As a medical practitioner for the last 20 years I have realised that to cure any disease one needs either or both of two important perspectives, namely knowledge and wisdom. Knowledge and wisdom in medicine complement and supplement each other in a manner that is rarely seen in any other field. With advancements in the last 50 years, availability of knowledge has made treatments easy and predictable, but unfortunately this dependence on knowledge has also eroded our abilities to effectively apply wisdom.
The current COVID-19 pandemic has revealed this handicap in a more lethal way. With limited knowledge of the disease, its containment and predictability of spread and fatality, a large part of the prevention and treatment of COVID-19 is now based on wisdom. It is possible to conclude that countries which applied common wisdom have done particularly well in the control of the pandemic, when compared to nations which were dependent on a knowledge that was slow to come and which has been patchy. The United States of America and India are classic examples where wisdom was thrown to the wind and the citizens paid heavily.
In the last one week, the buzz around a COVID-19 vaccine has ignited hope. There is talk of closure and an end to the most devastating health catastrophe which the post-modern world has witnessed. Hope is necessary, but it can also be a tool of self-deception and thus needs to be tempered with caution. Nietzsche had once said that hope in reality is the worst of all evils because it prolongs the torments of man. I wish that the hope generated by the “vaccine talk” around COVID-19 should not prolong the agony of an already tormented humanity. We thus need to see the vaccines in more light.
Of the 250-odd vaccines which are currently under various stages of development/evaluation, at least three have generated significant hope — the Moderna vaccine, the AstraZeneca vaccine and the Pfizer vaccine. All three are awaiting regulatory clearances before they can be made available to the public. While Britain has approved the Pfizer vaccine for use, the Food and Drug Administration of the United States (FDA) is using emergency powers to issue a temporary clearance to these vaccines. This is prompted by the hundreds of thousands of COVID-19 deaths which have ravaged the US. Despite the extraordinary powers of the FDA and despite a high powered advisory committee looking into the vaccination related data, the adverse effects of all three vaccines are bothering the wise.
Other than adverse effects, many questions have remained unanswered. How effective will these vaccines be in breaking the transmission of the disease? Historically, in many diseases, vaccination models have failed to break disease transmission. For COVID-19, a break in transmission is more important than the momentary immunity which these vaccines are supposed to provide. How many doses will be needed for acquiring immunity is still in the realm of foggy knowledge. In fact, the dosage question has been in the spotlight following the 90 per cent efficacy shown by two doses of the AstraZeneca vaccine as compared to 70 per cent with a single dose. Also, for how long does the immunity last post vaccination is something that is not known. This becomes important in the backdrop of the fact that a significant number of patients post-COVID infection have failed to show any antibodies against the virus. The spillover gains of this vaccination are also not known.
All of the above are questions that need answers in a biological realm but vaccination is not only a biological process. In developing countries like ours, it won’t be wrong to conclude that vaccination is a social phenomenon. It is dependent on a large number of socio-economic factors. Vaccination of a huge population like ours is a mammoth exercise and besides the availability of the vaccine the policymakers should concentrate on the preparedness for this exercise. We are a country with great disparities — economic, social and biological. Cohorts of masses vary in their demographic variables, in nutrition status and most importantly in their biological responses to immunisation (as has been shown by many studies). Gender variabilities in receiving vaccination are well known in our country. Boys generally have a higher vaccination coverage than girls, as reported by most surveys conducted across the country for childhood immunisation. Poor nutrition in India is also found to be a significant cause of immunisation failure. We don’t know how the 189 million undernourished Indians will respond to the COVID-19 vaccine.
Imagine this. Despite a robust, well-integrated Universal Immunisation Programme (UIP) in this country for more than 40 years, the UIP coverage has never gone beyond 60-65 per cent. It is thus anyone’s guess how we will be able to achieve a near 90 per cent coverage with the COVID-19 vaccine and if the policymakers decide for less than 90 per cent coverage, then there should be reasons to validate this decision.
Besides the anticipated inequities, the gaps in the logistics of giving the vaccine to such a huge population need careful consideration. The gaps in service delivery, the fact that most of these vaccines need cold chain maintenance and the actual cost of the vaccine, are matters which political and bureaucratic wisdom need to brainstorm over before it is too late. We need systems in place which can give the vaccine in a short period to large segments of population. Our response to the COVID-19 pandemic has generally been lethargic, lacklustre and lacking in wisdom. Evidence-informed policymaking regarding the vaccine is what we need more than anything else. A transparent and uniform accountability system to monitor the vaccine distribution and application is the need of the hour.
Vaccines are powerful but not perfect tools of disease prevention. Any vaccine which makes an entry in the middle of the current pandemic has to be viewed with caution not only because of its complicated biological effects (or lack of them) but also because of the complexity of its application in a country as diverse and as unique as India. Our strategy of dealing with the pandemic through a hasty, unplanned lockdown has not yielded good results. We need to tread the vaccine landscape with caution and, most importantly, with wisdom.
This article first appeared in the print edition on December 4, 2020 under the title ‘Virus and wisdom’. The writer is professor of orthopaedics, AIIMS, New Delhi. Views are personal.