrimination in COVID-19 ethical guidance’ (BMJ Blog, 27 August 2020) <https://blogs.bmj.com/covid-19/2020/08/27/indirect-racial-discrimination-in-covid-19-ethical-guidance/> accessed 8 January 2021.

    [6] Bambra (n 24) 965-966.

    [7] Melanie Moses, ‘A Model for a Just COVID-19 Vaccination Program’ (Nautilus, 25 November 2020) <http://nautil.us/issue/93/forerunners/a-model-for-a-just-covid_19-vaccination-program> accessed 8 January 2021.

    [8] Tonia Poteat, ‘Understanding COVID-19 Risks and Vulnerabilities among Black Communities in America: Syndemics’ (2020) 47 Annals of Epidemiology 1, 3.

    [9] Bambra (n 24) 966.

    [10] National Academies (n 16) 30-31.

    [11] ‘Beyond the data: Understanding the impact of COVID-19 on BAME groups’ (2020) Public Health England Report, 22-23 <https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/892376/COVID_stakeholder_engagement_synthesis_beyond_the_data.pdf> accessed 8 January 2021.

    [12] Harald Schmidt, ‘Is It Lawful and Ethical to Prioritize Racial Minorities for COVID-19 Vaccines?’ (2020) 324 JAMA <https://jamanetwork.com/journals/jama/fullarticle/2771874> accessed 8 January 2021.

    [13] Bambra (n 24) 967.

    [14] Shruti Srivastava, ‘Millions Escaped Caste Discrimination. Covid-19 Brought It Back’ (Bloomberg Quint, 21 August 2020) <https://www.bloombergquint.com/politics/millions-escaped-caste-discrimination-covid-19-brought-it-back> accessed 8 January 2021.

    [15] Ashwini Deshpande, ‘Differential impact of COVID-19 and the lockdown’ (The Hindu, 22 August 2020) <https://www.thehindu.com/opinion/lead/differential-impact-of-covid-19-and-the-lockdown/article32416854.ece> accessed 8 January 2021.

    [16] Schmidt (n 33).

    [17] Deshpande (n 36).

    [18] Ibid.

    [19] Olena Hankivsky, ‘An intersectionality-based policy analysis framework’ (2014) 13(119) Intl J Equity in Health 1, 2.

    [20] Ibid.

    [21] ‘Supporting older people during the COVID-19 pandemic’ (WHO, 3 April 2020) <https://www.euro.who.int/en/health-topics/health-emergencies/coronavirus-covid-19/news/news/2020/4/supporting-older-people-during-the-covid-19-pandemic-is-everyones-business> accessed 8 January 2021.

    [22] Awadhesh Kumar, ‘Impact of COVID-19 and comorbidities on health and economics’ (2020) 14(6) Diabetes Metab Syndr 1625, 1626-1627.

    [23] Ibid.

    [24] National Academies (n 16) 68-77.

     

    Image Credit: One India

  • Proposing a Legal Framework for Distribution of the COVID-19 Vaccination [Part I]

    Proposing a Legal Framework for Distribution of the COVID-19 Vaccination [Part I]

    Introduction

    Distributing the COVID-19 vaccination has been touted as the biggest policy decision in 2021. This stems from the utility and efficacy of vaccines in immediately addressing pandemics. Specifically, the COVID-19 vaccination not only protects the injected person, with a 70%-95% efficacy[1] but also provides ‘herd immunity’.[2] That is, the non-injected population is also benefited due to a reduced risk of transmission and infection, so long as 70% of individuals in society are vaccinated. Therefore, access to the vaccine determines how much and for whom the adversity of the pandemic is mitigated.

    Currently, most vaccine developers are in the final two phases of clinical trials, with some, like Pfizer/BioNTech’s and Oxford University/AstraZeneca’s, already receiving ‘emergency use authorization’ from multiple countries. Most countries have prepared a ballpark action plan for distribution, while the United Kingdom has already vaccinated more than 3.5 million people.[3]

    In this paper, I evaluate the most ethical framework for distributing COVID-19 vaccinations, amongst the population of one country, by its government. I address this question from the perspective of marginalized communities, using the approaches of realism, syndemics, and intersectionality. In Part I of this article, I will evaluate the conventional models for vaccine distribution. In Part II, I will provide an alternative framework for reassessing vulnerabilities during a pandemic, and propose a multi-value ethical framework.

