How the World’s Great Vaccination Hope Crashed

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S1: When I see pictures of India now with thousands of people dying every day and crowds desperate to get vaccinated, I keep thinking back to this moment in January

S2: 1st to allow me to congratulate you on your handling of the pandemic, launching the biggest vaccine drive in the world.

S1: This guy is a Swedish executive and he’s congratulating Narendra Modi, India’s prime minister, on what seemed at the time like a victory against covid Modi, who was speaking in Hindi to international thinker types at the World Economic Forum in Davos, which was held online.

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S2: Larry Gopnik, someone

S1: he told the crowd that India, quote, succeeded in saving the lives of the maximum number of its citizens

S3: when Modi was talking at Davos. I think a number of Indians would have looked at what he said or heard what he said and felt that he was sort of broadly right,

S1: that some on Subramanian, a journalist with Quartz,

S3: that, you know, on the evidence of the past year or the past nine months, India had done, relatively speaking, better than many advanced Western countries with much better health care systems.

S1: But the plan, as it was laid out in Davos, wasn’t just to sit back and enjoy India’s apparent covid successes. Vaccines were coming online, and India would undertake the world’s largest ever vaccine drive if India had a massive challenge on its hands. One point three billion people needing two point six billion doses. It also had a huge advantage over everyone else. The Serum Institute of India, the Serum Institute, or CGI, is the world’s largest vaccine manufacturer. And it’s not an exaggeration to say that it has helped vaccinate people in more than 100 countries. And that was the plan for covid to. I feel like it’s impossible to underline enough how much I ended up in the position as India’s and and almost the global South’s vaccination hope. How did it end up in that position?

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S3: It was always destined to happen. The company that would inevitably be called upon to supply much of the world with these vaccines is a company that has the largest vaccine manufacturer in the world, which is Cyro. Even back in March or April of last year, when, you know, scientists were still talking about trials that were forthcoming, there was a sense that the minute this went into production, the minute the rubber hits the road, serum would be involved in a huge way.

S1: But now that vaccination plan has fallen apart, only three percent of Indians are fully vaccinated. The Modi government was disastrously late to order vaccines, and the Serum Institute is failing to meet demand. And the other countries that depend on Indian vaccines like Nepal, Brazil, Kenya and Bangladesh are left scrambling today on the show. Why a country that produces most of the world’s vaccines failed to inoculate its own people and the millions of others depending on it. I’m Lizzie O’Leary, and you’re listening to What Next? TBD, a show about technology, power and how the future will be determined. Stick with us. This is a story about multiple bad decisions with terrible human costs, but we’re going to focus on two parts of this debacle, the ineptitude of the Modi government and the Serum Institute’s inability to do what’s been asked of it. While the Serum Institute might sound like an academic center, it’s a farm, a company, a family one. It’s run by CEO Adaa Poonawalla and was started by his father, Cyrus, in the 1960s. Back then, if you wanted immuno biologicals like vaccines in India, you had to import them at incredibly steep prices. So Cyrus created an alternative. The Poonawalla built the company into a manufacturing powerhouse. One common estimate is that 65 percent of the world’s kids get a vaccine from SII.

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S3: So over the last sort of 20 years and 25 years in particular, the Serum Institute has grown to supply, you know, for example, all of India suddenly with its childhood vaccines, but many other countries around the world, it supplies vaccines under UNICEF and WHL programs. These are vaccines that are sometimes quite basic, you know, measles, mumps, rubella, but also sort of sometimes more cutting edge kind of vaccine. So it works on H1N1, for example, and it’s become this center of expertise for manufacturing vaccines at scale.

S4: Hello and welcome. We’re inside the Serum Institute, the world’s biggest manufacturer of vaccines.

S1: I was watching some video about SII with the founder, and it was amazing to me. They talk about like the millions of children who have been inoculated against diseases because of SII.

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S4: Your brand is presence in sixty seven countries across the world.

S1: That’s phenomenal in this place seems it seems almost impossible to overstate how significant it is.

S3: I think that’s right. And I think in a normal year, as I would often fly under the radar because its work has become so perfunctory, it turns out vaccines that go to people and kids in India, South Asia and elsewhere in Asia, Africa, maybe Latin America, and because childhood immunization has been something that we’ve started to take so much for granted, which is a good thing, that’s the way it should be. I think very often, you know, in most years I would not be a household name outside India and maybe even in India.

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S1: Serum struck a deal with AstraZeneca to make their vaccine, and in India, it’s called covid shield. How much were they supposed to make and where was it supposed to go?

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S3: The agreement between AstraZeneca and serum is not a public domain document, so we don’t know what it contains. We can probably say that, you know, around March, April, May, it was reasonable to assume that if this vaccine got approved and a serum was starting to manufacture it, that India would be one of its big customers, you know, seeing him as an Indian company. India has one point three, one point four million people in urgent need of vaccinations. It’s sort of it’s logical to assume that those shots would come from serum. But that was never, as far as I know, put down in an agreement between the Indian government and serum.

