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Story Publication logo May 20, 2021

Why Is the World’s Largest COVID-19 Vaccine Campaign Faltering?


Volunteers from Indonesia's Red Cross prepare to spray disinfectant at a school closed amid the spread of coronavirus (COVID-19) in Jakarta. Image by REUTERS/Willy Kurniawan. Indonesia, 2020.

Veteran public health journalists from Science magazine explore what science knows—and is learning...

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On a Sunday morning in early April, as Mumbai was in a daze from the first weeks of a surge of COVID-19 and had instituted nighttime curfews, Baliram Boomkar asked his neighbors in the city’s Kaula Bandar slum whether they wanted a vaccine to protect them or had received one. Some said they had but only because their employers required it. One man said he’d get vaccinated if his company gave him time off to recover from side effects. “COVID is nothing,” he said. “People are only spreading rumors. It’s all a lie.” A woman said she was afraid to get the shot because the clinic might test her for COVID-19, find she’s positive, and then force her to quarantine—as happened last year. “I know I can’t avoid the vaccine, but I want to be the last in the queue,” she said.

“Lots of people [here] don’t believe that COVID exists and that God will provide if something happens,” said Boomkar, who lives in the slum and works as a “barefoot researcher” for the nongovernmental organization Pukar, which conducts health-related studies and also tries to improve living conditions. “They think it’s all politics.” The use of masks, despite the barefoot researchers distributing them and stressing their benefits, remained sparse.

A month later, India’s COVID-19 surge has become a tsunami, with hospitals overwhelmed and funeral pyres burning throughout the nights. Yet the country’s vaccination campaign is languishing, with less than 3% of Indians fully vaccinated as of 16 May. Widespread shortages of the shots have forced some vaccination clinics to shutter; at others, lines often form hours before they open. Some states are limiting doses to people older than 45, and to extend supplies, the government has recommended stretching the intervals between shots of the country’s most heavily used vaccine, Covishield, a version of the AstraZeneca–University of Oxford vaccine produced by the Serum Institute of India. But supply is only half of the dilemma.

Moving vaccines into arms in this country of 1.3 billion means reaching remote, difficult-to-access regions and tackling the profound divides between the lower and upper classes. And like almost everywhere in the world, India must confront the perplexing challenge of vaccine hesitancy. It’s now widespread in Indian society, far from limited to the slums that Pukar helps, but it is a new problem here. “India never had vaccine hesitancy” until COVID-19, says virologist Shahid Jameel, who directs the Trivedi School of Biosciences at Ashoka University.

Past mass vaccination campaigns in India have focused on children. Adults, even the wealthiest, do not routinely get immunized against influenza, shingles, pneumococcal disease, or anything else. “You won’t have too many adults asking for a vaccine, and you won’t have too many doctors prescribing it either,” says Renu Swarup, who heads the government’s Department of Biotechnology. “There is a lot of advocacy that we have to do to bring the public on board.”

Many blame a different surge for creating India’s unexpected reluctance toward COVID-19 vaccines: the rumors that spread constantly on social media. “It’s not a vaccine hesitancy that is deep rooted, like in Europe or the United States,” says Sai Prasad, an executive director at Bharat Biotech, which makes Covaxin, the country’s other COVID-19 vaccine. “This is literally due to disinformation or misinformation.” Among the false assertions in wide circulation are that the vaccines make people impotent, are worthless because some vaccinated people become infected, or even lead to death. “Adults are more finicky than children: They change their minds thanks to WhatsApp University and Twitter on a second-by-second basis,” Prasad says.

India began its vaccination program on 16 January, just 1 month later than the United States and the United Kingdom. But there was little sense of urgency. The nation wasn’t hit as hard by the first surge of COVID-19 in 2020 as many expected. By 1 March, India, which has one internet portal that allows anyone eligible for a shot to make an appointment at a local site, had vaccinated just over 12 million people with a first dose.

Even health care workers, the first in line for shots, were slow to get them. At the Christian Medical College (CMC), Vellore, in the state of Tamil Nadu, an esteemed training ground for doctors and nurses that has five campuses with more than 2700 hospital beds, 30% of the staff still had not received a shot 6 weeks after the information campaign began. By early April, after CMC administrators decided to post their own vaccination photos on social media and emphasized that 1600 unvaccinated staff had become infected and 12 had fallen critically ill, 99% of doctors and 90% of nurses and other hospital workers had received a shot.

