The Vaccine's Last Mile Problem
Bloomberg Businessweek|November 15, 2021
India is racing to vaccinate its villages, including many in remote and desperately poor areas where suspicion of the government’s motives runs deep
Upmanyu Trivedi, Chris Kay, and Malavika Kaur Makol

Outside a three-room concrete building coated in faded red paint, Neeral Kullu was waiting anxiously. The 35-year-old farmer had spent the late August morning walking across miles of jungle, dirt tracks, and lush fields to reach this makeshift vaccination clinic in Simdega, a rural district in Jharkand, one of India’s poorest states. At the entrance he was greeted by two white-coated nurses stationed at a small table laid out with syringes, Covid-19 vaccination cards, and paracetamol tablets. Still, Kullu was unsure he’d actually get an injection. The first time he’d tried, a couple of weeks earlier, fewer than five people had turned up, and he was told to come back the next day, because opening a precious 10-dose vial for so few recipients would be a waste. When he returned, a nurse told him his blood pressure was too high and sent him home.

On this visit, Kullu sheltered under a fig tree while he waited for his turn. His blood pressure was normal, but when a nurse tried to register him on the government’s vaccination tracking app, a new obstacle popped up: She couldn’t get a phone signal. Clutching her handset, she took five steps away. Still nothing. Then another five steps. Suddenly, a couple of small bars popped up on the screen. She could record Kullu’s shot. A few minutes later another nurse injected him with his first dose of AstraZeneca Plc’s Covid vaccine. Kullu, who wore a sky-blue polo shirt with a prominent tear at the chest, blue shorts, and rubber sandals, was elated. “The gods are supporting me today,” said the father of two, beaming.

Kullu was the latest beneficiary of one of the largest vaccination drives in the world—and one of the most troubled. Since India began distributing doses in January, the campaign to vaccinate its 1.4 billion citizens has hit snag after snag, held back first by shortages and then by chaotic distribution. Ten months later, the country finally has adequate supplies, but the current challenge is arguably the most daunting: getting shots into arms across the vast, impoverished countryside, where some two-thirds of Indians—many of them hesitant about receiving vaccines—live. Nationally only 24.8% of the population is fully vaccinated, according to Bloomberg’s Covid-19 Vaccine Tracker, a rate that lags those of Indonesia and Thailand and is less than one-third that of mainland China.

The stakes could hardly be higher, both for India and for the world. Public-health experts fear that a third wave of infections could soon wash over the subcontinent, shattering the uneasy calm that’s prevailed since the end of the second, which crested in May. Then, medical resources were so overwhelmed that some Delhi parks were converted into open-air crematoriums; in the northern state of Uttar Pradesh, the bodies of victims were left to float down the Ganges. Now, with most urban residents either vaccinated or previously exposed to infection, it’s in rural areas where the virus will find the largest pool of immunologically naive targets.

These are also places where the health infrastructure is rudimentary, to say the least. The state of Jharkand, for instance, has just nine hospital beds per 100,000 people, the second-lowest total in India; in the number of nurses per capita, it ranks dead last. Such environments give the virus ample opportunity to mutate, potentially seeding new variants that are even more formidable than delta, which was first identified in India almost a year ago.

In Simdega, Shyamal Santra watched approvingly as Kullu and other local residents got their shots. Thirty-seven years old with a 6-foot frame, Santra oversees vaccination efforts in rural Jharkand for the Transform Rural India Foundation (TRIF), a nonprofit funded by the Bill & Melinda Gates Foundation and the technology tycoon Azim Premji, among other donors. The organization is helping state governments deliver vaccines across 3,800 of India’s poorest villages—many of them difficult or even dangerous for health-care workers to access.

Santra’s territory is some of the most challenging, with few roads and minimal health infrastructure. It and other regions of Jharkand are also home to the Naxalites, a loose grouping of Maoist insurgents who periodically launch attacks on government officials and security forces. Since Santra began working in the state about a decade ago, he’s twice been taken hostage by the militants, who released him only after they were satisfied that his work was serving the rural poor.

His team is on a race against time to vaccinate as many of Jharkand’s inhabitants as possible, traveling to distant villages on foot, by motorbike, and in rugged makeshift ambulances. Sometimes they come across settlements that have had little contact with the government for years and whose residents are understandably wary of outsiders bearing what they say are lifesaving medicines. It’s painstaking work that demands a diverse set of skills: public health with some sociology and anthropology thrown in. If a new surge arrives before widespread vaccination, “it will be more devastating than what we have seen,” Santra warns. “There’s no second option.”

When Prime Minister Narendra Modi’s government officially kicked off India's vaccination drive in mid-January, it was with great confidence. “Our preparation has been such that vaccine is fast reaching every corner of the country,” Modi boasted shortly afterward. “We are completely self-reliant.”

On paper that assessment wasn’t entirely outlandish. Unlike almost all other developing nations, India has enormous production capacity, above all through the Serum Institute of India Pvt Ltd., the largest vaccine manufacturer on the planet. The Serum Institute made a deal in June 2020 to manufacture a billion doses of AstraZeneca’s shot, while another domestic company, Bharat Biotech International Ltd., was carrying out final-stage trials on a vaccine it developed in-house. And while India’s health-care system is underfunded and overtaxed, the country has extensive experience with large-scale vaccination campaigns, particularly for polio and other childhood diseases.

But it soon became apparent that even with these homefield advantages, the rollout wasn’t going to go smoothly. First, Modi’s government surprised scientists and provided ready kindling for anti-vax conspiracy theories by granting regulatory approval for Bharat Biotech’s Covaxin shot before the completion of trials. Then it took weeks to begin largescale distribution, haggling over pricing with the company as well as Serum Institute. (The World Health Organization added Covaxin to its emergency use list of approved inoculations this month, helping dispel lingering doubts about the efficacy of the domestically developed vaccine).

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