When health workers tried to convince Munir Pathan to take the COVID-19 vaccine in February, the 52-year-old farmer refused. The jab would kill him, he was certain. A resident of Janefal village in the western Indian state of Maharashtra, roughly a 228-mile drive from Mumbai, Pathan had read messages on WhatsApp, stating that vaccine shots are lethal and that if a doctor errs while administering the shot, it leads to an infection in the arm. The only way to save the person thereafter is by amputating the limb.
“My mother is 80 years old, while my father is a decade older. I was particularly scared to get them vaccinated,” Pathan says. “Also, there hasn’t been one COVID-19 case in our village since the beginning of the pandemic last year. Therefore, we did not want the risk of vaccines. It was only after our village head took the shot and survived that I started developing faith in vaccines.”
On April 27, over three months after the vaccination drive first commenced in India, Pathan took his first shot at a vaccination camp organized in his village. That day, health workers managed to inoculate 65 residents of Janefal, or 100 percent of its eligible population, setting an example for other rural residents of the country, and prompting vaccination drives in 16 nearby villages.
Janefal stands out as a role model, says Sunil Chavan, collector of the Aurangabad district, where this small village is based. Chavan, who heads the administrative affairs of the district with 4.5 million people, lauded the initiative of local leaders and health workers in Janefal, stating that they started creating awareness when the vaccine rollout was only beginning in India, marred by staunch resistance in its rural pockets. “Now, every village wants to be Janefal,” says Chavan.
India has witnessed a record surge in COVID-19 infections in the past month, with over 26 million total infections and 291,873 deaths so far. While many believe that the fatalities in India are undercounted, the infections and deaths continue to rise. On May 20 alone, the South Asian nation reported more than 250,000 cases and more than 4,000 deaths. After ravaging its cities, the devastating second wave of COVID-19 is now sweeping India’s villages, which have much poorer health infrastructure than their urban counterparts. The country’s rural areas house 895 million people or 66 percent of India’s population. However, nearly 60 percent of hospitals, 80 percent of doctors, and 75 percent of medical facilities, are located in urban areas.
According to a research report published on May 7, nearly half of the infections in India48.5 percent are now being reported from the country’s rural pockets. The report emphasized the power of vaccination as a primary tool to reduce the severity of infections. “We must vaccinate our people on a mission mode, even if it means suspending economic activity for a while after the second wave subsides,” the report noted, red-flagging the slow pace of vaccination in the country.
The World Health Organization, too, states that vaccines save millions of lives each year, and that vaccination against COVID-19 will stop the pandemic. However, vaccine penetration in rural India is hampered by many challenges, a major one being vaccine hesitancy, spurred by misconceptions that have been circulating, including that vaccines contain pig meat, cow blood, and can cause infertility, even death.
Vaccine hesitancy in rural India
A nationwide survey conducted in last December discovered that only 44 percent of people surveyed in India’s rural areas were willing to pay for COVID-19 vaccines, 36 percent said they would not, while the remaining 20 percent were undecided. Despite the rising infections and deaths, vaccine hesitancy prevails in rural India, owing to insufficient knowledge about the COVID-19 disease, says K. Srinath Reddy, president of the Public Health Foundation of India (PHFI), a non-profit health initiative. He blamed the reluctance on the poor literacy rate in rural India, which stands at 64.7 percent, as opposed to nearly 80 percent in India’s urban areas.
Myths about COVID-19 vaccines are the biggest hurdle to vaccination coverage in India’s hinterlands, says Satish Sable, a physician at the Primary Health Centre (PHC) for Janefal, a referral unit that serves as the first port of call to a qualified doctor for its rural residents.
“When the vaccination drive first started in January, people in villages were strongly opposed to it, as they were overpowered by rumors,” says Sable, who led the vaccination drive in Janefal. “If we organized an inoculation drive for 100 beneficiaries, only 40 would show up.”
According to Krushna Gavande, the chairperson of the village council of Janefal, the population of 525 people was “gripped” by a fear of vaccines. “Upon persistent convincing, villagers would agree to take the shot, but the next morning, when it was time to go to the hospital, they would back out again,” says Gavande. “They caught these rumors from WhatsApp. Many messages were doing the rounds, all blaming vaccines for untimely deaths and a host of illnesses.”
A few others, who tried to coax villagers into inoculation, faced greater resistance. Sayyed Bhudan, a police officer in Janefal, says that villagers would latch the doors of their homes, as soon as they saw him approaching. “The elderly population, especially, was petrified,” says Bhudan, “When I would tell them to get vaccinated, they’d say that I was plotting to kill the villagers through poisonous injections.”
Nirmala Jadhav, a 75-year-old woman from the village, too, fell for such rumors. “I was very scared,” she says. “When people from other villages would come here, they would bring stories of how vaccinations went wrong elsewhere–some felt dizzy, some got a fever, some had dysentery, and all of these people died, as no medicines work on the side effects of vaccination jabs.”
