How to approach Covid-19 vaccine hesitancy?

If there is one key lesson from India's pulse polio drive, it is simply this: connecting with the community is essential, and listening to the community pays

India, a perpetual paradox, is grappling with the fear of not getting the jab and the fear of getting it. Many wait anxiously for their turn to get the Covid-19 vaccine; others are running away from vaccinators.

In Champakana, a tribal village of barely 500 people, in Odisha’s Rayagada district, people fled when they heard that a health team was coming. Health workers who had come with 100 doses for those above 45 found no takers.

“Almost all the doors in the village were locked after we reached there, around 8 a.m. We waited for them for the next 2-3 hours, but as no one turned up, we wound up the camp,” Dr G Shailaja, medical officer of Kolnara community health centre, told the national media. The rumour mill, fuelled by video clips, had convinced villagers they would die within two years of being vaccinated.

The incident in early June is a telling marker of the serious problem of vaccine hesitancy in parts of the country, alongside vaccine shortages.

Data indicates vaccine hesitancy may be somewhat higher among the elderly population compared to the young, says health economist Rijo John. As more and more among the 45+ age group get vaccinated, getting the remaining ones in that group vaccinated would become increasingly challenging. The Government of India will have to find ways to encourage vaccine uptake among them, he says.

For the younger population, the demand is much higher than the supply, and there is no hesitancy factor kicking in as yet, John adds.

The second wave of Covid-19 infections has hit rural India more brutally. Worryingly, the hinterland, traditionally handicapped by weak health infrastructure, has had far fewer jabs than urban India. Reason: less access to vaccines as well as vaccine-wariness.

Vaccine hesitancy, however, is not a new story in India. Look back to India’s long-drawn-out battle against polio.

I remember walking down a narrow by-lane, flanked by open sewers, in the outskirts of Moradabad, in 2006. This was when few had hopes of India ever successfully defeating polio. There were pockets of severe resistance against the oral polio vaccine in several districts in Uttar Pradesh.

I met Muslim families convinced that a geopolitical conspiracy lay behind the persistent attempts to give polio drops to their children. Hina, a mother of four, told me she was highly suspicious of volunteers who knock on doors, trying to track children who have been “missed” during the regular polio vaccination drives. Listening to her, it was clear that the vaccine hesitancy one saw in these parts reflected a complete breakdown of trust in the State.

Hina alleged that her four-year-old son had been forcibly given polio drops when he was out playing. “We will not let the other children be vaccinated. We want to know why the government is so keen on protecting our children against polio when it pays no attention to other diseases that strike us. We have heard the polio drop makes male children impotent,” Hina told me.

The family’s anger at an uncaring, dysfunctional healthcare system helped seed irrational fear and complete distrust of “outsiders”, especially health workers and field operatives of international agencies. Mischief mongers tapped into fears and resentment.

Science had answers to most of their doubts about the safety and efficacy of the oral polio vaccine. But till then, no one they trusted had bothered to explain in a language and idiom they understood.

Despite all the difficulties, India finally eradicated polio.

Vaccines helped, but equally critical was social mobilisation - religious leaders got involved, so did other community influencers, academia, civil society, UN agencies, organisations like Rotary alongside frontline health workers. They went from door to door, lane to lane, trying to reach the unreached in the crucial last mile.

The past can guide the present.

The first thing to keep in mind is vaccine hesitancy is complex. Though one of the top 10 threats to global public health, it is part of a spectrum of conditions. There are hard-core anti-vaxxers. Then, there are those sitting on the fence, who have doubts and questions about vaccines or a specific vaccine and social copiers who are highly susceptible to misinformation and can swiftly shift to vaccine-hesitancy, says Dr Naveen Thacker, a Gujarat-based vaccination expert and president-elect of the International Pediatric Association.

What works?

“First, you have to listen to the community, its fears, anxieties. That is what we did during the polio campaign. Community mobilisers, religious leaders, medical doctors, teachers were all roped in to spread awareness. We had micro-planning,” says Thacker, a Rotarian, who was deeply involved in Rotary’s campaign against polio.

No single intervention can address the entire spectrum of vaccine-hesitancy, especially in the context of Covid-19, where evidence for effective strategies to address it is currently limited.

“There is a mutation of misinformation ...not just mutation of the virus. Therefore community mobilisers need to be equipped to convey uncertainty with total honesty,” says Thacker.

Other public health experts make the same point.

“The fundamental principle of vaccination in any pandemic, especially the Covid-19 that is spawning multiple mutants, is that ‘no one is immune unless and until everyone is immune,’ says P V Ramesh, a physician, public health expert and former principal advisor to the Andhra Pradesh Chief Minister and part of the state’s Covid management team.

One big problem, he says, is that the current approach to vaccination is too hospital-centric, app-based, and favours the rich and the upper-middle class rather than being people-centric and community-based. It excludes the most vulnerable.

“Paradoxically, we see vaccine hesitancy alongside denial of access to vaccines to everyone who most needs, and want them.”

Ramesh says vaccine hesitancy is partly due to the lack of proper communication. “Relevant information has to be communicated consistently, effectively, credibly, and authentically in a language that people understand, especially since we have not had adults being vaccinated on a mass scale like this in the past. There needs to be more granular communication that hinges on explaining in detail to village heads, community influencers, etc., why people need to be vaccinated and the possible side effects. This can be done at cluster levels, panchayat offices, sub-centres, primary health centres, using the existing cold-chain networks.”

He points out that the vaccine hesitancy challenge is further compounded by the epidemic of pseudo-science and magical remedies, which are likely to cause irreparable damage to the pandemic management.

Amid the doom and gloom, there are promising signs. It is important not to stereotype entire communities as vaccine-hesitant.

The tribals in Odisha’s Rayagada district fled fearing inoculation. But tribal communities are not the most vaccine-hesitant. Quite the opposite.

According to the government, vaccination per million population in tribal districts is higher than the national average, and 128 out of 176 tribal districts are performing better than the all-India vaccination coverage.

“In the tribal-dominated West Singhbhum District, where we work, the second wave of Covid19 has had a severe impact. We face the double challenge of food security and disease. We offer ration support to vulnerable families and continuing care to persons with severe mental illness,” says Dr Sachin Barbde, a physician who is part of Ekjut, an NGO that works among tribal communities in remote parts of Jharkhand.

There are lots of myths and false information going around about vaccines, says Barbde. He and his team are trying to address the problem by leveraging WhatsApp, which has a good reach even in remote areas, and with help from youth volunteers called yuvasathis

Yuvasathis have made short videos in local dialects like Ho, Santhali, Munda and shared them widely with their friends and communities. The volunteers accompany villagers to vaccination centres, help them with online registration. Ekjut also supports the West Singhbhum district administration in running a helpline for the post-vaccination follow up. The youth volunteers call villagers who have taken the jab to check if they face any problems, counsel them about proper care and urge them to take the 2nd dose in due course, Barbde told me.

The challenges on the ground are indeed daunting. But if there is one key lesson from the past, it is simply this: connecting with the community is essential, and listening to the community pays.

(The writer is an independent journalist and columnist.)

Disclaimer: The views expressed above are the author’s own. They do not necessarily reflect the views of DH.