ACADEMIA Letters On the Vaccination Program of India: A brief discussion on the emerging Ethical issues

India, despite being the world’s largest vaccine manufacturer is now struggling with various unprecedented social, legal, moral issues with the ongoing Covid-19 vaccination program for 1.3 billion people, the largest democracy in the world. With three major vaccines including Covishield, homemade vaccine Covaxin, and Russia’s Sputnik V, India is still facing acute scarcity of vaccines and raw material supply. This is not only unfortunate but also reveals the ethically-triggered facts about the imbalanced healthcare system between public and private sectors, ineffective inequitable healthcare policies, unaccountable data reports that raise mistrust and confusion, and a deeper concern about global unfair distribution. In this paper, I have briefly discussed some unparalleled ethical issues raised from the vaccination program of India.


Introduction
India, the largest vaccine manufacturer hub in the world is now troubled with various extraordinary worrisome issues emerged from the ongoing Covid-19 vaccination program for the adult population of its 1.3 billion people (Worldometer last updated till date). India's vaccination program has administered around 300 million doses so far which includes three vaccines primarily -the Indian version of Oxford University-AstraZeneca vaccine i.e. Covishield (by Serum Institute of India) with 88.07% of total vaccines, homemade vaccine Covaxin (by Bharat Biotech) with 11.91% and the recently approved Russia's Sputnik V with 0.02% so far . Even though India has recently hit a record with over 8 million vaccines engineered on a single day, it has completed fully vaccination only for 4% of the total population and currently, it is facing an acute scarcity of vaccines  Vaccinations, Our World in Data). This is not only unfortunate but also uncovers the ethically-triggered facts regarding the broken healthcare system, ineffective inequitable distribution policies, unaccountable data reports that raise mistrust and confusion, and a deeper globally unfair distribution. In this paper, I have briefly discussed some unprecedented ethical issues raised from the inoculation program of the novel corona virus vaccine.

Huge Adult Population
With the second largest population of 1.3 billion in the world, India needs an enormous number of vaccines to run a vaccination program for its 73% of the adult population (O'Neil 31st March 2021). A well-planned strategy is needed in advance with public health expertise to maintain the equitable and fair distribution of vaccines among such large numbers like 950 million adults (Dutta 11th June, 2021). The Government has initially failed to realize the need for the amount of vaccines until the devastating second wave hits and shakes the healthcare system completely. By the time the privately owned vaccine manufacturers, Serum Institute of India and Bharat Biotech have boosted their capacity after getting aid and orders from Government, it is already late to immunize such a large population. India is currently experiencing pathetic long queues of people waiting for getting vaccination due to acute scarcity of supply against the huge demand. Major ethical issues upraise due to Unplanned Equity of Access to Resources and violation of the Rights to Healthcare Protection due to unavailability of the life-saving vaccine against the lethal corona virus.

Over dependencies on privatized healthcare
This pandemic exposes many loopholes in Indian healthcare infrastructure. It highlights the deeper inbuilt injustice within healthcare and brings them to the surface. Indian Government spends only 3.5% of its GDP on the public health care system where the larger portion of the whole population is meant to be cured (The World Bank 2021). Now, the lack of necessary medications and resource crisis in the public sector are filled by private sectors and they consume around 72% of India's Current Healthcare Expenditure (CHE) (Pavithra 28th May 2021). This existing Unfair Distribution of Resource Allocation is the leading ethical predicamentsin inoculation. The most unjust fact is that the major healthcare facilities are significantly concentrated in metro cities and urban areas (Barik & Thorat 2015). The inhabitants of rural India already share a larger portion of the unhealthy population due to the unavailability and inaccessibility of the essential therapeutic medications and medical resources along with the host and community susceptibilities such as lack of sanitation, poor living conditions, the inadequacy of proper nutrition and safe drinking water, and basic medication. Moreover, with only 35% of the total population having health insurance coverage and insufficient number of Government run healthcare infrastructure, people are forced to pay many times more to private hospitals out of their own pocket (Statista Research Department 1st March 2021). The situation becomes more vulnerable when many rural areas of India do not have any private facility available to get the vaccination done as most of the rural inhabitants can not afford the hefty price of costly private treatment (Balarajan, Selvaraj, and Subramanian 2011). This fundamentally unfair health infrastructure is ultimately susceptible to different mutant viruses and eventually endangered the community health as a whole.

Policy paralysis and lack of knowledge
The Governance of India initially followed the Epidemic Diseases Act, 1897 while making policies to fight against the Covid-19 pandemic (Rakesh 2020). This aged law mostly focuses on social "policing" rather than concentrating on ethical rights-based well-planned scientific steps to handle a modern-day pandemic. Secondly, during the cool-down period of the early months of 2021 when the infection rate in India was less after the first wave of the Covid-19 pandemic, policymakers in Government organizations have underestimated the effectiveness of vaccination programs to prevent the second wave of infections. Surprisingly, the mass vaccination programs were not prioritized rather permissions were given to mass public gatherings like election rallies, religious events, social gatherings, and infectious disease prevention practices like social distancing, lock-down, usage of masks, and sanitizers were recklessly avoided.
Moreover, the sudden change in vaccination plan to make it open for all aged groups uncovers the unplanned inequitable hasty decision of the policy makers taken in a rush when the second dose is due for a large number of aged citizens and above 77milion people of above 60 ages have not been vaccinated yet (Lloyd-Sherlock, Kandiyil, McKee, Perianayagam et al 2021). This sudden inequitable decision leads to more spread of the virus and causes more deaths which could have been prevented with a planned equitable policy of vaccine distribution (Jean-Jacques & Bauchner 2021). Again, the online accessibility of vaccination program remains untouchable among the rural people who have minimal internet and smart phone accessibility. The whole scenario is worsened by the fact that the literacy rate is quite low at 74% only in India and the large number of Indian people who work in unorganized sectors do not have sufficient knowledge and awareness about the pandemic and community transmission of the Covid-19 virus (State of Literacy, Census 2001 to 2011). Also, there are allegations about the Covaxin vaccine which was given hasty emergency approval to use during the pandemic.
Most of the citizens are not transparent about the risks and benefits of the newly developed vaccine which is lacking enough phase III trials (Mitra & Hollingsworth 26th February 2021). Even there were questions raised about the side effects and violation of informed consent procedures among the trial participants. This develops huge confusion among common people which ultimately delays the process of inoculation.