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S1: It seems really hard for me to get my head around the fact that you have the world’s largest vaccine maker and this very important clinical trial happening at Oxford and with AstraZeneca. And yet, as you have detailed in your reporting, it’s impossible to know exactly what those contracts were and who was supposed to get what this seems like such a matter of global importance. Why is it so murky?

S3: Well, part of this is just how incredibly corporatist the pharmaceutical world is. The father of the vaccine shifts in the life cycle towards the corporatization. And so the further it shifts into the hands of companies like AstraZeneca, which are private companies, and the further they then make deals with other subcontractors, sub licences, all those contracts immediately now start to fall into the private domain. They’re confidential and it’s difficult to access them. You would think and as I do that in a, you know, sort of public emergency, there is a huge value to making this entire process less opaque, more transparent. But I think it’s very difficult to argue or to convince companies that a lot of this information should be in the public domain. They release what they choose to release, but nothing more. The link between public research and public domain knowledge, on the one hand, and private confidentiality just seems like it cannot be breached even in the midst of an emergency, which is quite shocking.

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S1: I agreed to sell vaccines to three main groups the Indian government, other countries doing direct purchases and the GAVI Alliance. Gabby is a public private partnership which donates vaccines to more than 60 countries through a program called Kovács. Serum was supposed to supply Kovács with 200 million vaccine doses. A news story last year called it the world’s best hope for enough vaccines. If your serum in this scenario, what’s your priority, is it vaccine doses to India? Is it vaccine doses to other countries via Kovács?

S3: The people at GAVI have told me that they always understood that serum’s priority alongside supplying India would be supplying vaccines to developing countries. So they understood that these two priorities would probably exist in parallel.

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S1: It just seems like a phenomenal amount of responsibility to have on the shoulders of one company.

S3: That’s right. And I think, you know, the case is being made by a number of people that this should never have been the arrangement, even for Kovács, that Kovács should have looked from the very beginning at multiple manufacturing centers. They should have ensured sort of wider licensing of a number of these vaccines and not just the AstraZeneca one. They should have leaned on governments early in the pandemic to ensure that, you know, for example, out of every 10 vaccines Pfizer made, you know, a certain number would go into the Kovács facility. They should have done that or the UK government and the E.U., you know, that was the way I think they would have taken pressure off this one single facility in western India. And you’re right. I mean, it’s unfair on India. It’s unfair on serum. It’s unfair on the people in the developing world who are waiting for their vaccines through Kovács. You know, it’s unfair all around for so much to devolve upon this one company.

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S1: But Serum’s said it could handle the orders, even though it was just one company competing for supplies in a global pandemic.

S3: The problem emerges when Kovács is trying to secure these vaccines in a world where the developing the developed world is also trying to buy exactly the same vaccines, there’s a shortage of supply. And even though countries like the U.S. and the UK may have kicked in money to the Kovács facility to subsidise these vaccines for the developing world, they’re also overbooking their doses. They’re buying up and hoarding vaccines and vaccine supplies. They’re sometimes diverting vaccines from where they ought to be going. And in this way, the supply shrinks. And Kovács, for all its noble ambitions, is ultimately unable to buy and distribute the vaccines that it needs to. So, for example, we know for a fact now that when the UK was temporarily running short of AstraZeneca vaccines back in March, at least five million doses were drawn from the serum pool and sent to the UK. That’s five million doses that didn’t go to India, that didn’t go to any of the Kovács countries. They just came to the UK. And so serum I have a certain amount of sympathy with the kind of pressures they’ve been under over the last five or six months because I think India’s demand is so huge and so urgent that the minute the country finally woke up to the fact that it needed vaccines urgently in January 2021, instantly serum was being stretched too thin.

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S1: When we come back, India wakes up to a tragedy. In hindsight, Narendra Modi’s speech to Davos in January seems like an astonishing act of hubris because at that same moment, covid was starting to spread in India and even though the government was talking about vaccines, they weren’t acting.

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S3: So the first seed of a vaccine came from AstraZeneca truth serum in May 2020. That’s when they got the first little batch of biological material with which they could start culturing the vaccine. It was a full seven months later in January 2021, when the Indian government officially placed its first order for vaccine doses from assume that seven month gap, I think cost India dearly.

S1: Did the Modi government just not order enough vaccines for India in that moment?

