Satyen Gangaram Pitroda– simply ‘Sam’ to friends and to anyone who has even remotely heard of him – carries the rather unwieldy title of ‘Adviser to the Prime Minister of India on Public Information, Infrastructure and Innovations’. Yet the man is more than just a designation. An inventor and serial entrepreneur – he holds some 100 patents worldwide – Pitroda made his fortune in the telecom industry, but his true calling has been in embedding technology in public policy and development debates in India.
As adviser to Rajiv Gandhi, prime minister at the time, Pitroda headed six technology missions in the 1980s. One of these related to immunization and gave India its first clear road map towards universalizing immunization and safeguarding the health of its children. Pitroda spoke to Ashok Malik about the technology mission on immunization, what it achieved, and what remains to be achieved.
In the mid-1980s, you headed six technology missions, including one on immunization. What was the big idea, the philosophy as it were, behind those missions? And why was immunization part of the mission mix?
As prime minister, Rajiv Gandhi established six technology missions – related to telecommunications, water, literacy, milk production or dairy development, edible oils and immunization. All of these were linked to the needs of a growing population. The immunization mission was geared towards finding a way to immunize 20 million pregnant women and 20 million children every year, year after year.
We faced four key challenges as we began the immunization mission. First, we had to acquire the right quantity of vaccines. Second, we had to store these vaccines and put in place the associated cold chain equipment and capacities. Third, we needed to deliver the vaccines to those who required them. And fourth, we needed to streamline documentation. These were the four big pieces of the immunization mission.
Before you began, did you have a fixed list of vaccines that every child in the country was entitled to? Or did you have to devise that list?
There was a fixed list, but we added a few vaccines. And this led to a big debate. I believe we began with a list of six vaccines – diphtheria, DPT and the standard stuff. That was not controversial. The biggest issue was the introduction of the polio vaccine. We felt it was necessary because India had the largest number of polio patients in the world.
So what was the problem with introducing the polio vaccine?
Well, for a start we had the largest number of polio patients in the world but we were not really producing any polio vaccine of our own. In addition there was a debate on whether to use the oral polio vaccine or the injectable polio vaccine. Within the oral polio vaccine framework, there was another debate on whether to give three drops or four drops or five drops. When it came to the injectable polio vaccine, there was a debate as to the efficacy of the cocktail vaccine.
I realized fairly quickly that parents were getting thoroughly confused. ‘Should I give my child the oral or the injectable vaccine?’ ‘Three drops or five drops?’ They needed clarity.
How did you resolve the problem?
We called a meeting of specialists. We needed to develop a national agenda, come to a consensus decision with which to go to the public – to tell people that medical specialists and public health decision makers had collectively agreed that, for example, three drops of the oral polio vaccine was good enough.
We decided we would develop expertise in the injectable cocktail vaccine over a period of time, but that it was not the requirement for the moment. It wasn’t an easy choice. There were big disagreements within the community on what was the right course to follow.
So the debate was settled…
Well, there was more. I said we needed to work on our own vaccine. We were not producing any vaccine then. The general wisdom was that this was not possible. The excuses poured in: ‘We don’t have capabilities, we don’t have resources.’
So we undertook some preliminary studies to see what we could do. We could probably send a team to Russia [then the Soviet Union] and France to come up with some sort of agreement with vaccine manufacturers there to start blending vaccines locally, and then packing, labelling and distributing them. This was the first part of the process but it was estimated this alone would call for an investment of Rs 300 crore. That was a lot of money back then.
But we took the risk. The immunization mission believed we [India] ought to be the largest producer of vaccines in the world at some point simply because we had this huge need, perhaps the biggest need. Today, I understand we are maybe the largest producer of vaccines in the world, or one of the largest. It’s taken 20 or 25 years. But it began because we took that risk back in the 1980s. Nobody remembers that, people have forgotten.
What exactly were the mechanics of that ‘risk’? How did you actually encourage long-term production of vaccines? Or even demand for vaccines?
We started basically by blending vaccines in India. Blending gave us some confidence, so we started distributing vaccines, and labelling vaccines. We worked on setting up a cold chain equipment network to store vaccines. This was the toughest part because of the unpredictability and scarcity of India’s energy supply. You couldn’t rely on the local power system in these circumstances.
So we had to come up with battery powered cold chain equipment, portable cold chain equipment. The whole logistics of moving the vaccine from the factory to putting it on the train or the plane had to be worked out given India’s needs and limitations. Industry came forward and played a role. They did whatever little they could in creating a reasonably robust cold chain.
Then we had to train all the people using the system, down the line. This was a massive task, and included laying down principles for documentation. I remember going to a small rural location in Uttar Pradesh to visit a primary health centre where they were administering vaccines. I asked to see the forms they were filling up. It turned out that for some reason they wouldn’t document the mother’s name but only the father’s. But the problem was when you asked the child’s mother her husband’s name, she wouldn’t say it. It was against tradition for a woman to utter her husband’s name in public!
So consider the confusion – and it was quite funny actually – you identified the newborn child by his or her father’s name, but you often didn’t know the father’s name. So how could you monitor which child had been immunized and which child had not? Why not use the mother’s name? There was no column in the form to record the mother’s name, I was told. We had all kinds of issues!
I went deeper into the documentation question. It was a learning process for me. When we analyzed and collated all the various forms that needed to be filled up on account of immunization, we had some 300 different forms in use in different parts of the country. Kerala had one set of forms, Uttar Pradesh had another set of forms and so on.
