There’s no white laboratory coat, but the stethoscope around Ajit Gajendragadkar’s neck gives away his ‘Dr’ prefix. The bespectacled paediatrician in a crisp, grey khadi shirt and black trousers alternates between animated gestures and folded arms while talking about his reviled topic of choice: the anti-vaccination (or anti-vax) movement.
Modern anti-vax sentiments can be traced to the late 19th century, when the Anti-Vaccination Society of America opposed compulsory smallpox inoculation until the 1910s. It resurfaced and gained ground in 1998, when researchers published a paper suggesting a link between the measles, mumps, and rubella (MMR) vaccine and child autism. The MMR-autism link has since been disproved multiple times, but the seeds of suspicion have sprouted into tendrils of misinformation.
The number of unvaccinated American children below age two today has quadrupled since 2011, but the movement also has tentacles across Europe—enough to be a suspect contributor to a measles outbreak across the continent.
That said, it may not be just a white people thing.
While there’s no official nationwide data for vaccine resistance, a 2017 38-country study on vaccine misperceptions by Ipsos showed that 44% of Indians it surveyed believed in a link between vaccines and autism. (The usual caveats apply: it was an online survey of 500 people in the country, and so is not likely to reflect trends among rural or lower-income groups.)
“These crusaders don’t understand. They’d have died at 32 [India’s life expectancy at birth at the time of independence] if it weren’t for vaccines,” says an exasperated Gajendragadkar.
We’ve spoken to Indian parents who claim herd immunity is a conspiracy, we offer.
“And what do they say?”
That if their children aren’t vaccinated but everyone else is, how can they be a risk to a group with supposedly better immunity?
“Too many people read shit on the internet but don’t use common sense,” he sighs. “Do they know about antigenic (immunological) memory, and how it wanes with age? Which is why booster shots are sometimes recommended? And the difference between live and dead (or inactivated) vaccines?”
One father said if we follow a lifestyle devoid of anything unnatural, there’d be no need for immunisation. Clean air, clean food, clean practices…
Gajendragadkar goes from a sigh to a guffaw.
“There was more natural food, better air and ways of life centuries before vaccines. By that logic, humans shouldn’t have been wracked by disease. When will this rubbish stop?”
Home birthing, homeschooling, extended breastfeeding, clean eating and natural medicine are five of six lifestyle choices Hemant and Sangeeta Chhabra made over the course of 30-odd years. The sixth was to not vaccinate their three children. A self-professed south Mumbai boy, Hemant owns the sprawling Hideout Getaway along with Sangeeta in Jhadpoli village off the Mumbai-Ahmedabad Highway.
“My oldest is 26 years old, so no, our decision to not vaccinate our kids had nothing to do with the anti-vaccine movement abroad,” says Sangeeta over the phone. “We trust nature with our bodies and know that the body can immunise itself.”
(Both Sangeeta and Hemant were vaccinated as children).
Their decision to go against the medical flow was met with initial pushback, including from Hemant’s doctor brother, who said they were “committing suicide”. But their families and friends eventually came around.
Unlike Sangeeta, another parent—who’s based in Kolkata and wants to remain anonymous—lives in fear of being outed as an anti-vaxxer. A mother of two adolescents, she talks at excruciating length about her undying faith in homeopathy.
“When my mom would ask if I’d given my kids the [polio and DPT or diphtheria-pertussis-tetanus] shots, I’d just nod,” she says. “My family still doesn’t know about our stance on vaccines. If they did, all hell would break loose.”
When her children were in a mainstream school, this parent fudged records to show they’re vaccinated. “I don’t need to do that now because they’re enrolled in an alternative school,” she adds.
Two fathers—Noel D’Costa, a Hyderabad-based IT salesman, and another who also requested anonymity—bring up the issue of cold chains. Do you know how terrible our vaccine supply chain is, they ask. How poor refrigeration makes vaccines deadly?
