Politics of Vaccine Nationalism in India: Global and Domestic Implications

Abstract

The fight against the Covid-19 pandemic has shifted from finding a cure to acquiring vaccines and organizing vaccination. The race for vaccination has exacerbated tendencies of hoarding, particularly among rich countries, academically expressed as vaccine nationalism. Vaccine nationalism is harmful to the global effort in the fight against the pandemic. India in contrast has been quite generous to its neighbours in sharing vaccines pursuing its own form of vaccine nationalism. The strategy pursued by India can be read as an effort to gloss over the failures in initial pandemic management, to improve diplomatic leverage and reinforce an idiom of nationalism. Such an effort however has potentially harmful effects undermining trust in the vaccine as well as in the government. The politicization of vaccine also has counterproductive outcomes for democratic practices within the country.

Keywords:

• vaccine
• diplomacy
• South Asia
• Covid-19
• nationalism
• India

Introduction

The speed at which the scientific community came up with the Covid-19 vaccine and the extent of global cooperation in this effort has been truly remarkable. Since then, politics around vaccines have again come to the forefront undermining the possibility of an equitable global health approach. On the one hand, the severity of the pandemic and its disastrous consequences for national economies has created race and hoarding tendencies, particularly among the rich countries. Vaccine nationalism is harmful to the global effort in the fight against the pandemic. In contrast, India appears to have been as quick in developing vaccines but also quite generous to its neighbours. India has pursued its own forms of vaccine nationalism, to gloss over the failures of initial pandemic management, to improve her standing in the international community through vaccine diplomacy and construct an idiom of nationalism. Such an effort is also underpinned by potential harmful effects on trust in the vaccine and in the government, as well as counterproductive outcomes for internal democratic practices. The following article looks at the politics of vaccination and vaccine nationalism pursued by India that has taken a different turn, which in many ways may have serious and multifaceted implications, both domestic, and global.

Failure to restrain the pandemic

When the pandemic made its landfall at the beginning of 2020, India and South Asia were seen to be much less affected while the rate of morbidity related to the pandemic was much higher in Europe. The delusion of not being affected drove the Indian nation towards figures that are now the second-highest in the world, both in terms of the number of people infected and the mortality rate. With a plummeting economy, sharp fiscal deficit (Business Today, 2020), and rising unemployment (Y. S. Sharma, 2020), the dire condition of public health infrastructure exposed by the pandemic hit hard (Jaffrelot and Jumle, 2020; Vishnoi, 2020). The government failed to ‘flatten the curve’ and ramp up testing capabilities (Our World In Data, 2021) despite the warning by public health officials (Miller, 2020). The rising protests of migrant workers (Migrant Workers Solidarity Network [MWSN], 2021), questions regarding the emergency package (Narayanan, 2020) including how short-term reliefs packages of free food grains were marred by political and administrative hurdles (Business Today, 2020) – showed clearly that the ‘atmanirbhar Bharat’ (self-reliant/self-sufficient India) mission popularized by Prime Minister Narendra Modi was heading towards an abyss. Neither the chowkidar (gatekeeper), the chaiwallah (teaseller) nor the recent rishiraj/rajarshi (sage king) personae of the prime minister could deal with this real and unprecedented crisis (Chatterjee et al., 2021). A way out of this self-inflicted mess lay with the vaccines and India’s unique position within vaccine production, distribution, and procurement globally.

What is vaccine nationalism from the global north perspective?

Vaccines are political. Government-organized vaccination campaigns are projects that presume to shape the immunity of whole populations. This is not a neutral practice; it requires assessment in its relation to state power, national identity and the individual’s sense of obligation to self and others (Holmberg et al., 2017).

The pace of creation of Covid-19 vaccines is unprecedented and reflects the ability of combined scientific efforts. The Covid-19 vaccination programme with an estimated 5 billion doses across the world is the largest exercise of its kind in history. But the vaccination has also led to a scramble among countries to stockpile for its own citizens, which we label ‘vaccine nationalism’, to fierce competition among states to develop vaccines, and to vaccine diplomacy. Nations have used their ability to procure, produce and distribute vaccines as a measure of state power, both domestically and internationally. In the case of Covid-19 vaccines, by virtue of investments in vaccine manufacturing and advance purchase agreements, nearly half of the planned 2021 supplies of the leading vaccine candidates have already been secured by a small contingent of wealthy nations – Australia, Canada, Japan, the United Kingdom, the United States and the European Union. Together, these countries account for just 14 per cent of the global population. Duke Global Health Innovation Center reports that high and upper-middle-income countries have collectively reserved nearly 5 billion vaccine doses, known as ‘advance market commitments’. The US has entered into at least six bilateral deals, totalling more than 1 billion doses – more than enough to inoculate the entire American population. The European Union, Britain and Canada have each entered into seven bilateral deals, with the potential of securing enough doses to cover their populations two, four, and six times over, respectively (Weintraub et al., 2020). Companies such as Sanofi, Astra Zeneca have made explicit their commitment to supply to the USA and UK on priority causing consternation among other states. The African Union has claimed 270 million doses of vaccines, but most countries have not started the process due to lack of funds.

