Earlier we, TJJ and DD, had written in IJME, that during the pandemic with high case-fatality in those above 65 and younger adults with chronic lung, heart or kidney diseases or diabetes, vaccination must be administered early as a life-saving procedure (1). It was pointed out that protection delayed may be protection denied to drive home the urgency of vaccination for saving lives. At that time, Phase III vaccine trials were in progress and we had adequate data on safety, but efficacy had yet to be measured. Good immunogenicity had already been documented in Phases I and II in which there were no signals of safety problems. Efficacy was “on promise” when we argued for early vaccination of those at risk of death.

It has been distressing to read about countless deaths of people from Covid-19, during the months March to May 2021. The total number of deaths reported in the second wave (between March 11 and May 27, 2021) was over 160,000 (2). We believe that this number is an under-estimate because India does not practise public health surveillance and the authorities do not verify cause of death diagnosis at local levels. About 2000 Covid-19 deaths in Mumbai (60% of total deaths) have occurred in the age group over 60 years (3). Till date only 31% of this age group in Mumbai has received two doses of the vaccine, the majority since the first week of March (3). In Kerala state, 2716 deaths (over 70% of total deaths) occurred in the age group above 60 years, between March and May (4).

Extrapolating from the Mumbai and Kerala data above, we attribute one lakh deaths (65% of 160,000) to Covid-19 among the over-60 population – lives that could have been saved with two doses of a vaccine given at the appropriate time. Government opened up vaccination to those above 60 years from the first week of March. There was no public education on the safety and efficacy of the two vaccines, and as a result vaccine hesitancy began growing through social media. By April 21 only 47% of those of eligible age to receive vaccine had actually got at least one dose (5)

From the literature, we understand that all currently used Covid-19 vaccines with two-dose schedule offer near-100 per cent protection against life-threatening severity of Covid-19 – hence are life-saving if given twice, four weeks apart (6, 7). In order to be effective, the first dose should have been given in the first week of February 2021, and the second in the first week of March. Our plea for using vaccination to protect lives was made in October 2020, a clear three months earlier. The situation is tragic because we had safe vaccines made in India, and approved for emergency use on January 3, 2021 (8). Ethics and epidemiology demanded early and prioritised vaccination of those at risk of loss of life – for those who died without two doses of a vaccine, protection was denied by avoidable delay.

There were easily tracked data on those above 65 using Unique Identification Number (UID, Aadhaar) and on people with chronic diseases since many, if not most, are under healthcare either in public or private sector clinics/hospitals. Vaccination of these groups was the ethical responsibility of the pandemic management authorities.

We believe that over 100,000 lives were lost for want of an ethics-guided national policy to vaccinate for saving lives, in spite of our alert in IJME, and in spite of vaccines undergoing Phase III trials as we wrote in October 2020. Although many may believe that ethics applies only to what is done, it applies also to what was due but not done. Withholding a life-saving intervention is unethical, as in this case of having promising vaccine candidates available, but not offering them to those who were facing the risk of Covid-19-caused mortality. To be right for saving lives is greater than to be righteous by mindlessly following man-made rules and conventions, which are actually meant for the best interests of the public. What better interests are there, than saving lives?

T Jacob John ([email protected]), Retired Professor, Christian Medical College, Vellore, Tamil Nadu INDIA; Dhanya Dharmapalan (corresponding author – [email protected]), Consultant in Paediatric Infectious Diseases, Apollo Hospitals, CBD Belapur, Navi Mumbai, INDIA; Jagdish Ratnanni ([email protected]), Director, ‘Foundation of The Billion Press’, and Faculty Member, Bhavan’s S P Jain Institute of Management and Research.