But in Tamil Nadu, one of the country’s most urbanized and industrialized states, the broader public remained tepid toward the shots. On a morning in early April in Vellore, CMC vaccine researcher Gagandeep Kang walked downstairs from her office on the main campus to the hospital’s COVID-19 vaccination clinic for her second dose. Kang paid her 250 rupees (about $3), and was vaccinated. But only a dozen other people sat in the outdoor waiting area. No one took a selfie as they got the shot or high-fived a nurse in thanks. Across town that day in the Salavanpet neighborhood government clinic where vaccine is free, only 22 people showed. The hospital had 370 doses in its refrigerator left from a batch of 500 it had received 5 days earlier.

A slow start

Tamil Nadu hadn’t yet been slammed by COVID-19 again. But even in parts of India where cases were mounting, COVID-19 simply wasn’t always perceived as a big threat. “You’re in an environment where you see death so frequently,” says CMC head J. V. Peter, a critical care specialist. “When you see people dying due to other illnesses at a higher frequency than COVID, why should people pump their fists and say, ‘Hey, I’ve got my vaccine!’ or why should they push towards getting a vaccine?”

Kang faults the government for not “preparing the ground” earlier for a massive adult immunization program. “The systems were set up for 100 people a day at immunization centers,” she says. “We could scale up to five times what we’re doing.”

The challenges multiply in more rural areas. In Jawadhi Hills a few hours’ drive away, Kang and others at her college have a project at the rural village of Vallithathankottai, helping the Malayali tribe with everything from clinical services to improved sanitation. The village’s 99 houses are nestled up a steep mountain road, and a few dozen members of the tribe gathered one afternoon in their leader’s house to discuss the pandemic with Kang and Science. Only three villagers had been vaccinated, at a clinic 5 kilometers away. Others were noncommittal. “If it’s for our protection, we will all take the vaccine,” said one villager, who like the others was not eligible at the time. But there was little fear of the virus. “It’s not going to come to us,” said one villager. Or it’s simply harmless, the leader speculated. “We might have got it and it would have gone without us knowing."

In mid-May, as cases continued to climb in Tamil Nadu but hope arose that the devastating wave of COVID-19 had peaked countrywide, varying degrees of vaccine hesitancy remained. In wealthier, urban communities, the fact that the company making Covaxin has yet to publish its efficacy data and that the version of Covishield used outside of India has been linked to clotting problems continued to feed some reluctance. Researchers speculate that many Indians would rush to get the messenger RNA vaccines currently only available abroad. Still, demand is growing. “There have been few signs of hesitancy among the middle class and they are scrambling for vaccine slots,” Kang now says.

Neonatologist Anita Patil-Deshmukh, who founded and runs Pukar, says the barefoot researchers report that in the Kaula Bandar slum, the surge has led at least “a few” pandemic doubters to change their minds, as they watched constant images of crematoria on TV and had relatives in their home villages become ill and unable to access care. But they remain exceptions. “Most people are still reluctant to take [the vaccine],” Patil-Deshmukh says. “Vaccinating people who live in the slums is still a huge issue.”

The government needs to make it easier for the poor, she says. “Most people in the bottom of the pyramid do not possess the smartphones needed to do online registration, and those few who may possess it do not know how to navigate the system,” she says, adding that Pukar soon hopes to set up registration stations in Kaula Bandar.

Kang said the Indian government should fulfill a commitment to setting up vaccination points within 2 kilometers of everyone. “We’re a big country, and to reach people is challenging.” She suggests some areas may need vaccinators to go door to door. “In India, in many places you have to think about outreach programs because the most vulnerable people are not going to get to vaccination centers.”

Despite India’s huge population, the effort could pay off quickly, some researchers argue. “Trying to vaccinate everybody is not the point,” says Anurag Agrawal, a pulmonologist who heads the Institute of Genomics and Integrative Biology, a division of India’s Council of Scientific and Industrial Research. India has a relatively large population of young people, who may be less vulnerable to serious symptoms. If immunization becomes widespread in those who are 45 and older, particularly in those with conditions like diabetes and obesity that can worsen COVID-19, hospital admissions and death will plummet, Agrawal contends. He calculates this population only totals about 200 million—a number India’s vaccine supply should soon be able to cover.

“India does not really have a vaccine problem,” he says. “It has a people’s outlook problem. And this upsurge may again bring people back to reality.”


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