Why should we be concerned?

World Health Organization officials have voiced concerns at ‘vaccine nationalism’, which could increase the risk of the coronavirus mutating further, after a week-long row over a shortfall in EU supplies of Covid-19 vaccines. The WHO has asked wealthy countries to stop hoarding the Covid-19 vaccines through advance purchase agreements. While developed countries are struggling to inoculate all of their own people, most developing countries are yet to begin inoculation for lack of vaccines. To cite one instance, at the WHO press conference on 29 January, a nurse from Pakistan and a midwife from Uganda pleaded for vaccine supplies. ‘They are right at the end of the queue’, said Michael Ryan, WHO executive director. ‘They see people at the top of the queue fighting about where they are in the line. It looks like fighting over the cake – when they don’t even have access to the crumbs’, he said, commenting on the vaccine row in Europe.

“We all need to ask ourselves, ‘would I have the vaccine if I thought it meant a health worker in the south wouldn’t get that vaccine today?’ We all need to examine our own consciences, then tell our leaders what we want them to do.” (Michael Ryan, in Eaton, 2021)

The WHO has explicitly stated that such vaccine nationalism, without due regard to the intensity and spread of the contagion, will not only prolong the pandemic but also constitutes a moral failure (Farge, 2021). In addition, it is epidemiologically self-defeating and clinically counterproductive. Allowing the majority of the world’s population to go unvaccinated will not only perpetuate needless illness and deaths and the pain of ongoing lockdowns but also spawn new virus mutations as Covid-19 continues to spread among unprotected populations. What is more disconcerting is that new mutants may lead to vaccine resistance. As of 21 February 2021, out of the 128 million vaccine doses administered, more than three quarters were in just 10 countries that together account for 60 per cent of global GDP. As of today, almost 130 countries, with 2.5 billion people, are yet to administer a single dose (Kretchmer, 2021). In short, as UNICEF Executive Director Henrietta Fore and WHO Director-General Dr Tedros Adhanom Ghebreyesus in a joint statement pointed out, ‘in the Covid-19 vaccine race, we either win together or lose together … Covid-19 has shown that our fates are inextricably linked. Whether we win or lose, we will do so together’ (Fore and Ghebreyesus, 2021).

‘Vaccine nationalism’ is not a new phenomenon. In fact, the WHO director referred to the 2009 H1N1 pandemic, where wealthy countries reserved huge numbers of vaccine doses, leaving developing economies to rely on donations that arrived much later. It was only when the H1N1 pandemic began to recede that developed countries offered to donate vaccine doses to poorer economies. Consequently, as one of the studies shows, an estimated range of deaths from between 151,700 and 575,400 people perished worldwide from 2009 H1N1 virus infection during the first year the virus circulated (Centers for Disease Control and Prevention [CDC], 2012). We are currently witnessing a repetition of the past phenomenon, whereby although the high-income countries have pledged to donate the excess vaccines to low and medium-income countries, that might happen only after carrying out vaccination of their own population (Furlong, 2021), similar to what happened during the H1N1 pandemic.

India’s global and regional vaccine diplomacy

As the world’s largest producer of vaccines, alternatively, the ‘Pharmacy of the World’ as popularized by External Affairs Minister Subrahmanyam Jaishankar (Das, 2021), India’s vaccine nationalism has taken a different turn. The scientific ability to innovate vaccines has been used as a marker of pre-eminence and for the construction of national identity. Indian pharmaceutical companies are major manufacturers of vaccines distributed worldwide, particularly those for low-income countries, supplying more than 60 per cent of vaccines to the developing world. Despite the strong manufacturing base and early access to Covid-19 vaccines, Indian companies are struggling to produce enough doses to sufficiently manage the pandemic. One of the main pharmaceutical companies involved, the Serum Institute of India (SII) – arguably the largest vaccine manufacturer of the world, and at present engaged with the manufacturing of Covishield, a local name for the Oxford-AstraZeneca vaccine – has explicitly stated that most of its vaccine would go to Indians before it goes abroad.