    1. Evaluating the Conventional Models for Vaccine Distribution

    The decision to distribute COVID-19 vaccines is inherently ethical because it involves allocating an important resource in a resource-scarce world. Thus, determining who can pre-maturely mitigate the pandemic’s adversity. There are four models in conventional discourse that have sought to answer the distribution question. In this section, under each model, I will critically evaluate the role of law in distribution and the ethical values that guide prioritized distribution.

    Neoliberalism

    Neoliberalism is characterized by a strict separation between the state, society, and the market.[4] The objective of all economic activity in the markets is wealth and efficiency maximization.[5] To this end, greater involvement of the private sector in the economy is justified because the market allocation of resources is more efficient. Any state intervention beyond a minimum supporting role is conceived as inefficient because rent-seeking, corruption, and capture by special interests are inevitable.[6]

    The diminished role of the state in securing redistribution means that individuals are responsible for their welfare and income. Therefore, individuals would themselves be responsible for ensuring access to the vaccination, notwithstanding their socio-economic status. They must attain this access by successfully competing in the “free market”, through instruments like price point discovery.[7] The underlying rules of competition create a level playing field where fair bargaining over market transactions can occur, so long as the requisite effort is made. This is because the rules are universal in their applicability, and create a distinct economic space, free from state coercion.[8] Therefore, access to the vaccine is determined by one’s ability to pay for it.

    State intervention is only justified when there is a market failure, but even then, preference is accorded to non-state solutions like direct public action or self-regulation.[9] Neoliberalism addresses equity concerns, like non-access to the vaccine, through safety nets and income transfers rather than through market regulation.[10] Otherwise, inefficiencies are introduced into the system, which distorts market incentives, and thus undermines the goal of economic growth.[11] This means that vaccine developers would lose the incentive to undertake expedient and mass production.

    Critique:         Neoliberalism denies that any redistribution to disadvantaged groups is covered by legal reforms. There is no focus on how economic gains are distributed, and the effect of reforms on vulnerable social groups.[12]Neoliberalism’s refusal to acknowledge the distributive function of legal regulation is flawed because rules necessarily always operate to distribute resources and powers to various groups and actors in particular ways.[13] The neoliberal machinery devises a particular allocation of risks, resources, powers, costs, burdens and benefits among different market actors. The effect is that the existing propertied class receive greater entitlement, whilst others are disadvantaged.[14] This perpetuates the inequalities already in status quo, impacting accessibility to the vaccine. Therefore, the relevant question is not whether distributive concerns must be considered, but rather their manner of incorporation in the process of market reform. To this end, the state, which guarantees the regulatory underpinnings of a market economy, must inherently play a greater role in regulating the distribution of economic gains from the market.

    The idea to distribute vaccines based on personal purchasing power is flawed because it ignores the fact that vaccines possess inelastic demand. Therefore, given short supply at short-term and medium-term levels, the price will continually go up to unaffordable rates. This increased price does not encourage new suppliers because the intellectual property rights and R&D is held only by a few developers.[15]

    Utilitarianism

    Utilitarianism assesses the morality of a decision based on its consequences, whether it maximizes benefits and/or minimizes harms. Under this rationale, priority is accorded based on the greatest clinical risks and greatest utility to social functioning. The clinical factors consider the risk of severe morbidity and mortality, risk of infection, and risk of transmission.[16] The greatest utility to society is measured in terms of the risk of negative societal impact, i.e., the public utility of one’s occupation/social role to society and other individuals’ lives and livelihood.[17]

    Therefore, in this pandemic, utilitarianism would prioritize age (above 50/60 years) and associated comorbidities (identified set of diseases) based on the risk of morbidity/mortality and infection, followed by occupation (healthcare and frontline workers) based on the risk of negative societal impact and risk of infection.[18]

    Critique:         Unlike neoliberalism, there is limited value in the utilitarian model because it recognizes the distributive role of law in allocating benefits. Moreover, it pursues this based on a rational objective criterion.