Cost of vaccine and division in society
Indian citizens at a private healthcare facility are paying Rs 700 ( USD 10) to Rs 1500 ( USD 20) per shot of the Covid vaccine for the age of 18-44 years which is in the range of the highest price spent for the vaccine in the world (Nagarajan 10th May 2021). Highly regulated by private hospitals, the Indian healthcare system is causing a huge burden on poor people. The ongoing interrelation between poverty and inequality is not only an economic issue but numerous ethical factors emerge from it. The vaccine costs are definitely a burden for an average Indian family if they do not want to wait in the long queue of government hospitals. This is increasing divisions in social classes as education, travel, and job are now dependent on the vaccination status. Also, there is a huge number of homeless people present in every major city of India. They have been already facing major socio-economic injustices and now due to un-affordable vaccination policies they are facing physical, mental, and emotional trauma from various harassment.

Vaccine Nationalism
Vaccine Nationalism aims to prioritize the local or domestic needs of a country by securing vaccines and other therapeutic treatments to protect one's own nation. On a pathetic note, this is actually an ongoing process of securing and hoarding vaccines and therapeutics by the powerful, rich countries at the expense of less-wealthy countries (Eaton 2021). This globally unfair practice not only sharpens the gap of haves and have-nots but it also leads to the ineffective and lethal situation to handle a pandemic. Any unsystematic and disorganized inoculation may lead to different mutants of the virus that may eventually evade the immunity set out by the vaccination (Lagman 2021). Unfair distribution ultimately uncovers the uneth-ical view of treating vaccines and essential medications as a market commodity than means to improve the public good. It affects global health and economic well-being since it is high time we need to realize that no one is safe if anyone is unsafe and poses threat to others. Due to this inequitable distribution, the global community is now confronting with scarcity in supply. Vaccines are not available in many developing countries including India. India where most vaccines were produced in the past is now facing acute scarcity with its huge population pressure due to poor infrastructure and raw material supply from developed countries. This pandemic unveils the bitter truth again that the most deprived population is always the poorest people of the poor countries. India also has the role to play along with other deprived countries to demand surplus vaccination and raw materials from the developed countries for a globally fair and clinically sustainable and well-organized inoculation.

Conclusion
Vaccination is a complex system intertwining science, healthcare, social, legal, and moral dimensions and a fruitful vaccination should take care the well-being of all these respective dimensions. Vaccination to the world's largest democratic population is obviously not an easy job specially when we are already struggling with an unfairly distributed healthcare system. There is an essential and immediate requirement to develop a well-planned equitable vaccination policy for fair and justifiable vaccine distribution. Vaccine production on a large scale with regulated costs by Government policies is also needed to avoid extra pressure on healthcare budget of different states within the country. Even World Health Organization (WHO) has appealed researchers, vaccine manufactures, and fund providers to endorse "Solidarity Call to Action" (WHO 29th May 2020). Also, we need transparent, accountable, up-to-date data from the governing bodies that develop the bridge of trust between public health authorities, government, and people. Hiding of information, and research data only raise confusion and mistrust among people that eventually delay the process of vaccination which we have already witnessed. Transparency and accountability ultimately ease this huge process at the initial level.
A well-planned equitable resource allocation plan is immediately required, not only for the systematic fast vaccination but also to promote fair distribution within the healthcare system. It is high time to prioritize the vaccination process by keeping aside any kind of discrimination including political, social, racial, class, gender, and interstate favoritism. Low income group, people with comorbidity, and senior citizens who are highly affected by this pandemic should be immediately prioritized. Government needs to allocate more financial expenditure for vaccines procreation and for its successful deployment. The cost of vaccines should be fairly regulated everywhere and the government should supervise so that no private healthcare can misuse inappropriate vaccination charges as means of their business profitability.
Moreover, free vaccination should be regulated as soon as possible for a speedy and effective vaccination. Any kind of fraud business with vaccination should be punished in an immediate manner. These offensive acts should be treated as the most vicious criminal acts against the survival of human existence in general.
Furthermore, a successful vaccination program requires cooperation and mutual trust between the governing bodies and common people. As a responsible community citizen, every individual should take the obligation to grow awareness among unaware people by posters, regular campaigns in locality (with proper protection of masks and sanitation) and also in social media to promote the necessity of vaccination to avoid the exposure to serious illness and death rates. People need to be careful that with the continuous upcoming threats of new variants and virus such as Delta variants, Black Fungus, it is absolutely necessary to be vaccinated as soon as possible. For a smooth vaccination process, the vaccine registration procedure should be easy and straight forward which can be understandable by all and should be available in non-internet or non-digital medium too specially in rural and underdeveloped areas. Finally, the worldwide pandemic, on one hand, unveils the huge injustice within the global social structure and on the other hand, it makes us realize again that we are a member of one single global community. This is neither someone's own problem nor a particular group of individuals' problem. Since the risk is common, we should view ourselves as global citizens with broader and wider perspectives and perform community and global responsibilities rather than confine our duties within a local spectrum.