We hired Dr Kumar, an Information Technology expert, to look at all the forms, consolidate them and come up with maybe 10-12 standard forms for immunization, which would be used across India. We did a lot of these things, not directly connected with providing vaccines to children but important by themselves.
In addition, we had the problem of educating people on the need to immunize their children on time – to tell them that this or that would happened if their children didn’t get the vaccine when needed. We didn’t want to scare them but, rather, teach them about the good implications of using vaccines. Education was a big process. We tried different things – we decided to observe an immunization day in a week, an immunization day in a month, drum up support using local media and idioms. We tried many methods to educate and inform people about the need for vaccines.
Was there resistance?
Of course there was resistance.
What sort of resistance?
One was sheer ignorance about vaccines: Yeh kya faltu cheez hai (What is this useless thing?). Two, there was resistance even within the medical community. We were told, you are introducing vaccines but don’t have the infrastructure to guarantee this. You don’t have cold chain equipment, and the delivery system. In addition, as we found in some rural areas, there were government doctors who would pilfer vaccines and sell these illegally, and not administer them free to children who needed them. There was corruption in the system, and tackling these sorts of things was part of the package. Even before we realized it, it became part of the mandate of the technology mission on immunization.
Why was Rajiv Gandhi so keen on immunization?
Simple, he was convinced that children’s health was a big issue if we were to convert our large population into an asset. He was equally convinced that immunization was a starting point in ensuring children’s health.
What were the administrative obstacles – I hesitate to use the word hostility – you faced, as in the case of the 300 different types of forms? After all you were setting up a national programme.
Like I said, right from education to acquiring vaccines to storing vaccines and setting up the cold chain equipment… All of that… Delivering immunization services, that is getting the whole system, with the doctors and nurses, to function efficiently. This was a huge logistical task and being attempted on a scale that had never been done before. I must admit there was also a lot of fear and apprehension, ki chalega ya nahi chalega (whether it would work or wouldn’t).
You started off in 1985 and by 1989 the Rajiv Gandhi government had been voted out. You must have set yourself some targets in terms of immunization, so as to measure the achievements of the technology mission on immunization?
As I said earlier, our target was to immunize 20 million children and 20 million pregnant women a year, and every year, year after year.
Did you achieve that?
I don’t think so. Not in that time frame. But we did put a lot of things in place, and I think these have contributed to India achieving those immunization numbers today.
Let’s set aside the numerical targets. What did you put in place that has contributed to sustainability?
We put in place local production of the polio vaccine. We put in place a lot of awareness on vaccines, on education, training, cold chain equipment. So we put in place the basic infrastructure.
I know you’ve moved out of immunization but I’d like you to look back at the situation after 20 years. Today we have very robust vaccine production facilities and capacities in the country, in the private sector and the public sector. But we still have the largest population of unimmunized children. Why is this? Take a bird’s eye view.
It’s essentially a problem of logistics. As a country, we are not very good at logistics.
Could you expand on that? How can it be tackled?
Essentially, we need to get our hands dirty. Implementation is a national challenge in everything we do, partly because people see implementation as a Shudra’s job, it is not a Brahmin’s job. The Brahmin’s job is to talk about it, give lectures and theorize. Somebody has to dirty their hands, to actually do things. And that is considered the Shudra’s work. Not many people want to do it. In a nutshell this afflicts our immunization programme as well.
Even in the mid-1980s was there any discussion in the meetings you attended, or any occasion when you had to persuade people at meetings involving government officials or policy makers, about the socio-economic impact of immunization?
Of course! Lots of discussion, lots of articles written saying this is was an important, even critical aspect of children’s health, just like nutrition. We have to immunize our children, their future is at stake. Look at the number of polio cases. I am happy to say that now, 20 years down the road, polio is almost eradicated. This is a big, big accomplishment.
Let’s come to a subject close to your heart: innovation. We are a country that produces individuals who innovate, but often outside the country. Within the country there are limitations. We have copied other people’s vaccines. Have we innovated and made our own vaccines?
Today I think there is a lot of hope about producing our own vaccines, a lot of new technology is being worked upon. True, in the past we have not really been big inventors of vaccines. But if you speak to Dr [M.K.] Bhan at the Department of Biotechnology, you will realise the interesting promise that now exists for indigenously developed vaccines.
When you started speaking of capacities or promoting capacities for making vaccines in India, were you looking at primarily the public sector? Was the private sector part of the vision too?
It was mixed. In some cases we needed the private sector. The Serum Institute of India in Pune started gaining momentum around then, for instance. Of course, we had a strong thrust towards building public sector vaccine manufacture capacities as well.
Was the private sector willing to come on board, to take on the challenge?
To be fair it was far too early for many of them. They were more interested in pharmaceuticals than vaccines.
You were recommending making vaccines in India. How did the import lobby respond to that, the companies that were bringing in vaccines from abroad? There must have been big pressure from this section.
Oh big pressure, big, big. Like everywhere else – even in telecom, for example – we had a vaccine import lobby. These were the people who said, ‘You’re crazy. Do you think India can make vaccines?’ We were told it was too sophisticated for India, it required a lot of technology Indians apparently didn’t understand, and that India could never make vaccines.
And all this was done because importing vaccines was a lucrative business. So did you actually have people campaigning against you?
Sure, sure; absolutely, absolutely. They determinedly said Indians were not capable of making vaccines, that vaccines were too complicated. There was a news article disparaging us (the technology mission on immunization) as dream merchants.
And to think the dream is a reality today. India has among the world’s largest vaccine manufacturing capacities. Thanks so much for taking us, and yourself, back in time to those early years in India’s immunization and vaccines debate.