    However, its main problem lies in assessing vulnerabilities through only a clinical lens. It ignores that socio-economic factors also contribute to overall vulnerability during the pandemic, as I argue in the next section. Additionally, it doesn’t acknowledge that even within the identified categories, some are more vulnerable than others. Therefore, it has the effect of compounding existing socio-economic inequalities.

    Lottery

    This approach prioritizes distribution through a random selection of names. This is premised on the assumption that such selection is egalitarian and impartial, and also overcomes the inherent moral relativity/ambiguity of human reasoning.[19]

    Critique:         Random lotteries acknowledge the role of law in distributing benefits, but they lack any rational prioritization to effectively and immediately address the pandemic. While absolute objectivity is unattainable, avoiding moral reasoning altogether is merely “an easy method to avoid hard decisions”.[20] The assumption that everyone’s life is equally important fails to acknowledge the differential disparities that differentially threaten such lives.[21]

    First Come First Serve

    Like lotteries, this approach is premised on avoiding moral decisions and the assumption that everyone has an equal opportunity to access the vaccine.[22]

    Critique:         While this approach acknowledges the role of law in distributing benefits, it is completely blind to the socio-economic realities. Given scarcity, it is inevitable that access will be confined to those with better connections, access to information, communication, and transportation. All these factors are, in turn, tied to one’s socio-economic status. Thus, there is disproportionate denial to disadvantaged communities.

     

    References:

    [1] James Gallagher, ‘Covid vaccine update’ (BBC, 30 December 2020) <https://www.bbc.com/news/health-51665497> accessed 8 January 2021.

    [2] Rebecca Weintraub, ‘A Covid-19 Vaccine Will Need Equitable, Global Distribution’ (HBR, 2 April 2020) <https://hbr.org/2020/04/a-covid-19-vaccine-will-need-equitable-global-distribution> accessed 8 January 2021.

    [3] Lucy Rodgers & Dominic Bailey, ‘Covid vaccine: How will the UK jab millions of people?’ (BBC, 23 January 2021) <https://www.bbc.com/news/health-55274833> accessed 24 January 2021.

    [4] Manfred Steger & Ravi Roy, Neoliberalism (OUP 2010) 3-4.

    [5] Kerry Rittich, Recharacterizing Restructuring (Kluwer Law International 2002) 50-52.

    [6] Rittich (n 4) 55-59.

    [7] Sahil Deo, Shardul Manurkar, et al, ‘COVID19 Vaccine: Development, Access and Distribution in the Indian Context’ (2020) Observer Research Foundation Issue Brief No. 378, 6 <https://www.orfonline.org/research/covid19-vaccine-development-access-and-distribution-in-the-indian-context-69538/> accessed 8 January 2021.

    [8] Rittich (n 4) 131.

    [9] Rittich (n 4) 74-76.

    [10] Ibid.

    [11] Steger (n 4).

    [12] Rittich (n 4) 130.

    [13] Steger (n 11)

    [14] Rittich (n 4) 158-160.

    [15] Deo (n 7).

    [16] National Academies of Sciences, Engineering, and Medicine, Framework for Equitable Allocation of COVID-19 Vaccine (National Academies Press 2020) 102-105.

    [17] National Academies (n 16) 8.

    [18] Ibid.

    [19] Richard Zimmerman, ‘Rationing of influenza vaccine during a pandemic’ (2017) 25 Vaccine 2019, 2023.

    [20] Ibid.

    [21] Erica Moser, ‘Many ethical questions involved in prioritizing groups for vaccine distribution’ (The Day, 13 December 2020) <https://www.theday.com/article/20201213/NWS01/201219766> accessed 8 January 2020.

    [21] Ibid.

    [22] Zimmerman (n 19).

     

    Image Credit: Crowd Wisdom 360

  • Sanitation & Hygiene Concerns In Government Schools In Tamilnadu: Need For Digital Intervention

    Sanitation & Hygiene Concerns In Government Schools In Tamilnadu: Need For Digital Intervention

    Ensuring that there are proper health and hygiene facilities and awareness for girls at the school level is an extremely important building block for quality education.