The Janefal model
In addition to vaccine hesitancy, COVID-19 inoculation in India’s countryside is hindered by many other challenges. These include online registrations for rural residents, who have limited digital literacy and smart phone accessibility, organizing villagers for vaccination at local healthcare centres, which are often locatedmiles away, and arranging enough shots in a country, which is already reeling from an acute vaccine shortage. It took Janefal three months of vaccine advocacy, faith building, and community mobilization before it achieved the milestone of 100 percent vaccination of its eligible population.
Sarla Zalte, who has been serving as a health worker in the village for nearly three decades, says that she has made dozens of home-to-home visits since January, trying to persuade villagers into getting inoculated. She says she would reason with residents, comparing the COVID-19 vaccine with the Bacille Calmette-Guerin and Hepatitis B jabs for newborns, insisting that like these immunization shots, the only purpose of COVID-19 vaccines was to build immunity against the novel disease.
“I got my first vaccine shot on February 1, and the second one, four weeks later. I would tell villagers that despite getting both the shots, I was healthy, safe, and alive. I did not have to get my arm amputated either,” says Zalte. “But they had harbored too many misconceptions.”
Although villagers were still unconvinced, the village administration knew that it was important to vaccinate the villagers against COVID-19, especially since a neighboring village, Shelgaon, had started reporting infections. Residents of Shelgaon would often visit Janefal to obtain water and there was also the threat of them spreading the virus in Janefal.
To fast track the process, the village administration, in early April, created a taskforce comprised of healthcare workers, the medical officer at the local PHC, police officers, the village head, and other members of the village council. The team mapped out the eligible population and started organizing door-to-door awareness campaigns, debunking myths, and listing benefits of vaccination. Every member of the taskforce got their shots, says Zalte, and showed pictures and videos of their vaccinations to villagers. They also worked longer hours to demonstrate that vaccination was safe.
During the awareness campaigns, the taskforce discovered an unprecedented fear–villagers were afraid of hospitals, as they feared that doctors would kill them, rob their bodies of their kidneys, and sell them on the black market. This fear, too, was rooted in rumors and hearsay. “To overcome this fear of hospitals, we decided to hold the vaccination camp in the village,” says Gavande.
Once the vaccine was available, the taskforce decided to hold the vaccination camp on April 27, an auspicious day celebrating the birth of the Hindu god, Lord Hanuman. The vaccination drive was preceded by a testing camp the same day, where the medical officer proposed to test the villagers for COVID-19, only to discover that the village was also plagued by a testing hesitancy. On the designated morning, eight to 10 villagers fled the village, fearing the tests.
“They said they did not want to get tested because they barely left home and could not be infected,” says Bhudan, the police officer. “When we probed further, we realized that they were afraid of testing positive and being sent away to hospitals. We assured them that we would house the infected persons in a local school, which we had turned into a quarantine center. To ease the fear of the testing process, all of us in the taskforce got tested first.”
Sable tested 101 villagers for COVID-19 that afternoon through Rapid Antigen Tests, and none of them tested positive for the disease. “Everybody was overjoyed with the negative results,” says Bhudan. “The villagers started clapping and whistling, overcome with relief. A few of them were still scared to get vaccinated, but as more and more people emerged with no immediate side effects from the jabs, the reluctance started fading away.”
To enable online registration for vaccines, the taskforce had collected ID cards of all the eligible villagers, and registered them through three mobile phones with internet connections. Sable then vaccinated 65 of the 75 beneficiaries. The remaining, he says, were in post-operative or antenatal care, and their vaccination was completed in the weeks that followed.
“The nearest PHC is eight kilometres away,” says Pathan, the farmer, “With the distance and fear of hospitals, most villagers would have avoided the vaccine, had the camp not been organized in the village.”
The PHC for Janefal caters to 16 other villages with a total population of 32,000 people. Before the drive in Janefal, Sable had managed to inoculate about 400 people under his jurisdiction. After Janefal, the number has increased to 3,500. “Now, more villages, with much higher populations, are coming forward, asking us to conduct vaccination camps. After seeing Janefal, they are of the view that if this tiny village can manage 100 percent vaccination, they can too,” says Sable.
Although infrastructure and the shortage of vaccines remain rife, Janefal’s model must be adapted in other villages of the country, says Reddy of PHFI. “[It] shows local leadership, local community spirit of support,” says Reddy. “You cannot do vaccination or any major health program with a top-down approach,” he added.
Residents of Janefal, meanwhile, are awaiting their second shots. “Nothing happened to me after I took the shot,” says septuagenarian Jadhav, a tinge of surprise still coloring her voice. “I went to work in the fields soon after the injection. I even encouraged my relatives to get their shots.”