Most routine vaccines should be preserved between 2 and 8 degrees Celsius. So, how dangerous is a vaccine at room temperature? Answer: Not at all.
When the city sleeps
A routinely administered vaccine loses potency or becomes useless—not lethal—at temperatures above 8 degrees Celsius. This doesn’t, however, mean there’s no problem.
The lack of temperature record registers, over-dependence on ice packs and absence of stabilisers for deep and ice-lined refrigerators in pockets of India portend poorly for immunisation coverage. A 2016 survey by the Bill and Melinda Gates Foundation-funded Immunisation Technical Support Unit (ITSU) found that India has a 25% wastage rate for vaccines other than BCG (the vaccine against tuberculosis, which had a whopping 50% wastage rate).
“Vaccine logistics have always been a concern, but since newer vials come with temperature indicators, cold chain complications aren’t as pronounced as they were decades ago,” says global health, policy and bioethics researcher Anant Bhan, president of the International Association of Bioethics. “This is an area ripe for technological innovation, but in no way can this be used to question immunisation itself.”
The seemingly urban anti-vax stance is markedly different from vaccine resistance in rural pockets, Bhan adds. When a hobbled public health system otherwise cold shoulders the people most dependent on it, doubts linger when a drive is announced. Vaccine programmes do, after all, presuppose trust in the state. Which was why after the Emergency—during which the Indian government carried out forced sterilisation programmes—pockets of people across the country believed immunisation was a cover for sterilisation.
Orthodoxy also plays a role, as was seen in Malappuram, Kerala, during the 2017 measles-rubella (MR) vaccination drive. Reports of medical staff being assaulted and parents storming schools has been the district’s undoing in a state that otherwise has about 90% immunisation coverage among children aged 16 and below.
In neighbouring Pakistan, distrust in the US government once adversely affected inoculations. Take the fake drive organised by the CIA to obtain Osama Bin Laden’s DNA. After English daily The Guardian published this story, the Taliban began shooting doctors administering the polio vaccine and later banned it outright.
Back in India, Muneer Masoodi, former head of social and preventive medicine department at Srinagar’s Government Medical College, names pockets where resistance hinders national Universal Immunisation Programme (UIP) efforts: Ballabhgarh in the Delhi-NCR, east Khasi Hills in Meghalaya, and parts of Nagaland and Mizoram.
“It’s one thing to proclaim yourself an anti-vaxxer as a lifestyle choice or because of what you read online,” Masoodi concludes, but a different issue entirely if people are refusing immunisation because of poor communication and a lack of outreach on the part of the state. This, as we’ll see later, can have serious implications.
Vaccination vs treatment
Raj Shankar Ghosh, deputy director of vaccine delivery and infectious disease at the Bill and Melinda Gates Foundation, wastes no time getting to the point. Within seconds of our meeting in New Delhi, he shares a paper listing the return on each dollar invested in vaccines from 2011 to 2020—the ongoing Decade of Vaccines, earmarked by the World Health Organisation (WHO)’s 194 member states.
Taking into account the broader economic and social value of preventing death and disability, every dollar invested in vaccination during the decade was estimated to result in a return of 44 times the costs incurred. The highest returns were associated with averting measles, at 58 times the cost through two routine immunisation doses and outreach campaigns, he says.
Although the paper that Ghosh shares does not cover polio, he says that all vaccines included in the UIP have an ROI that is manifold the investment. This return on investment points to costs that’d otherwise be borne by governments or parents for hospitalisation of a disease-afflicted child. Monetary setbacks would also include wage loss incurred by parents, and cost of medications.
The argument being that the vaccine is a cheaper solution.
It’s a point Dr Gajendragadkar takes pains to highlight: not being vaccinated against some diseases can literally cost you. India, he adds, reports the highest number of measles cases in south and southeast Asia. With high incidence, the likelihood of subacute sclerosing panencephalitis (SSPE), an often-fatal form of brain inflammation caused by measles, also increases.