    Introduction

    Achieving quality education at school level is a dynamic process that needs to revise the elements according to the needs of the social setting. One such element is a policy that promises an education system to promote gender equality from the grassroots. The problem needs an intervention with an enhanced infrastructure for maintaining sanitation and hygiene for girl students and a holistic understanding of gender issues through awareness that leads to organic social change. The state, undoubtedly, is responsible to ensure quality education and resolve the gaps in education using innovative methods. Tamil Nadu is one of the best performing states as far as literacy rate is concerned. However, realistic social barriers still exist that need intervention and customized strategy. According to the 2011 census, Tamil Nadu stood third after Kerala and Maharashtra. The male literacy rate was around 87% and the female literacy rate was around 73%.
    This article attempts to decode the most important factors,sanitation and hygiene, in ensuring ‘quality’ of education for girls. This particular aspect encompasses three main Sustainable Development Goals (SDG) of the UN; Quality Education, Gender Equality and Water & Sanitation. The last goal of providing access to clean water, sanitation and hygiene (WASH) particularly in rural areas is the means to achieve the former two goals of gender equality and quality education.

    Need to prioritize WASH for quality education

    Tamil Nadu employs more than 50% of its women in remunerative labour. Girls tend to drop out of schools either because of customary practices or because of the demand for labour. In some cases The lack of awareness and knowledge on menstruation and menstrual practices are also major factors contributing to this drop out. Despite several initiatives and attempts at establishing proper sanitation and hygiene practices particularly in schools, most of these initiatives fail to gain attention across social barriers, especially those initiatives surrounding menstruation and their importance. This exposes the limitation of community-based initiatives and their impact. Specifically Water, Sanitation and Hygiene practices, commonly known as WASH. Tamil Nadu is estimated to have 6.1 million adolescent girls and yet around 7837 schools have either dysfunctional toilets or no toilet facilities at all. The implication of such poor infrastructure is an adverse impact on learning and results in drop out from schools in most of the cases. Ensuring that there are proper health and hygiene facilities and awareness for girls at the school level is an extremely important building block for quality education.

    The lack of awareness and knowledge on menstruation and menstrual practices are also major factors contributing to this drop out. Despite several initiatives and attempts at establishing proper sanitation and hygiene practices particularly in schools, most of these initiatives fail to gain attention across social barriers, especially those initiatives surrounding menstruation and their importance.

    Access to toilets and sanitation facilities is a privilege that only a few have access to particularly in rural areas where people practice open defecation owing to the lack of toilets. Tamil Nadu has performed brilliantly in this respect since the implementation of Swachh Bharat Abhiyan Scheme in 2014. Over 48 lakh toilets were built in rural areas since 2014, with Tamil Nadu becoming an open-defecation free state.
    The Government of India recognized the role played by sanitation and hygiene in ensuring that quality education is delivered. In 2014, the MHRD had launched the ‘Swachh Bharat Swachh Vidyalay’ initiative. The scheme was implemented to ensure that there were separate functional toilets for girls and boys. In addition to ensuring separate toilets, the scheme also focuses on maintaining a certain level of hygiene and sanitation. While it is not enough that this initiative has been implemented in schools across the country, it is also important that parents, teachers and children are aware of the same. Proper hygiene and sanitation does not end in school, it is imperative that this awareness is spread in local communities and villages as well. As a part of the scheme, government schools in rural and urban areas are eligible to nominate themselves for the ‘Swachh Vidyalay Puraskar’. This acts as an incentive for schools across the country to improve their WASH standards.