And yet the reality seems to be moving in a different direction altogether. India has adopted a disarming vaccine policy. The Indian Prime Minister has stated that India’s vaccine production will be used for the benefit of all humanity to fight the Covid-19 pandemic. India has announced assistance of vaccines to neighbouring countries and supplied Bhutan, Maldives, Nepal and Bangladesh as ‘gifts’ or grants in line with New Delhi’s ‘Neighbourhood First’ policy (Hindustan Times, 2021; Srivastava and Kay, 2021). Consignments of Covishield vaccine doses have also been delivered to Seychelles, Mauritius and Myanmar and plans have been made to supply vaccines to Sri Lanka and Afghanistan after regulatory clearances. India is also providing contractual supplies to Saudi Arabia, South Africa, Brazil, Morocco, Bangladesh and Myanmar. Such action has been applauded by the United States as that of a ‘true friend’ (Business Today, 2021).

The Covid-19 vaccine, the latest and the most sought-after commodity in international diplomacy, provides India some leverage with neighbours otherwise enamoured by Chinese investments. India has faced stiff competition from China for influence in its South Asian neighbourhood with China’s increasingly visible footprint in Sri Lanka, Maldives, Bangladesh, Nepal, African countries and elsewhere. Lacking the kind of economic resources that China commands, India’s efforts to match that influence have been largely ineffective thus far. From the point of view of international diplomacy, one cannot, therefore, blame India to take advantage of her resources and extend her geo-political diplomacy, even if that comes at a time of global health crises. It is undeniable that India’s vaccine gifts will serve to polish its global image and earn her goodwill, especially in South Asia where it is often criticized for its ‘big brother’ behaviour.

It must also be noted that India’s vaccine diplomacy has not been without a challenge from China. From the very outset of the pandemic, China tried to influence, or maybe to change the Covid-19 narrative that (still) blames China for the pandemic, by providing Personal Protective Equipment, testing kits, medical aids and equipment, and even financial aids to South and South-East Asian countries (So, 2020). However, China’s initial leverage has since then been cut short (at the time of this writing), because of their lack of transparency and information in what mattered the most, the vaccine. Two of China’s pharmaceutical companies, Sinovac and Sinopharm have mainly been involved in manufacturing the Covid-19 vaccine. Researchers have published some data from phase 1 and 2 trials of the Sinovac vaccine. There has been conflicting information about its efficacy (Reuters, 2020), with researchers in Brazil reporting 50.4 per cent versus those in Turkey claiming 91.25 per cent. Similarly, Sinopharm has undergone phase 3 trials and has claimed 78 per cent efficacy, while a study in UAE puts it at 86 per cent. The international medical research community does not yet have fixed numbers to work with (Joshi, 2021). Although several South-East Asian, Middle Eastern and Latin American countries have signed deals with Sinovac, many have also expressed doubts and hesitancy. In the Philippines, lawmakers have criticized the government’s decision to buy a Chinese vaccine. Officials in Malaysia and Singapore, which both ordered doses from Sinovac, have had to reassure their citizens that they will approve a vaccine only if proved safe and effective. In addition, delays in shipping the vaccines, as well as China’s own recent history of vaccine scandals (Wee, 2020) and vaccine hesitancy have not helped (Minter, 2021; Yang et al., 2020).

This is where India has scored cookie points against her Chinese counterparts. The numerous Covid-19 vaccines developed in India underline the global collaborative networks of capital and resources. The SII is in the process of developing four other Covid-19 vaccines, apart from the Covishield. Two of these in-house initiatives are developed in collaboration with Novovax and Codagenix in the US. Indian medical companies like Biologicals E have partnered to manufacture vaccine in collaboration with Janssen Pharmaceuticals in Belgium, and Baylor College of Medicine in the US (Vaidyanathan, 2020). The list is long and expanding: Indian Immunologicals in Hyderabad is working with Griffith University in Australia, to test and manufacture the university’s vaccine; Dr Reddy’s lab Gamaleya National Centre in Russia are developing Sputnik V; Gennova Biopharmaceuticals in Pune; and HDT Biotech Corporation in the US are working on yet another vaccine. Such collaborative manufacturing capacity impacts India’s position in international politics. Independent of international collaboration Indian companies – Bharat Biotech and Zydus Cadila are also developing vaccines that are currently in various stages of clinical trials (Banerjea, 2021).

