India’s Vaccine Rollout Stumbles as COVID-19 Cases Decline. That’s Bad News for the Rest of the World

India’s COVID-19 vaccination scheme looked set for success.

For the “pharmacy of the world,” which produced 60% of the vaccines for global use before the pandemic, supply was never going to be a problem. The country already had the world’s largest immunization program, delivering 390 million doses annually to protect against diseases like tuberculosis and measles, and an existing infrastructure that would make COVID-19 vaccine distribution easier. Ahead of the launch, the government organized dry runs, put up billboards touting the vaccines and replaced phone ringing tones with a message urging people to get vaccinated.

And yet, one month into its vaccination campaign, India is struggling to get even its health workers to line up for shots. In early January, India announced a goal to inoculate 300 million people by August. Just 8.4 million received a vaccine in the first month, less than a quarter of the number needed to stay on pace for the government’s goal. So far, vaccinations are only available for frontline health workers, and in some places police officers and soldiers.

And even that initial interest might be waning. India’s vaccine scheme relies on a mobile phone app that schedules vaccination appointments. On the first day doses were administered, Jan. 16, some 191,000 people showed up. But four weeks later, when those people were summoned for the second dose, only only 4% returned.

A. Valsala, a community health worker in the southern city of Kollam who spent months fighting COVID-19 door-to-door, skipped her appointment to get her first dose of the vaccine after a hectic day on Feb. 12. “I don’t feel the need to rush because the worst is over,” she says. “So there is a sense that it is okay to wait and watch since there are concerns about how these vaccines were developed so fast.”

Read more: How the Pandemic Is Reshaping India

A. Valsala’s comments point to a troubling trend—one reflected in TIME’s interviews with health workers across India. A combination of waning COVID-19 cases nationwide, questions over the efficacy of one of the two vaccines currently authorized for use in the country and complacency are resulting in growing hesitancy to get vaccinated.

“There is a reduced perception of threat with regard to the virus,” says Dr. Chandrakant Lahariya, a New Delhi-based epidemiologist. “Had the same vaccines been available during the peak of the pandemic in September and October, the uptake would have been different.”

A troubling sign for the rest of the world

Public health experts are now concerned that the sluggish start could impact the subsequent phases of the vaccination drive, especially when the vaccination scheme is widened next month to include older people and those with preexisting conditions.

“In India, people have an inherent trust in doctors,” says Dr. Smisha Agarwal, Research Director at the Johns Hopkins Global mHealth Initiative. “So when [doctors] don’t turn up to get vaccines, it reaffirms any doubts that the general public might have.”

In an effort to accelerate the vaccination drive, the government started walk-in vaccinations as opposed to allowing only those scheduled for the day to get the shots. It also set up new vaccination centers across the country.

Read more: The U.S. COVID-19 Vaccine Rollout Is Getting Faster. But Is It Enough?

For now, India might be an outlier: a country with a surfeit of vaccines with few takers. But its experience shows that, while the first challenge is stocking up on vaccine supplies, convincing people to take them can be its own huge task. It might be a portent for the rest of the world as the number of COVID-19 cases decline globally and vaccines become more widely available, warns Dr. Paul Griffin, an infectious diseases specialist at the University of Queensland in Brisbane.

It’s easy to be complacent about getting a vaccine when cases are declining, Griffin says, “but now, when the trajectory looks favorable, is the right time to step back and realize that this will be our reality for a long time if we don’t speed up the vaccinations at this moment.”

How India fell behind on vaccinations

Despite being well-positioned, India’s vaccination drive got off to a rough start. The hasty approval of the country’s homegrown vaccine, Covaxin, with little data available while Phase 3 trials were still underway (those remain ongoing) drew criticism from health workers and scientists. The mainstay of India’s vaccination scheme is Covishield, the Indian variant of the vaccine developed by University of Oxford and AstraZeneca, which has been approved by regulators in the U.K., the E.U. and elsewhere. However, Covaxin is the only vaccine on offer in some vaccination centers in urban areas and health workers don’t get to choose which jab they receive.

“Covaxin might be efficacious but what guides me is data,” says Dr. Nirmalya Mohapatra at the Dr. Ram Manohar Lohia Hospital in New Delhi, where only Covaxin is available. “We also want vaccines faster because we have seen deaths because of this disease but that doesn’t mean we should cut corners with the data.”

But even for Covishield, there aren’t as many takers as expected. In the western city of Nagpur, fewer than 36% of those scheduled to take the vaccine turned up Feb. 11, as per a Times of India report. In the north, the city of Chandigarh is planning to set up counselling centres to dispel fears about the vaccines. In a hospital in the southern city of Thrissur, Dr. Pradeep Gopalakrishnan was the last one to get the vaccine on the morning of Feb. 8. “No one came in after me, so around 69 doses set aside for the day remained unused,” he says.

Experts say the lack of enthusiasm could also be attributed to a decline in cases. India’s daily case average has dropped to less than 12,000—down from more than 90,000 in September. At the peak of the pandemic, health care systems were overwhelmed, with shortages of hospital beds and oxygen cylinders being reported across the country. India’s official COVID-19 tally, now at nearly 11 million, surged to No. 2 in the world, behind the U.S (where it remains to this day).

Read more: France Defying Death Threats to Convert Anti-Vaxxers

In a Feb. 4 press conference, the Indian Council of Medical Research said that more than 20% of subjects over age 18 from across the country tested in late December and early January had antibodies for the coronavirus that causes COVID-19, meaning they likely had the disease and recovered. Similar studies in Mumbai and Delhi showed even higher levels of antibodies—up to 56%, according to Delhi’s health minister. Several health workers interviewed by TIME said they contracted COVID-19, and were less concerned about getting the vaccine immediately because they believe they have immunity.

But health experts warn India is far from herd immunity. And many worry that people not taking vaccines seriously might not bode well for India, given that other countries’ later waves of COVID-19 were even more severe than those early in the pandemic. Already, Maharashtra, the worst-hit state in the country, has seen a COVID-19 spike in recent days, with daily cases above 5,000 on Feb. 18 for the first in two and a half months

‘The worst is not over yet’

On a global level too, the tendency to let the guard down might hamper efforts to bring the pandemic under control. Experts say vaccination is necessary not only to get long-term immunity but to also reduce the potential for new mutations, which are largely behind recent surges in cases in the U.K and Brazil.

“High vaccination coverage rate reduces the potential for new variants,” says Griffin of the University of Queensland. “The more cases we have in circulation, the more chances there are of generating mutations that confer some kind of benefit to the virus.”

Even in countries like the U.S. and the U.K., where vaccination started during a surge in cases, there is a risk that people lose enthusiasm once cases decline. Experts emphasize the need for better communication with the public to ensure that vaccination drives don’t slow down with COVID-19 case counts.

“There isn’t any time to wait because the worst is not over yet,” says Agarwal of Johns Hopkins. “Despite the fatigue, ramping up the vaccination is the only and best weapon we have against what might otherwise be a very long winter.”