    Capitalizing the Digital Wave

    With Tamil Nadu’s rural internet penetration through mobile phones at 41.98%, there is a significant potential that can be tapped in the state’s ICT usage. While creating awareness is one side of the coin, spreading awareness is another. This is where the potential of ICT can be harnessed, in spreading awareness. The government of Tamil Nadu has made available textbooks, lessons and other educational material on their ‘DIKSHA’ portal which is essentially a YouTube channel. On this channel, students from different classes can access their study material. This could be one of the possible means through which awareness can be created across districts and villages on the importance of sanitation and hygiene.
    Some of the government schools in Tamil Nadu have demonstrated an exceptional WASH record, thereby proving the fact that if the administration is focused the results can be excellent as shown by Thiruvallur and Vellore districts. Schools in these districts have maintained excellent sanitation and hygiene standards and have been recipients of the SVP. The initiatives taken by these schools to spread awareness on the importance of sanitation and hygiene have largely been behaviour oriented. By involving parents and the larger community, these initiatives have been successful and effective as well. Community-based initiatives are to create and spread awareness on various social welfare schemes. Apart from creating awareness, such initiatives also tend to bring communities together. The implementation of the SBSV scheme has facilitated the use of ICT as well. While the integration of ICT in the process is a welcome change, there is a lack of clarity on what exactly it is being used for.

    Importance of awareness on Menstrual Hygiene

    It has been established that several initiatives were taken in the past and are being taken to improve ‘WASH’ practices in the country, particularly in schools to improve enrollment rates as well as reduce dropout rates. Educational institutions in the country, particularly schools have an inherent responsibility to educate adolescent girls on menstruation, talk about the changes it brings about in a girl’s body. A 2014 report by Dasra foundation posits that close to 23 million girls drop out of school annually due to a lack of awareness. 79% of girls and women in Tamil Nadu were not aware of menstrual hygiene and practices that are followed at the time of menstruation. Lack of awareness of menstrual hygiene and the practices that are required to be followed at the time of menstruation makes a girl/woman extremely susceptible to infections. This is largely attributed to the stigma that is created around menstruation and the notion that it is an ‘impure’ phenomena. A study conducted in 2015, in Padappai, points out that only 43.33% of girls were aware of menstruation when they experienced it the first time. The source of information in most of these cases was the mother while the teachers and schools had a very small part to play in the process. Therefore, a layer of stigma surrounding the issue is apparent that is far from being institutionalized. Institutionalizing the issue would lead to it being discussed in schools, which in turn would normalize it and break the stigma around it. There are a plethora of possibilities that ICT brings about. Schools could tap into this potential and make use of it to communicate effectively to their students. In rural India particularly, simply creating awareness and breaking the stigma around menstruation will not suffice. Often, this stigma is reinforced by women in the family. In order to move beyond this, schools must ensure that lessons on menstruation are conducted for both girls and boys alike. Not only does this induce awareness among boys but it also makes them more sensitive to the issue.

    A 2014 report by Dasra foundation posits that close to 23 million girls drop out of school annually due to a lack of awareness. 79% of girls and women in Tamil Nadu were not aware of menstrual hygiene and practices that are followed at the time of menstruation.

    Awareness through Digital Platform

    Tried and tested methods of spreading awareness in a community has generated results but is not enough. Improving sanitation and hygiene standards in learning institutions requires the participation of all the stakeholders involved in the process. While this may be an initial attempt at de-stigmatizing the issue, undoing centuries of discrimination and oppression requires a systemic approach. Tamil Nadu government’s ‘DIKSHA’ portal is a good place to start. In addition to developing online resources, there must also be some sort of portal that mandates uploading information related to the sanitation and hygiene measures that are being taken in schools. Additionally, it is important to use digital interventions to create awareness and reinforce the message in a timely manner. While infrastructure creation is a part of the goal, it is equally important to establish the need for it and educate people. This is where the digital intervention comes into the picture. One of the goals in Tamil Nadu’s Vision 2023 Project is to encourage PPP as a mechanism for infrastructure creation. This could be one of the potential means through which awareness is spread by introducing digital interventions in rural areas. It could either include installing a TV in Gram Panchayat offices which could display campaigns on the importance of sanitation and hygiene/menstrual hygiene, etc. With respect to creating awareness on menstrual hygiene which is a systemic issue because of the stigma attached to it – the solution needs to be systemic as well. For starters, creating conversation around menstruation is extremely important. Something called the ‘culture of silence’ exists in Kenya particularly in rural areas where girls refrain from speaking about menstruation and puberty. Identifying practices like this is a start when it comes to de-stigmatizing menstruation. While removing GST on sanitary napkins is one way to make the product more accessible, it is important to make people realize why there is a need for using one in the first place and the consequences of not using it. This brings us to the question of whether it is enough for the state to build infrastructure alone and if its responsibility ends there as opposed to also creating awareness on how to go about using the said infrastructure as well as educating people on its importance.

