Ambulance attendant Roman Stebakov has come face-to-face with COVID-19 many times - but he'd rather take his chances with the disease than get himself injected with Russia's Sputnik V vaccine.

"I won't get vaccinated until, I don't know, they break me and vaccinate me by force. I don't see the point in it, there are no guarantees it's safe," says the paramedic from Oryol, 300 km (185 miles) south of Moscow.

Outside one of the city's hospitals, a young woman, Alina, is clutching a bunch of papers certifying her grandmother's death. The old woman was unvaccinated and died of COVID-19 three weeks after being admitted.

But despite her loss, Alina, 26, says she won't take the vaccine because she has heard too many scare stories.

"There's not enough data, not enough checks."

Their attitudes help explain why the first nation in the world to approve a COVID-19 vaccine - and then export it to more than 70 countries - is struggling to inoculate its own population and has racked up record 24-hour death tolls on 21 days in the past month.

In conversations with Reuters, doctors and officials reeled off a host of factors that have fed the spread of the disease and forced Russia to revert to its tightest restrictions since the early months of the pandemic. 

Besides vaccine hesitancy, they cited mixed messaging from the authorities, inconsistent policies, unreliable statistics and attempts to shift responsibility away from Moscow and on to the leaders of Russia's republics and regions.

The health ministry did not immediately reply to a request for comment for this story.

WAITING IN AMBULANCES

At Oryol's Botkin Hospital, chief physician Alexander Lyalyukhin traced the origin of the latest and most virulent COVID wave to three weeks after the start of the school year in September. At that point some Russian regions sent students home for remote learning. Oryol, like most others, kept schools open.

The hospital is short of anaesthesists and infectious disease specialists. Most COVID patients need oxygen support and the supply is tight.

"Perhaps because the virus is more aggressive. We sometimes have fewer patients than there were in winter, but they consume more oxygen, by about a third," Lyalyukhin said.

Ambulance paramedic Dmitry Seregin said patients commonly wait for several hours in ambulances.

"The healthcare system cannot withstand such an influx. This wave is more than twice as strong in terms of the number of cases and the severity of the disease," he said.

Vladimir Nikolayev, deputy head of the regional health department, told Reuters there were still available beds and patients who needed oxygen were getting it.

"Unfortunately, if we'd carried out active vaccination we might not be in this situation," he said.

What Oryol is experiencing is typical of the country as a whole. The latest official figures on Monday showed the region ranked 40th out of Russia's 85 territories for new cases, with 326 in the previous 24 hours, and five new deaths.

As of last week, nearly 38% of people in Oryol had been injected with their first dose, compared with 39.4% nationally.

In Seregin's view, the low rates are down to official miscommunication about the vaccine. At first authorities said the injection would be good for two years, then they told people it would need renewing after six months, he said.

"Statements appear with different information from the very same people, and these make people distrustful of the state."

A source who previously worked in the COVID operations centre of one of Russia's regions said the country had locked down early at the start of the pandemic but then blundered by declaring victory too soon and going ahead with a national referendum in June 2020 on constitutional changes to allow President Vladimir Putin to run for potentially two more terms in office.

"We kind of drew a line on the coronavirus, vaccinations, masks and all the rest of it. And now we have what we have - an insane mountain of corpses," the source said.

UNRELIABLE DATA

Official figures on the pandemic's toll vary widely.

As of Monday, cumulative deaths stood at 239,693, according to the national coronavirus task force. The state statistics office puts the figure nearly twice as high, at around 462,000 between April 2020 and September 2021, while Reuters calculated that the number of excess deaths in Russia in the same period was more than 632,000 in comparison with the average mortality rate in 2015-2019.

Some experts say under-reporting of deaths has made people complacent.

"People think what's the point of me running away from it if it's no more scary than the flu," said Elena Shuraeva, head of the Oryol doctor's trade union.

Her husband Aleksei Timoshenko, a doctor at the COVID hospital, said the picture he sees at work was 6-7 times worse than implied by official figures. "And now people are afraid, they really see that many are getting sick and many are dying,” he said.

All this leaves a dilemma for Putin, who has repeatedly urged people to get vaccinated but said last month that even some of his own friends had delayed doing so.

A source close to the Kremlin said there was evidence that the latest restrictions - which include a nationwide workplace shutdown this week and increasing requirements for people to prove their vaccine status to get access to certain venues - was prompting an increase in take-up. Oryol's governor Andrei Klychkov said people were being vaccinated three times faster than before.

The source close to the Kremlin said compulsory vaccination was out of the question because it would rebound on the government. "It will be seen as an attack on freedom. And that, you know, could be like a powder keg."