S3: They didn’t. I’ve talked to a number of people about why the Modi government didn’t do enough last year, you know, just as the US government had done in terms of giving money to its manufacturers to scale up capacity, the Indian government should have done the same thing. But serum with a number of other manufacturing plants in the country that are currently not manufacturing any vaccines at all for covid. And they could very well be one line of argument goes that the Indian government is just not as well off as the US government. And so it doesn’t have the money to, you know, take a bet on a vaccine that may not pass through approvals. But I think that’s sort of disingenuous. India has all the money that it needs for a program like this. And further, even if no vaccine made it through trial at all, you know, and the Indian government had given millions, hundreds of millions of dollars to see them, it could simply have asked them to treat that money as a down payment on future childhood vaccines. And they didn’t do that. And then finally, you know, you come to January twenty twenty one and the very first order of vaccines that India places from serum is around the region of 10 million doses, 10 million in a country where you will need two point six billion doses to vaccinate the entire population. Even if you wanted to argue that the government should have waited until the end of approvals and trials to take a bet on this vaccine, all of those were done and dusted by the end of December twenty 20. So by early January, India should have been out there saying we need to vaccinate the entire country. You know, here’s advance payment or here’s an order of half a billion doses. And this is the scale at which we want to start. And instead we’re starting in poultry regions of 10 and 11 million. It was only in March that they placed their first order of one hundred million or so that doses. But by that time, the shortage was already dug into deep.

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S1: By March, covid was out of control and the Serum Institute was struggling to meet vaccine demand, the Modi government was so alarmed that it banned vaccine exports. That meant Kovács, which was depending on 200 million doses from the Serum Institute, only received 28 million. The country is relying on those doses will have to wait or find another source. SII is still behind on its production targets, only hitting about 70 percent of its monthly goal, despite getting hundreds of millions of dollars from the Indian government. And just last month, the Poonawalla asked for 400 million more raising eyebrows across India. All these numbers are massive. And yet I think about what they mean on the ground for people trying to get vaccinated. Before I came in to talk to you, I got a news alert that Delhi vaccination sites were out of vaccine. I wonder when you talk to people in India, whether it’s, you know, colleagues, friends, family, what’s their experience trying to get vaccinated?

S3: It’s been bad, you know, but it’s also been bad in particular ways, so, you know, my parents were both about 60. They just about managed to get their second doses instead of late April, which is when they would do and at the time, sort of a dire shortage had not yet set in. As of May 1st, the vaccinations were thrown open to everybody above the age of 18. That is an additional 600 million people that suddenly came online looking for vaccinations. There’s a huge sort of bottleneck in terms of the fact that you need to download an app to get you to register to get a vaccine. The app crashes a lot. There’s all sorts of sorts of delivery issues that it’s just a completely different kettle of fish. But also, we have to think about the fact that, you know, people like me, people like my parents and my sister extremely well. Indians living in the cities.

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S1: Your parents are in Chennai,

S3: they’re in Chennai, and they live around the corner from the hospital where they got vaccinated. They could walk there and walk back. And so, you know, that one small, thin layer of Indians at the top might still get their shots. But there’s a huge, deep, broad section of Indians below them who may not know how to use an app, who may live in villages or small towns, or the vaccines aren’t reaching, who may not have personal connections to get themselves immunized, who may not know that it is in everyone’s best interest to get immunized as far to fast as possible. There’s just so many moving parts here in a country like India that is still largely poor, that takes effective delivery and communication and organization. That’s just something that the government is failing completely at.

S1: This may be a simple question to an incredibly complicated situation, but where do you put the blame for all of this?

S3: Everywhere, I mean, you know, it starts in May or June last year, the scientists at Oxford decided that they would not allow wide licensing of the vaccine and they would give it only to one exclusive licensee, which is AstraZeneca. This lack of transparency from the Serum Institute as regards its funding, as regards what it’s investing in this a complete lack of action last year from the Indian government in terms of investing in scaling up capacity and ensuring that they were planning for a vaccination drive. The pitiful auto’s of vaccines earlier this year, the US’s own role in sort of restricting vaccine supply exports under its Defense Production Act, which means that companies like serum often can’t get the kinds of filtered media and biologicals and bioreactor bags that they need. And the US has, again, an insistence on hoarding AstraZeneca vaccines that it hasn’t even approved, let alone has started using. So there’s so much going on here, there’s so much going on, and it’s just impossible to know what to pick at. In terms of the one problematic piece, it’s just all problematic. And if we’re really paying the price for that.

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S1: Someone Subramanium, thank you very much.

S3: Thank you, Lizzy. It’s been great.

S1: Samantha Subramanian is a senior reporter at Quartz. That is our show for today. TBD is produced by Ethan Brooks and edited by Allison Benedikt and Torie Bosch. Alicia Montgomery is the executive producer for Slate podcasts. And TBD is part of the larger What Next family. It’s also part of Future Tense, a partnership of Slate, Arizona State University and New America. And I want to recommend you go back and listen to Thursday’s episode of What’s Next. It’s a Palestinian perspective on what’s happening on the ground in Israel and the occupied territories. What next will be back on Monday. Have a good weekend. I’m Lizzie O’Leary, and thanks for listening.