    Ensuring Effective Policies

    Some of the government schools in Tamil Nadu have demonstrated an exceptional WASH record, thereby proving the fact that if the administration is focused the results can be excellent as shown by Thiruvallur and Vellore districts. Schools in these districts have maintained excellent sanitation and hygiene standards and have been recipients of the SVP.

    Initiatives like the SBA, SBSV and SVP are focussed around creating infrastructure and incentivizing schools to implement hygiene practices. Sanitation happens to be a state subject, and each state faces its own challenges with respect to addressing the problem. For instance in a state like Tamil Nadu where there is decent infrastructure, the drop-out rate for girls is still on the higher side. A lack of awareness on menstrual hygiene has also contributed to the drop-out rates in the state. Evidence suggests that not all government schools in Tamil Nadu have toilets and the ones that have toilets, do not maintain them well. Perhaps now the state must implement initiatives that focus on capacity building and behavioural change in order to ensure that the results are more impactful and also long-lasting. The initiatives that the state implements in the future must focus on intrinsically motivating people to implement sanitation and hygiene practices in their lives. Apart from that, the state must also conduct follow-up workshops that engage with people and communities and teach them how to use toilets, etc. In addition, whenever a new initiative/scheme is launched, state governments must also make sure that there are bodies/committees in place in every district that happens to be a beneficiary of the scheme. As communication becomes easier and more efficient in the digital age, initiatives that are implemented in the future must focus on knowledge creation.

    References

    https://www.orfonline.org/expert-speak/gender-dimensions-of-school-closures-in-india-during-covid19-lessons-from-ebola-66643/https://poshan.outlookindia.com/story/poshan-news-strong-connect-between-sanitation-and-health/348492https://swachhindia.ndtv.com/23-million-women-drop-out-of-school-every-year-when-they-start-menstruating-in-india-17838/https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6286883/http://sujal-swachhsangraha.gov.in/sites/default/files/Five%20schools-%20WASH%20in%20School%20-%20practices%2C%20Tamil%20Nadu-%20Clean%20school%20.pdfhttps://mhrd.gov.in/sites/upload_files/mhrd/files/upload_document/Swachh_Vidyalay_Puraskar_Guidelines.pdfhttps://www.researchgate.net/publication/294638502_Awareness_about_menstrual_hygiene_among_adolescent_girls_in_rural_area_of_Kancheepuram_district_-_Tamilnaduhttps://timesofindia.indiatimes.com/city/chennai/tn-second-in-rural-smartphone-use/articleshow/67291628.cmshttps://www.researchgate.net/publication/333561228_Availability_and_Utilization_of_Sanitation_Facilities_A_Micro_Study_from_Rural_Tamil_Naduhttps://swachhindia.ndtv.com/swachh-bharat-abhiyan-tamil-nadu-to-go-open-defecation-free-on-october-2-25278/#:~:text=Tamil%20Nadu’s%20Swachh%20Bharat%20Abhiyan%20Journey&text=The%20state%20has%20a%20total,declared%20free%20from%20open%20defecation.&text=Tamil%20Nadu%20has%20improved%20its,per%20cent%20in%20four%20years.&text=Over%2048%20lakh%20toilets%20(48,since%202014%20in%20rural%20areas.https://www.wsscc.org/2016/08/10/wsscc-menstrual-hygiene-management-training-kenya-breaks-silence-menstruation/

  • Genetic Engineering Key To Developing COVID-19 Vaccine

    Genetic Engineering Key To Developing COVID-19 Vaccine

    Scientists throughout the world are engaged in a herculean effort to develop a vaccine for the COVID-19 virus that has killed hundreds of thousands of people and decimated global economic activity. Without such a vaccine, normal life as we knew it before the pandemic began is unlikely to return any time soon.

    The key to such a vaccine is genetic engineering, which has already resulted in the development of several successful vaccines.

