By Dr KK Aggarwal
The strict control exercised by the central government over Covid-19 vaccinations has caught the attention of the Delhi High Court. It directed the government to explain the rationale for keeping “strict control” over the class of persons who can be vaccinated presently. It said that the government was either donating the vaccines or selling them to foreign countries rather than inoculating its own people when its approach should be to vaccinate Indians urgently “yesterday and not tomorrow”.
The government had initially vaccinated healthcare and frontline workers and then those above 60 years and/or those above 45 years suffering from comorbidities (see box: Who gets the jab first). But this approach is discriminatory as those below 45 years suffering from comorbidities are not entitled for the vaccine.
The right to adequate healthcare flows from the sanctity of human life and the dignity that belongs to all persons. Health is a fundamental human right under Article 21 of the Constitution which has as its prerequisites, social justice and equality. It should be accessible to all.
Even for vaccination, the government should not discriminate between different age groups suffering from comorbidities. Such patients are high-risk and should be vaccinated. Even the list of comorbidities is not exhaustive. Many health problems like asthma are not included in the list.
In fact, the government cannot be the deciding authority regarding who falls under the definition of comorbidity. It is the doctor treating the patient who should decide this.
In medicine, comorbidity is the presence of one or more additional conditions often co-occurring with a primary condition. The term “comorbid” has three definitions:
- Indicates a medical condition existing simultaneously but independently with another condition in a patient.
- Indicates a medical condition that causes, is caused by, or is otherwise related to another condition in the same patient.
- Indicates two or more medical conditions existing simultaneously regardless of their causal relationship. The governor of New York State had released a list of comorbidities and underlying conditions that could be used to determine who is eligible for the vaccine. The list is subject to change as additional scientific evidence is published and as New York obtains and analyses additional state-specific data. As per the list, adults with the following conditions due to increased risk of moderate or severe illness or death from the virus are eligible for vaccination.
- Chronic kidney disease
- Pulmonary disease, including but not limited to COPD (chronic obstructive pulmonary disease), asthma (moderate-to-severe), pulmonary fibrosis, cystic fibrosis and 9/11 related pulmonary diseases
- Intellectual and developmental disabilities, including Down Syndrome
- Heart conditions, including but not limited to heart failure, coronary artery disease, cardiomyopathies or hypertension (high blood pressure)
- Immuno-compromised state (weakened immune system) including but not limited to solid organ transplant or from blood or bone marrow transplant, immune deficiencies, HIV, use of corticosteroids, use of other immune weakening medicines or other causes
- Severe obesity (BMI 40 kg/m2), obesity (BMI of 30 kg/m2 or higher but < 40 kg/m2)
- Sickle cell disease or Thalassemia
- Type 1 or 2 diabetes mellitus
- Cerebrovascular disease (affects blood vessels and blood supply to the brain)
- Neurologic conditions, including but not limited, to Alzheimer’s Disease or dementia
- Liver disease
It is quite astonishing that the Indian government did not consider the above mentioned health problems while drafting the list of comorbidities.
In addition, the Indian government is exporting Covid-19 vaccines, when, in fact, its own citizens are not getting it. It should first vaccinate all its citizens and then export the surplus. Export of Covid-19 vaccines at the cost of the lives of its own people is a violation of the fundamental duty of the government and infringes on the fundamental right of the citizens of India.
On March 3, 2021, the Delhi High Court took suo motu cognisance of the Covid-19 vaccine drive in the matter, Court on its Own Motion versus Union of India, Writ Petition Civil No. 2944/2021. As the government has not included judges, lawyers and court staff in the list of frontline workers, the chairman of the Bar Council of Delhi had sent a communication to the chief justice of the Delhi High Court on March 1, 2021. He requested that appropriate directions be issued to the concerned administrative/medical authorities to make available necessary infrastructure in the Court premises, particularly in medical dispensaries and other appropriate places conducive for vaccination. He listed members of the judiciary, employees/staff working in the courts as well as advocates to be vaccinated just like frontline workers.
The Court noted that the need of the hour was to vaccinate the masses on a war footing to secure the life and health of all those who step out of their homes to attend to their avocations and professions. Courts, by their very nature, are places which have a very high density of people on a daily basis. Hundreds of cases are listed in any given Court complex every day.
Apart from judges, the substantial Court staff, advocates who have to attend to their respective cases and a large number of litigants visit courts on a daily basis. As the cases listed on any given day are mostly different from those listed the previous day or the next day, the litigants constitute a different group every day. This peculiarity exposes the judges, the staff and lawyers to the risk of contracting the disease. In fact, the number of persons visiting a court complex such as Tiz Hazari on any given day may well be in excess of the number visiting hospitals for treatment.
Further, it was noted that the full court of the Delhi High Court had already taken a decision to re-open physically; subordinate courts will do so from March 15, 2021. Once that happens, there is bound to be a surge in the number of people coming to courts, who, till now, had been conducting their cases partially through the online mode.
It is clear that the number of positive cases increases with greater intermingling and congregation of people. Most court premises are air-conditioned. With increased footfalls, there is likelihood of the rate of infection among those who attend the courts spiking.
The Court also noted that it would be necessary to ascertain the availability of the two vaccinations, namely Covishield and Covaxin manufactured by Serum Institute of India (SII) and Bharat Biotech, respectively. On March 4, 2021, both SII and Bharat Biotech stated before the Court that as of now, they had the capacity to manufacture in excess of the present demand. However, on March 10, 2021, the Court adjourned the case concerning the vaccination of judges, lawyers and court staff on being appraised that a transfer petition had been filed before the Supreme Court on the issue by Bharat Biotech.
It is important that everyone who is in direct public dealings should be considered as a frontline worker and vaccinated first. Also, India should not forget and ignore its citizens and keep exporting the vaccine.
—The writer is President, Confederation of Medical Associations in Asia and Oceania, and former National President, IMA
Who gets the jab first
The government has listed 20 comorbidities for which vaccination is needed:
- Heart failure with hospital admission in the past one year.
- Post-cardiac transplant/left ventricular assist device (LVAD).
- Significant left ventricular systolic dysfunction (LVEF less than 40 per cent)
- Moderate or severe valvular heart disease.
- Congenital heart disease with severe PAH or idiopathic PAH.
- Coronary artery disease with past CABG/PTCA/MI and hypertension/ diabetes on treatment.
- Angina and hypertension/diabetes on treatment.
- CT/MRI documented stroke and hypertension/diabetes on treatment.
- Pulmonary artery hypertension and hypertension/diabetes (for more than 10 years or with complications) and hypertension on treatment.
- Diabetes (for more than 10 years or with complications) and hypertension on treatment.
- Kidney/liver/hematopoietic stem cell transplant: recipient/on wait-list.
- End stage kidney disease on haemodialysis/CAPD.
- Current prolonged use of oral corticosteroids, immunosuppressant medications.
- Decompensated cirrhosis.
- Severe respiratory disease with hospitalisations in the last two years/FEV1 less than 50 per cent.
- Diagnosis of any solid cancer on or after July 1, 2020 or currently on any cancer therapy.
- Sickle cell disease/bone marrow failure/aplastic anemia/ thalassemia major.
- Primary immunodeficiency diseases/HIV infections.
- Persons with disabilities due to intellectual disabilities/muscular dystrophy/acid attack with involvement of respiratory system/persons with disabilities having high support needs/multiple disabilities, including deaf-blindness.