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COVID-19 is out of control in India, where most vaccines are made. How did that happen?

The coronavirus thrives when humans let their guard down. Following months of relaxed restrictions on face masks and social distancing and amid emerging COVID-19 variants, India is suffering a record-breaking surge of new infections that has sickened millions of people, threatening the world’s largest democracy with a fractured health care system and harrowing death toll.

Mixed messages about the pandemic likely gave the Indian public a false sense of security, several experts told the PBS NewsHour. But the brutal truth is now undeniable. In late March, the country’s daily new infections hovered around 47,000, according to data from the World Health Organization. Since April 22, India has reported more than 314,000 new infections each day, surpassing the United States’ previously held record of 313,000 new daily infections in early January. Current models project that India’s surge will likely continue until mid-May and then begin to taper.

Chart by Megan McGrew/PBS NewsHour

“There’s a wall of infections that’s about to hit,” said Dr. Ashish Jha, dean of the School of Public Health at Brown University. “It’s going to get meaningfully worse.”

Getting the country vaccinated will play a big role in ultimately bringing down those numbers, but COVID-19 is exhausting the nation’s supply of raw materials needed to test for and inoculate against the virus. Paradoxically, India is the world’s largest vaccine producer, but the nation is running out of supplies to make life-saving doses for its own people. Public health experts have demanded that the global community, particularly the United States, step up to address the country’s vaccine shortfalls.

A woman is consoled by her relative after her husband died from the coronavirus disease (COVID-19) outside a COVID-19 hospital in Ahmedabad, India, April 26, 2021. REUTERS/Amit Dave

India’s second surge

Starting in September, reports of new COVID-19 infections and deaths dwindled across India, particularly in cities. Some people speculated that the nation had reached natural herd immunity and praised it as a coronavirus success story.

“When the battle against Covid-19 just started, concern was raised that such a vast country like India will get devastated due to the dearth of resources,” Prime Minister Narendra Modi said during a Jan. 22 virtual address for Tezpur University in India. “But, India has shown that if you have resolved to do something and resilience, it takes little time for readying the resources.”

Wedding invitations began to circulate in a country renowned for huge marriage receptions with hundreds, if not thousands of guests in attendance. Political rallies resumed ahead of state elections in parts of the country, and Modi himself held multiple rallies to campaign for his allies, drawing thousands of his supporters. The Kumbh Mela, a Hindu religious gathering that crowded along the Ganges River in the Himalayan foothills, is estimated to have attracted 3.5 million pilgrims in April.

“Everything had opened up, and we thought the virus had gone away,” said Dr. Shahid Jameel, a virologist who directs the Trivedi School of Biosciences at Ashoka University in India. “This communication made people complacent. Then, people were not taking the precautions they should be taking.”

As the country opened up, more transmissible, harder-to-beat variants took hold in India. Sequencing of COVID-19 testing data shows multiple variants, including B.1.1.7 and B.1617, are infecting a growing number of people. Over the last month, new infections have soared across the nation; variants are likely contributing to the surge, though a lack of testing makes their prevalence unclear. Test positivity rates are at 18 percent, and confirmed infection rates could be vastly under-representative, Jameel said.

“When you have a variant problem, that’s a signal you need to vaccinate faster,” said Dr. Amesh Adalja, an infectious disease expert and senior scholar at Johns Hopkins University Center for Health Security.

That means it’s critical that more Indians get vaccinated, but that’s becoming increasingly difficult in some places. In recent weeks, the nation’s health care infrastructure has been overwhelmed with COVID-19 cases, just as the world saw in Italy, Brazil and in parts of the United States, including New York City. Many Indian hospitals and communities say they have run out of testing and vaccine supplies and pleaded for supplies on social media.

Right now, India needs to treat those who are infected, cut transmission chains and scale up vaccination programs, Dr. Soumya Swaminathan, chief scientist for the World Health Organization said.

World Health Organization (WHO) Chief Scientist Soumya Swaminathan attends a press conference organised by the Geneva Association of United Nations Correspondents (ACANU) amid the COVID-19 outbreak, caused by the novel coronavirus, at the WHO headquarters in Geneva Switzerland July 3, 2020. Fabrice Coffrini/Pool via REUTERS

Modi said every Indian age 18 or older could be vaccinated, starting May 1.

But there’s a catch. Currently, India produces 60 percent of the world’s vaccines, largely through the Serum Institute of India, the world’s largest vaccine manufacturer, which played a vital role in generating enough COVID-19 vaccine doses to slow the pandemic’s spread. The Serum Institute has worked to deliver COVID-19 vaccines on contracts negotiated with dozens of countries around the world. But the country has been running out of raw materials to produce enough vaccines to immunize its own population of 1.3 billion people.

So far, India is producing roughly 2 million vaccine doses each day, Swaminathan said. But the country needs to vaccinate between 6 and 7 million people per day, she said, and that rate demands that India “needs to be increasing manufacturing capacity several fold.”

People queue up to receive a dose of a Covid-19 coronavirus vaccine at a vaccination centre in Mumbai on April 27, 2021. (Photo by Punit PARANJPE / AFP) (Photo by PUNIT PARANJPE/AFP via Getty Images)

America breaks its ‘silence’

In February, President Joe Biden signed the Defense Production Act to boost U.S. COVID-19 vaccine production. But that decision cut off exports of raw materials, such as vials and stoppers, to India. On April 16, Adar Poonawalla, chief executive of the Serum Institute of India tweeted at Biden, asking that Americans “lift the embargo of raw material exports out of the U.S. so that vaccine production can ramp up.”

The spokesmen for the Serum Institute did not wish to comment to the PBS NewsHour beyond Poonawalla’s tweeted statement.