    The key to such a vaccine is genetic engineering, which has already resulted in the development of several successful vaccines. The active ingredients for the HPV (Human Papillomavirus Virus) vaccine, for example, are proteins produced from genetically modified bacteria. The hepatitis B vaccine, Erevebo, a vaccine for Ebola, manufactured by Merck, and the rotavirus vaccine are other examples of GE vaccines. A genetically modified rabies vaccine has been created for dogs and cattle.With these successes in mind, experts anticipate that recent advancements in genetic engineering could substantially shorten the development timeline for a COVID-19 vaccine. It takes on average ten to fifteen years to develop a vaccine, and the most rapidly developed vaccine was a mumps immunization, which still required four years to develop from collecting viral samples to licensing a drug in 1967.

    Time is clearly of the essence as there is the potential for a second wave of COVID-19 infections in the fall and winter, which would have further negative implications for public health and the global economy. The sooner we have a vaccine, the better off we’ll be, though serious logistical challenges remain.

    The Vaccine Race Begins

    On January 10, 2020, Chinese scientists greatly aided the vaccine development effort by publishing the genome of the novel coronavirus, SARS-COV-2. The virus is widely believed to have originated in bats near the city of Wuhan, China. It then jumped to another species, which was consumed by humans at the wet markets of Wuhan or came into direct contact with humans in some other way.

    After examining the genome, Dan Barouch, the Director of Virology and Vaccine research at Beth Israel Deaconess Medical Center in Boston, said, “I realized immediately that no one would be immune to it,” underscoring the importance of quickly developing an effective immunization.

    More than 120 possible vaccines are in various stages of development throughout the world, most of which are gene based with the hope that an effective and safe vaccine can be produced by the end of 2020 or early in 2021. This would be an astonishing accomplishment. By comparison, the Ebola vaccine, which is also genetically engineered, took five years to develop.Ken Frazier, the Chief Executive of Merck, which is working on a vaccine for COVID-19, has tried to dampen down expectations for a quick breakthrough, saying the goal to develop a vaccine within the next 12-18 months is “very aggressive. It is not something I would put out there that I would want to hold Merck to …vaccines should be tested in very large clinical trials that take several months if not years to compete. You want to make sure that when you put a vaccine into millions if not billions of people, it is safe.”
    Peter Bach, the Director of the Center for Health Policy and Outcomes at Memorial Sloan Kettering, added, “To get a vaccine by 2021 would be like drawing multiple inside straights in a row.”

    Genetic Engineering Is Our Best Bet

    To create a genetically engineered vaccine, scientists are utilizing information from the genome of the COVID-19 virus to create blueprint antigens (a toxin or other foreign substance which provokes an immune response that produces antibodies), which consists of DNA or RNA molecules that contain genetic instructions. The DNA or RNA would be injected into human cells where upon it is hoped the cell will use those instructions to create an immune response. If this type of vaccine is developed, it could offer protection for many years as the COVID-19 virus does not appear to mutate as quickly as influenza, though this critical variable could change in the future.
    RNA vaccines are considered to be better at stimulating the immune system to create antibodies. They also create a more potent immune response and therefore require a lower dosage. However, they are less stable than DNA vaccines, which can withstand higher temperatures; RNA vaccines, though, can be degraded by heat and thus need to be kept frozen or refrigerated.

    The DNA or RNA would be injected into human cells where upon it is hoped the cell will use those instructions to create an immune response. If this type of vaccine is developed, it could offer protection for many years as the COVID-19 virus does not appear to mutate as quickly as influenza, though this critical variable could change in the future.

    The Risks Of Moving Quickly

    Vaccine development is traditionally a lengthy process because researchers have to confirm that the drug is reasonably safe and effective. After the basic functionality of a vaccine is confirmed in a lab culture, it is tested on animals to assess its safety and determine if it provokes an immune response. If the vaccine passes that test, it is then tested on a small group of people in a phase one trial to see if it is safe, then in a phase two trial on a larger group of people. And if it passes those hurdles, a larger scale phase three trial is designed, which would involve at least 10,000 people.