“So are you going to die because of the measles vaccine, or are you going to die because of SSPE?” he shoots.
Vaccine indispensability, however, comes in varying shades. Let’s consider the rotavirus shot, which was included in the UIP in 2017. Priced at $1 per dose (and you need three), it’s more expensive than more common vaccines such as the oral polio vaccine ($0.10-0.13) and offers the lowest “returns” because diarrhoea, its most common symptom in infants and children, is easily treatable.
And some argue that apart from polio, DPT and measles, most other diseases for which vaccines are being introduced aren’t fatal or even difficult or expensive to treat.
Take pneumonia and diarrhoea, for which vaccines have been included in the UIP recently. The cost of treatment for these conditions is less than the price of their new vaccine counterparts, argues Jacob Puliyel, head of paediatrics at St Stephens Hospital in Delhi.
“If the money being spent on these relatively useless vaccines were invested by the government to address healthcare access and clean air and water, the benefits will extend not only to these diseases but a whole host of ailments,” he said. Puliyel was a member of the National Technical Advisory Group (NTAGI), which recommends the vaccines that should be part for the UIP.
“People will tell you that a certain vaccine reduces disease likelihood by half. But for a rare disease, or one that rarely causes a major problem, it’s probably meaningless,” Puliyel says. For instance, the sales pitch for the pneumococcal conjugate vaccine (PCV) is that pneumonia accounts for 25% of infant mortality. But most pneumonia cases are caused by a virus against which PCV has absolutely no effect.
The decision to make a vaccine mandatory under a public health programme should depend on the cost-benefit analysis, which in turn depends on a parameter called NNT, or the numbers needed to treat to prevent one person from getting the disease.
Now is the peak pneumonia season in Delhi and Dr Puliyel has been seeing parents of affected children almost every day since September. Nearly all the cases were caused by viruses. The WHO, he adds, recognises that immunisation prevents bacterial pneumonia in just 3.6 children per 1000 who are vaccinated.
There’s more. All strains of the pneumococcus bacteria are sensitive to penicillin and can be treated accordingly. It doesn’t help that the vaccine’s market price is Rs 3,800 ($52); and since three shots are required, we’re talking over Rs 10,000 ($138) for one person.
Procurement rates for government immunisation programmes will, however, be significantly lower than market prices. Still, that’s theoretically tens of thousands of rupees at least spent on every 1,000 people to prevent three or four cases of pneumonia that could be treated with Rs 50 ($0.69) of Septran, the WHO-recommended treatment for pneumonia, Puliyel adds.
PCV is the first patented vaccine introduced in India, and is available under routine immunisation programmes to children in 128 districts across six states; the central health ministry plans to eventually make it universal.
The ghost of informed consent
In January 2017, Bengaluru-based Saurabh Kalra decided to voice his displeasure with Karnataka’s MR drive on Change.org. Titled “Forced Re-Immunisation of Kids in Karnataka Schools”, his petition, with 656 supporters, pointed fingers at the state machinery’s motives:
- “Is there any way we can discuss this with a government body? Can a health official take a personal undertaking that this vaccine is important and more importantly harmless?”
- “Why are parent’s [sic] not made a part of it nor their approval sought in writing before vaccinating [sic]?”
The MR drive, part of the government’s campaign to eradicate measles and curb rubella by 2020, also had poor turnout in Tamil Nadu.
“I’d read a WhatsApp forward about schools making vaccinations mandatory. Since my daughter was already immunised against measles as per WHO standards, I saw it as a coercive exercise,” Kalra explains over the phone.
There’s a twist to this anti-vax tale, however. Kalra claims to be a staunch believer in vaccines. His bone of contention, he explains, was lack of informed consent.
“Once I got to know the drive wasn’t compulsory, I simply decided not to send my daughter to school,” he stresses. “As parents, we should have been given detailed information about why the combination booster is important even after two measles shots. That information was never shared with us. If you give us half-baked information, what do you expect?”
