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Since a second wave of COVID-19 infections struck India in February 2021, the country has been devastated. With more than 25 million cases and 300,000 reported deaths, the virus has delivered a knockout punch to the public health system, with the most marginalized communities bearing the brunt of it.

Now, with vaccines finally on the horizon and the United States promising to deliver 25 million doses worldwide, a new challenge emerges: How we do ensure that India’s most vulnerable populations obtain fair and equal access to vaccinations?

Most of us in India have now experienced the loss of lives among immediate and extended families and networks of friends and colleagues. For multiple weeks in late April and early May, when the surge had engulfed urban India, we could receive daily distress calls and messages from our contacts looking for hospital beds, oxygen and medicines. By the middle of May, although reports of distress and deaths among our own urban networks had decreased, the disease had gradually progressed to the countryside, where public health infrastructure has been historically stretched. People there lack access to the resources needed to tide over health shocks. It was yet another reminder that the poor and marginalized are going to be hit disproportionately hard by the crisis.

Since the first phase of vaccinations in January 2021, India has partially vaccinated approximately 11.3% of its population, with only 3% fully vaccinated. Despite being the largest producer of vaccinations in the world and an early exporter of doses to other countries, India has faced an overwhelming surge likened by many to a “tsunami” that will take a long time to subside given the current pace of vaccination rollout.

India’s past vaccination programs have been lauded for their sheer size and commendable outcomes. This time, the challenge seems magnified, with a severe demand-supply mismatch and an urgent need for rapid vaccination rollout without adequate time to plan and implement a systemic approach. The ongoing COVID crisis presents an added challenge, with health systems and health workers consumed and burnt out, leading to a crisis of its own. Now more than ever, many high risk and vulnerable populations have been left out - poor, homeless, elderly, disabled, transgender people, migrants, construction workers, urban poor, rural, tribal communities and so many more. Equity is flying blind in India in the vaccine crisis.  

The story of inequitable access for vulnerable individuals is not unique to India. In most country-level efforts, vulnerable, disadvantaged and marginalized populations remain at the fringes. They have lost work and lost wages, and they often are unable to seek health care when they critically need it. They are not on any priority lists, they cannot cross the technology hurdle to register themselves for services as needed, they cannot thrive in the lockdown, they lack the resources to bear adverse health shocks and, as a result, have been hit the worst. Almost 70% of individuals live in rural areas, which have poor healthcare access and have witnessed disproportionately higher numbers of infections and deaths from COVID.  Vaccination efforts have been anemic in these locations, lagging 15% behind that of urban centers.  

While India has opened up vaccination for everybody over the age of 18 years, vaccine access currently hinges on an online registration system, which is likely to act as a barrier for those who lack access to digital technology and technological know-how. Additionally, vaccination centers could become superspreader locations in themselves, if authorities don't efficiently administer and manage them. High-risk populations often cannot navigate these crowded spaces to get their vaccination, or could be turned away after waiting for hours for it.  

So, what can a country as large as India do in the present circumstances to enhance the vaccine coverage and reduce infection risk for vulnerable and high-risk populations? We suggest four ways to tackle this challenge:  

First, pre-existing health inequities have been exposed and exacerbated by the COVID-19 pandemic. To clear up past wrongdoing and change these poor outcomes, efforts must be made to ensure that local, regional, national and global responses to COVID-19 have equity at the core of their design, so plans are inclusive of everyone, especially the marginalized.  

Second, vaccines are short all over the country, but some states like Karnataka and Tamil Nadu have prioritized high-risk populations and created accommodations to include them in the vaccination drive. These mobile, high-risk, marginalized groups in peripheral urban and rural areas also should be identified and prioritized.  

Third, academia, the scientific community, philanthropic, private and public sectors should come together to innovate and contextualize all developments in the form of diagnostic tools, treatments and vaccines. Further, the distribution and utilization of these resources should be timely and equitable.  

Fourth, involve the marginalized groups––disabled communities, transgender communities, migrants and other vulnerable populations––in the planning and implementation of vaccination programs. They can offer pragmatic advice on accessible vaccine centers, transport from home and back, and vaccinating the caregivers. They can also offer relevant strategies to reduce vaccine hesitancy by way of contextually appropriate communication.  

India has a tall task to perform. It has to vaccinate its citizens, and quickly. It has to anticipate new variants, conduct relevant research, follow scientific evidence and do so fairly and transparently. As India ramps up its vaccination drive, it cannot ignore its peripheral communities. A global approach means changing all of our mindsets––realizing that by supporting all communities and every individual within those communities, each of us can benefit from the good. We can only end the ravages of COVID when we end the gross inequities that have been exposed by the disease. The pandemic is not over until it is over for everyone.  

Shubha Nagesh is a Senior Fellow with the Atlantic Fellows for Health Equity. She is a medical doctor and a global health consultant and currently serves as Director- Research & Community follow-up Programs at The Latika Roy Foundation in Uttarakhand, the Himalayan state of India. She is on Twitter at @snagesh2. Neha Raykar, PhD, MA is a Senior Fellow with the Atlantic Fellows for Health Equity. She is Associate Director at IDinsight India and Senior Fellow with the Atlantic Fellowship for Health Equity. She is on Twitter at @Neha_Raykar. The views expressed are the authors' own.