Which way to go – global or national?

The shift away from nationalist politics to global politics in India highlights how global changes affect local reconfigurations. India’s vaccine diplomacy has quite expectedly raised questions about immediate domestic availability. In terms of immunization, India, as of 2 March 2021, fares way below most of the countries that have so far started vaccinating (Ritchie et al., 2021). The success of the Covid-19 immunization programme will determine how India copes with the pandemic – with implications for both lives and livelihoods. These legitimate apprehensions come with two further questions: the financial resources for the acquisition of sufficient doses of the vaccines, and the capacity to distribute, store and administer them (Gupta, 2020).

Attitudes of vaccine nationalism within India, moreover, have potential for political ramifications if it has consequences for adequate domestic supply. Here, the domestic politics of vaccine supply may assume importance particularly when the ruling Bhartiya Janata Party (BJP) had promised free vaccines to all in its Bihar Election Manifesto and in Madhya Pradesh; the government of Tamil Nadu has made a similar promise ahead of elections in the state (Hebbar, 2020). The promise of free vaccines by the central government for political outcomes will potentially create tensions by singling out particular states in a federal framework.

In India, economic liberalization transformed the federal structure from cooperative federalism to competitive federalism as states vied for private capital (Saez, 2002). In the current health crisis, the central state and the local state government agreed on a plan regarding who should receive it on a priority basis and how much. Yet politics creeped into the public discourse as a free vaccine became an election promise. Many see this as the first indication that the central government will procure the vaccine – or vaccines – at rates it negotiates, and state governments may then be asked to purchase their own stocks. This will put pressure on other states to follow the same route. For the central state to assure free vaccine across the nation, it may have to be brought under the flagship Universal Immunization Programme, part of the National Health Mission, but the financial provisions for such a programme are quite inadequate.

The politics around the regulatory approval for vaccines has had the effect of undermining India’s leverage. India has given emergency approval to two vaccines so far, the Covishield and Covaxin. The former is the vaccine by AstraZeneca and Oxford University while the latter is the indigenous vaccine developed by Bharat Biotech. Critics found in such haste a political desire of the government to be one-up that is amateurish, if not unprofessional and unethical (National Herald, 2021). The speed of approval has been driven by nationalistic political forces pushing for a ‘swadeshi’ – or locally made – shot, along with the firm’s own ambitions to be a frontrunner (Kay, 2021). The plan of the government was shelved after serious concerns were raised by scientists about the need for proper trials. The emergency approval to the two vaccines by the Drugs Controller General of India that states ‘approval granted for restricted use in the emergency situation, in the public interest as an abundant precaution, in clinical trial mode, to have more options for vaccinations, especially in case of infection by mutant strains’ (Government of India. Ministry of Health and Family Welfare, 2021). Such a convoluted statement is suggestive that the approval was granted not under ideal conditions with trial results and some have suggested that the regulator gave approval under duress (National Herald, 2021).

To make things worse for public faith in the vaccines are concerns raised by the companies producing the vaccines about each other’s vaccine efficacy. Bharat Biotech founder Krishna Ella claimed that Covishield had reported more adverse side effects while Adar Poonawalla of SII made the snide comment that Covaxin was as safe as water (The Quint, 2021). In the middle of the controversy are important questions about the credibility of India’s regulatory regime, reinforced by the lack of transparency and absence of vaccine trial data. It is important to remember that the success of vaccine is not only based on the medical efficacy (both the vaccines have been found to effective) but also perceptions. China and Russia claim to have developed coronavirus vaccines several months ago, but the lack of data raises concerns and prevented international acceptance.

India could have handled the situation better. The impact is visible in the mandatory recorded telephonic message that people in India hear every time they make a phone call, insisting they should have faith in the effectiveness of the vaccine and not give in to rumours. Although India has vaccinated more than 5 million frontline and medical workers, news reports suggest opposition to certain vaccines. The vaccine rollout has fallen flat with little over half the targeted number of people coming forward for shots – hesitation that is largely being blamed on the hasty approval of Bharat Biotech’s shot which is still deep in Phase III trials (Kay, 2021). The government has retorted to nationalism and likens objections to the rollout of the vaccines before phase three trials to questioning ‘the valour of our soldiers’ (Scroll, 2021).