There’s also something to be said about the withholding of information on vaccine side effects—more a right to know issue than a tin-foil hat proclamation. Individuals aren’t consistently told about the small risk of death associated with the pentavalent vaccine, which is replacing the DPT vaccine in states such as Kerala and Tamil Nadu. Or why Sri Lanka, Bhutan and Vietnam withdrew the vaccine from their government programmes, and later reintroduced it. Or why three deaths linked to the vaccine (perhaps even more) in Tamil Nadu haven’t raised loud, pertinent questions.
What, then, do we make of the lack of awareness in India of the rotavirus vaccine’s risk of intussusception? Or of nearly 1% of PCV users reporting adverse events like bronchiolitis (an infection of the lungs), gastroenteritis (inflammation of the stomach and small intestine) and pneumonia? Underpinning all this is NTAGI’s non-disclosure clause, where members are not allowed to talk about the process undertaken to approve a vaccine.
Non-disclosure and selective dissemination push confused parents into caginess. Nowhere was this more evident than with the MR drive in Tamil Nadu.
“Since 2017, people here have started questioning vaccination drives more openly,” says Ameer Khan, convenor of the Tamil Nadu chapter of Jan Swasthya Abhiyan (JSA), a collective of 18 national health and welfare organisations. The questioning, in some instances, morphs into disdain when people learn of what they see as coercion on the part of the government. Such as the disbursements of the state’s Dr Muthulakshmi Reddy Maternity Benefit Scheme being linked to the number of vaccinations administered to a child.
Then there’s the mistrust towards Big Pharma. Case in point: the 2009 human papillomavirus (HPV) “demonstration project”, in which eight girls in Andhra Pradesh and Gujarat died from complications arising from HPV vaccines made by GlaxoSmithKline (GSK) and Merck Sharp & Dohme (MSD). This project, overseen by the American NGO PATH, the Indian Council of Medical Research, Drug Controller General of India and the state governments in question were subjects of a 2012 writ petition in the Supreme Court. The case is ongoing.
Why is this important? Because (a) this was never a “demonstration project’, and (b) the 30,000 girls between the ages of 10 and 14 were either minorities or from backward communities, with most residing in local boarding schools. There was no monitoring of side effects by GSK and MSD. In short, this was a clandestine clinical trial flouting the basic tenet of parental consent.
“So it wouldn’t be wrong to question why some new vaccines are in the UIP,” says JSA national convener and physician Amit Sengupta. “There are also vaccines administered here, whose efficacies were proven in other countries or other demographic groups.” The science is sound, he says—and some of the new vaccines’ efficacy has been proven in other countries—but commercial practices are another matter.
Hyderabad-based salesman Noel D’Costa, is a staunch believer in “natural hygiene” or orthopathy. To the extent that this 52-year-old is one of the staunchest vaccine disbelievers you may come across.
“Disease is the price you pay for breaking the laws of nature.”
“Saying you need a vaccine for better immunity is like saying you should break a finger to prepare for a fracture.”
“Some of the preservatives in vaccines are toxic.”
“The recent polio controversy was no surprise. The whole system is crazy.”
“It’s a whole lifestyle. Once you give up poisonous foods and habits, you’ll realise that your immunity gets better.”
“I used to try to talk people about it, but I’ve stopped preaching. I save my breath to cool my porridge.”
“We grew up with chickenpox and the cold. Why do you need vaccines for it now?”
Back in Mumbai, we lob D’Costa’s volleys at Dr Gajendragadkar.
He fidgets with his wristwatch and exhales deeply before checking an invisible list off his fingers: Chickenpox may be harmless, but not so when you’re older or if you’re pregnant. Yes, the “cold” or pneumonia vaccine is an expensive monopoly product, but senior citizens aged 65-plus may get relief from it, as will people with COPD (chronic obstructive pulmonary disease). It’s also optional.
“As for the rest of it,” he concludes, “no amount of natural living is infallible. Microbes have preceded, and will outlive, humans.”