The day India started coronavirus vaccinations, Amit Mehras name was on the priority list. But he never made an appointment. Im not inclined to get vaccinated just because its available, says the 47-year-old Delhi hospital worker.
Two and a half thousand miles away, strolling past a popup inoculation centre near Red Square in Moscow, Magomed Zurabov is similarly reluctant. Suspicious that the pandemic was deliberately engineered, he has no intention of being vaccinated, he says. Instead, he is taking the necessary precautions: wearing a mask and using disinfectant.
As vaccinations rates soar in Israel, the UK, the United Arab Emirates and other countries that have monopolised supply, and poorer nations make do with a trickle of doses, a third category are beginning long climbs. Supply is less of an issue in Russia, China or India, all of which produce their own vaccines. But their respective government programmes have had slow starts, and there has been little public clamour to speed things up.
People have not shown that eagerness and urgency to be vaccinated, says Ajeet Jain, a doctor at the Rajiv Gandhi Super Speciality hospital in Delhi. India is going through that phase where the disease is no longer prevalent except in a few states. People are relaxed that the disease is over from their point of view.
A woman receives a dose of a Covid-19 jab at Dasappa hospital in Bangalore, India, this week. Photograph: Jagadeesh Nv/EPA
The experience of India, Russia and China may prove, in time, to be typical. Even once vaccine shortages are alleviated, much of the world could still take years to achieve widespread Covid-19 vaccination, encumbered by the challenges of reaching vast and far-flung populations, lack of interest from the public and other, more pressing health priorities.
Some countries may shake off growing pains: Indias rollout has accelerated in the past fortnight, with private clinics enlisted to help administer shots and new groups, including anyone over 60, invited to make appointments. The programme hit 3m doses a day this week which, if maintained, would put it within reach of its target of vaccinating 20% of the population by August.
Uptake was slower than expected among the 30 million healthcare and frontline workers who were prioritised for the first round of doses, with some hesitant about receiving Covaxin, a locally developed vaccine that was pressed into use before the release of phase 3 trial results. (Interim data has since shown that it is 81% effective.)
That caused quite a bit of confusion, as a result of which healthcare workers who were supposed to be vaccinated in the first round, and who understood this process a little better than other people, didnt come forward as much as they should have, says Dr Shahid Jameel, a virologist and director of the Trivedi school of biosciences at Ashoka University.
India has also held off from deploying its entire workforce of vaccine deliverers to fight Covid-19, keeping about half at work administering jabs for other deadly diseases, Jameel says. There is a childhood immunisation programme, there is one for pregnant mothers, and they have to go on unhindered despite Covid.
The most significant impediment may be that, since September, virus rates in India have dropped steeply. And in a country with a median age of about 28, Covid-19 has not proved especially deadly, implicated in about 160,000 recorded deaths, a third of the number of Indians who die from tuberculosis each year. Signs of a second wave taking off in the past week may change the calculation for some.
Look at death rates in South Asia and youll know why people are not dying to get vaccinated, says Oommen C Kurian, a senior fellow at Delhis Observer Research Foundation thinktank. Their sense of risk is considerably lower than, say, a Londoner.
The same is true for the average resident of Beijing, though not for demographic reasons. China has employed blunt but effective quarantine measures to contain Sars-CoV-2 successfully, and life in the country has largely returned to normal. Though it authorised its first vaccines for emergency use in July, just 4% of the country has been vaccinated so far.
One of the most important contributors is this perception that China has a low risk of infection, said Yanzhong Huan, director of the Center for Global Health Studies at Seton Hall University in New Jersey. So people think, why bother to get vaccinated? Were already safe.
The country aims to inoculate 40% of its population by July, a target that will require administering about 4m shots a day, up from about 640,000 a day on the latest public figures.
But Beijing must also balance commitments to supply at least 463m doses to countries overseas, many of them donations to strategic partners. So far, it is under little pressure to hoard those vaccines for use at home. People view this as an example of China being a global leader, something that showcases China being a responsible and reliable great power, Huang says.
Russia has been hit harder by the virus, losing 90,000 lives on official figures thought to be a significant underestimate. But there, too, uptake of the vaccine is tracking well short of government targets of inoculating 60% of the population by mid-year.
A poll of Russians this month found that two-thirds were unwilling to receive the locally developed Sputnik-V shot, in spite of peer-reviewed research suggesting that it is safe and effective. Their scepticism extended to the origins of the coronavirus, with 64% believing that it was a biological weapon, the independent poll said. (Most virologists disagree and say there is no evidence that the virus was engineered.)
Lack of trust in the Russian government is a key hurdle, says Sergei Rybakov, a representative of the Doctors alliance, an opposition-linked medical union that has criticised the official response to the pandemic. Though the state has marketed Sputnik-V overseas, including with its own Twitter account, it has done less to promote the vaccine among Russians, he says.
The task of the state is to show that the vaccine is necessary, the vaccine is safe. In Russia this hasnt been done to the extent it needs to be, Rybakov said. You need to show people that not getting the vaccine is more dangerous than getting it.
Similar hurdles are likely to slow rollouts elsewhere, too, as countries assemble one of the largest logistical operations most have ever undertaken. Even once supplies are secured, some may struggle for years to reach the 70% of the population thought to be required for herd immunity, says Babak Javid, an infectious diseases scientist at the University of California, San Francisco.
They might focus their efforts instead on reaching healthcare workers and the most vulnerable, he says. Youre not going to eliminate Covid deaths, but youll eliminate the likelihood of healthcare infrastructure being overwhelmed.