Of course, there is an aspect to this debate that is tied to larger epistemic questions. Critics have highlighted how structures and incentives prioritize concerns of the developed country and scale back the achievements and concerns of developing countries (Muraskin, 2017). The owners of Bharat Biotech expressed a similar sentiment when they argued that Indian companies are unfairly targeted. However, such an argument cannot undermine the need for trial-based evidence. The lack of trial data on vaccine efficacy has created vaccine hesitancy and doubt in India and internationally. The stance of the Indian government to approve vaccine before completion of stage III trials has drawn comparison to how China and Russia approved vaccines early and without releasing efficacy data. These moves did not provide either country any gain in public health. India as a major producer has much to lose by acting on an impulse to show-case an indigenous vaccine on the victory stand while undermining the scientific regulatory process. Potentially, India can now be bracketed with Russia and China into an arbitrary BRICS-like category of regulatory laxity reflected by indigenous vaccine approvals without efficacy data (Kurian, 2021).

The confusion about vaccine efficacy has had more immediate domestic implications with concerns raised by opposition parties following ludicrous claims made by religious leaders and others. They have questioned not only the efficacy of Covaxin; one opposition politician from Uttar Pradesh claimed that the vaccine may cause impotence. Akhilesh Yadav, former Chief Minister of UP, has dubbed it the ‘BJP vaccine’ (Rehman, 2021). The country’s health minister had to tweet to clarify the matter and other claims have been refuted by drug regulators (Hindustan Times, 2021; Menon, 2021). During its Bihar election campaign, BJP has made inaccurate claims that compare India favourably with the US and the UK (A. Sharma, 2020). Supporters of the government have used social media to make incredulous claims about the efficiency and cost-effectiveness of Indian vaccine compared to vaccines developed in the US and the UK. These claims have been covered by the mainstream Hindi-language TV channel, ABP News.

Finally, the question of access to vaccines is marred by politics. In a country beset by massive inequalities in income, wealth and social status, access to vaccines remains a difficult question. The central issue in the politics over the distribution of the vaccine rests on private production and distribution but public investment in research and government role in the rollout. The success of vaccination not only requires a steady supply of vaccines but more importantly the logistical organization. On the supply side, the private production of the vaccine creates grounds for allegations of profit dominating public health. In terms of distribution and vaccination, the government has taken responsibility for the frontline workers, but questions remain about the rest of the population.

The politicization of vaccines, in terms of the electoral announcement and hurried permissions, can dent confidence in both vaccines and one’s own government. This has been reflected in the YouGov-Mint-CPR Millennial Survey that shows the relationship between the perception of the government’s performance during the pandemic and political association influencing attitudes towards vaccination. Those rating the government favourably were more willing to take the vaccine immediately. Age, gender, religion and region also did not seem to influence attitudes towards vaccination strongly. Another strong predictor of attitudes towards vaccination was political affiliations. Those who said they support the BJP are most likely to take the vaccine immediately but those in support of the Indian National Congress party are not far behind. Those who do not support any party are most sceptical about taking the vaccine immediately (Verma et al., 2021).

Acknowledgement

The authors express their sincere gratitude to Arild Engelsen Ruud, Professor in South Asia Studies; Katerini Storeng, Associate Professor, University of Oslo, and the Global Health Politics research group at the Centre for Development and the Environment, University of Oslo, for their insightful comments and suggestions on the article.

Additional information

Notes on contributors

Niladri Chatterjee

Niladri Chatterjee is an historian and postdoctoral researcher at the Centre for Development and the Environment (SUM), University of Oslo. He is also an associate researcher in the Department of History and Philosophy at North South University in Bangladesh. His research concerns modern South Asia, global health politics, and the politics of disasters. He writes regularly on culture and politics in India.

Zaad Mahmood

Zaad Mahmood is an Assistant Professor at the Department of Political Science in Presidency University, Kolkata. His research interests include political economy focusing on public policy, capital-labour-interaction, work and its politics, and Indian politics. He is the associate editor of Oxford Development Studies and member of the editorial board of Conjuntura Austral: Journal of Global South. He has published in Business and Politics, Journal of South Asian Development, Studies in Indian Politics, Indian Journal of Labour Economics, and Industrial Law Journal.

Eleonor Marcussen

Eleonor Marcussen is postdoctoral fellow in History in the Department of Cultural Sciences, Linnaeus University, and a member of Linnaeus University Centre for Concurrences in Colonial and Postcolonial Studies where she teaches colonial history and postcolonial theory. Her current research is on socio-environmental relations and infrastructure in late nineteenth century colonial India. She has previously researched politics of historical disasters.