    These trials are necessary because trying to develop a vaccine quickly can compromise its safety and efficacy. For example, the US government rushed a mass immunization program to prevent a swine These trials are necessary because trying to develop a vaccine quickly can compromise its safety and efficacy. For example, the US government rushed a mass immunization program to prevent a swine flu epidemic in 1976 that may have caused an increase in the number of reported cases of Guillain-Barre Syndrome, which can cause paralysis, respiratory arrest and death. The pandemic never materialized, though widespread public concern about flu immunization did.

    Many Challenges Remain

    Historically, the odds of producing a safe and effective vaccine are small, with just six percent of vaccines under development ever making it to the market. There are many diseases and viruses for which there are no vaccines (for example HIV/AIDS, Zika, Epstein-Barr and the common cold, among many others), even though great efforts have been made to develop them. Therefore, despite the gigantic efforts of drug companies and governments to produce a COVID-19 vaccine in the shortest possible period, there is no guarantee they will be successful.
    epidemic in 1976 that may have caused an increase in the number of reported cases of Guillain-Barre Syndrome, which can cause paralysis, respiratory arrest and death. The pandemic never materialized, though widespread public concern about flu immunization did.Soumya Swaminathan, the chief scientist for the World Health Organization said that an “optimistic scenario” is one in which tens of millions of doses could be produced and initially distributed to health care workers. Mass immunizations could begin in 2022, but to inoculate the world and “defeat” COVID-19 could take four to five years. She added, however, that this outcome “depended upon whether the virus mutates, whether it becomes more or less virulent, more or less transmittable.”
    epidemic in 1976 that may have caused an increase in the number of reported cases of Guillain-Barre Syndrome, which can cause paralysis, respiratory arrest and death. The pandemic never materialized, though widespread public concern about flu immunization did.

    The COVID-19 virus highlights just how vulnerable humankind is to the natural world, which periodically produces pandemics such as the Spanish flu, the Bubonic plague, Polio and Asian flu that have the ability to kill many millions of people.

    Assuming the virus doesn’t mutate, there are many logistical challenges that could slow mass immunization once a vaccine is developed. There is no precedent for scaling up a vaccine to potentially several billion doses. To do so would require a great deal of investment in vaccine production facilities throughout the world. Manufacturers would also have to scale up the production of vials, syringes, band aids and refrigeration units for temperature-sensitive vaccines.
    epidemic in 1976 that may have caused an increase in the number of reported cases of Guillain-Barre Syndrome, which can cause paralysis, respiratory arrest and death. The pandemic never materialized, though widespread public concern about flu immunization did.Additionally, it is not known if the vaccine would require one or two doses to confer immunity, or if it would have to be re-administered every few years. We would also have to determine how a vaccine would be shared internationally. There would clearly be tremendous pressure for any country that developed a vaccine to use it domestically before sharing it with other nations. It’s also possible that the race to develop a COVID-19 vaccine could siphon off dollars and manpower dedicated to developing treatments and vaccines for other deadly diseases.
    epidemic in 1976 that may have caused an increase in the number of reported cases of Guillain-Barre Syndrome, which can cause paralysis, respiratory arrest and death. The pandemic never materialized, though widespread public concern about flu immunization did.Among the most difficult public policy questions we’ll have to face, would the vaccine be made mandatory? The possibility has already triggered push back from vaccine skeptics who view such a policy as a threat to their “inalienable sovereignty” as free individuals.
    epidemic in 1976 that may have caused an increase in the number of reported cases of Guillain-Barre Syndrome, which can cause paralysis, respiratory arrest and death. The pandemic never materialized, though widespread public concern about flu immunization did.The COVID-19 virus highlights just how vulnerable humankind is to the natural world, which periodically produces pandemics such as the Spanish flu, the Bubonic plague, Polio and Asian flu that have the ability to kill many millions of people. Despite the inevitable challenges and trade-offs we face, the new tools of genetic engineering offer us the best chance of controlling, and possibly eliminating, the outbreak of future pandemics.
    This article is published earlier on 23 June 2020 in Genetic Literacy Project.
    This article, with images, is reproduced under ‘Fair Use of Articles & Images’ policy of GLP – https://geneticliteracyproject.org