On Sunday, the Biden administration committed to sending India supplies to stem the flood of new cases and deaths. This includes therapeutics and oxygen to treat those already infected and personal protective equipment for India’s health care workers. The U.S. also said it would fund BioE, a company that manufactures vaccines in India, to produce at least 1 billion COVID-19 vaccine doses by December 2022.

“Just as India sent assistance to the United States as our hospitals were strained early in the pandemic, we are determined to help India in its time of need,” Biden tweeted Sunday.

The announcement comes as rates of vaccination in the U.S. slow, leaving states with surpluses of unused vials while the WHO and others urge the Biden administration to step up and help India.

On Monday, the U.S. said it would share as many as 60 million doses of AstraZeneca vaccine, once the vaccine has undergone federal review of safety and efficacy data.

While AstraZeneca’s COVID-19 vaccine has not been authorized for emergency use in the U.S., it has been produced and used in India (under the name Covidshield) to vaccinate millions of adults. Swaminathan said experiments and data have shown the AstraZeneca vaccine is effective at “neutralizing” multiple variants.

The U.S. decision to help India breaks “an almost inexplicable silence over the last several days as this crisis unfolded,” said Deepa Ollapally, associate director and research professor for the Sigur Center for Asian Studies at George Washington University. The Biden administration dragged its feet to help an ally, she said, but this recent diplomatic shift “will go a long way.”

The world must pay attention to what is happening in India, Ollapally said, adding that in an interconnected world, countries “hoarding” vaccines do so at their own risk.

The pandemic “is showing us how important domestic health systems are for global well-being — how interconnected it really is. It’s quite astonishing,” Ollapally said. “Who would have thought this was the lesson we’d be learning in 2021?”

Looking at how COVID-19 vaccines have been distributed so far reveals “a very serious equity issue,” Jameel said.

“If anyone is unprotected anywhere in the world, then everyone is at risk.”

Empty COVISHIELD dose manufactured by Serum Institute of India, at a vaccination centre on March 22, 2021 in Guwahati, India. (Photo by David Talukdar/NurPhoto via Getty Images)

The role of patents and politics

The coronavirus pandemic’s devastating effects in India have exposed the dangers of keeping life-saving resources in a handful of places around the world and renewed calls for work to further global vaccine equity. On Jan. 18, the World Health Organization called upon world leaders to improve global access to coronavirus vaccines.

The organization urged nations that had an abundance of vaccines to turn over those doses to COVAX, or the COVID-19 Vaccines Global Access, so they could be distributed to countries where most health care workers still treat COVID-19 patients while unvaccinated, repeatedly exposing themselves to risk of infection and death.

“Distributing COVID-19 vaccines quickly and equitably is essential to end this pandemic, restart our economies and begin to tackle the other great challenges of our time, like food insecurity, inequality and the climate crisis,” the declaration said.

But beyond distributing existing doses, another solution would be to enable more manufacturers around the world to produce proven vaccines. Yet there are enormous roadblocks to adding more producers beyond the companies who currently control the vaccines.

Intellectual property rights and international regulations have undermined efforts to build up regional technology to develop, produce and expand access to vaccines, Swaminathan said.

Patents are “sacrosanct,” Adalja said. They legally protect creators’ inventions and incentivize innovation. If someone attempts to recreate patented technology without permission, they can be sued. During the COVID-19 pandemic, however, this practice has left an abundance of highly safe and effective vaccines in a few privileged hands, widening already-existing global disparities, Swaminathan said.

Even if patents were temporarily waived, Jha said it will take more than that to support countries desperate for vaccines and an end to the pandemic.

“What you need much more than patents is wholesale technology transfer,” he said. “You need a whole team of people helping stand up manufacturing capacity.”

During the G7 summit in June, leaders are expected to discuss how to build more flexibility into intellectual property rights and patents so that life-saving technology can be more readily shared during public health crises. Swaminathan said there needs to be a different model for research and development in matters of health and especially during a pandemic—for ethical, epidemiological and economic reasons.

“We want a fair system,” she said. “There’s no place for greed here, but there is a place for reasonable returns on investment.”

Supporters of Bharatiya Janata Party (BJP) wearing face cutouts of Indian Prime Minister Narendra Modi attend a public rally being addressed by him during the ongoing fourth phase of the West Bengal’s state legislative assembly elections, at Kawakhali on the outskirts of Siliguri on April 10, 2021. (Photo by Diptendu DUTTA / AFP) (Photo by DIPTENDU DUTTA/AFP via Getty Images)

Beyond vaccines

The urgency of India’s surge will require more than scaling up vaccination campaigns. Even if every person in India were to be vaccinated tomorrow, weeks would pass before they would be fully immunized. Hundreds of thousands of people are getting infected daily, and thousands are dying. To slow the virus’ spread and reduce suffering, Jha said that Modi “has to get serious about pushing for universal masking.”

To ensure full compliance with face masks and social distancing, the government and public health officials must be transparent with disease data so people understand the true risks they face, Jameel said. “Don’t sugar-coat it. If people trust their system, they will comply with the system.”

This could begin to counteract the botched government messaging that suggested India had beaten the coronavirus.

Some cities, including Mumbai and Chennai, have put temporary lockdowns into place to restrict people from interacting with others and potentially spreading the virus. Testing should be used to inform where else these actions are needed, Swaminathan said.

She also said the government should help those whose economic livelihoods would collapse if they are unable to work remotely from home. Doing so will weave a safety net to prevent people from going to work while sick, reducing the potential for further spreading the virus.

As the virus continues to spread and cases climb, time is India’s enemy in making these changes, Jha said.

“The single biggest lesson of this entire pandemic is that when you don’t act quickly this virus beats you every time,” Jha said.