In rural India concerns about COVID-19 vaccines are now increasingly commonplace. People voice their concern about what will happen to them if they get vaccinated and have doubts that the government is sending inferior quality vaccines to them. Vaccination sessions in local health centres often see very few or no takers. In contrast, urban vaccination sites face increased demand, especially in the 18-45 age group, and vaccine shortage is a major issue.
From a public health and equity perspective, this is a cause for worry. The fear of vaccines and rural communities not only resisting but also outright rejecting vaccination is a reality. There have been several reports recently highlighting this. A few weeks ago, villagers in Barabanki (UP) jumped into a river to escape COVID-19 vaccinators. Efforts by local health authorities to create awareness and convince people are of little avail. There are contrasting dimensions to COVID-19 vaccine rollout: one where people are enthusiastically accepting it and the other of resistance. There are many diverse factors at play in this, which may go beyond the health concerns and have more to do with socio-anthropological aspects of health-seeking behaviour.
Vaccine hesitancy is not a recent phenomenon. It is neither limited to a particular community or country, nor have we seen it only in the context of COVID-19. Various studies have shown that the acceptance of vaccines among African-American communities is relatively low in the U.S. Polls have also shown significant hesitancy among Hispanics and people in rural areas.
The fear around vaccines among people of colour, especially African-American populations, has to be discussed and understood in the context of Tuskegee experiment. It has often been considered one of the major incidents influencing how people of colour perceive public health interventions. This public health study which began in 1932 tested the progression of syphilis, while leaving many African-American participants without treatment for 40 years. Several participants experienced health complications, infected their partners and died due to their untreated syphilis. This experiment is believed to have left an indelible scar in the minds of many people of colour who now continue to carry deep mistrust for public health functionaries and vaccines.
We have also seen vaccine hesitancy among the urban and the more educated or ‘aware’ populations, with pockets of populations of socio-economically well-off communities refusing to get their kids vaccinated. While vaccine hesitancy can lead to a firm rejection of vaccines, there’s also a possibility of people changing their perceptions over time.
Most of our fears and apprehensions stem from a deep impact of something adverse or unfavourable that we have personally experienced or our social circles have experienced. Over time these become our beliefs, our innate guards. In the context of the concerns described at the beginning of this article, we must look at vaccine hesitancy from a distinct lens of fear and not necessarily scepticism for new vaccines. These individuals, and the communities they belong to, are probably not really challenging medical science, or questioning vaccine trial results, adequacy or inadequacy of evidence. Rather, they seem to indicate deep-seated fears and belief in conspiracies, the fear of perhaps being discriminated and deceived and of being omitted (from societal benefits).
Parts of rural Rajasthan, where we have seen high vaccine refusal rates, are also often poorly resourced, and often tribal. Communities in this region here have believed that the widespread poverty and the general backwardness that they had been pushed into is a result of historically institutionalised discrimination imposed on them by those in power. They believe that they have been systematically alienated of their land rights, forest rights and kept deprived of basic education and health care. All of this has led to a state of despondency and, more than that, a very strong feeling of distrust and resentment against government institutions and those in power.
Such contexts cannot be ignored while we try to understand what might be fuelling the extreme fear and resistance around COVID-19 vaccine. The underlying causes revolve around their feeling discriminated, betrayed and exploited. They have lived with the notion that their lives have little or no value. It is thus natural for them to look at everything new, especially adult vaccination efforts during a pandemic, with suspicion and have their guards up. It’s the trust deficit which is at play here!
Communities might not see the impact of a vaccine instantly, as it’s usually preventive in nature rather than curative. People are used to taking medications or intravenous fluids when they are unwell or in pain, and they may feel better almost immediately, but that’s not the case with vaccines. On the contrary, vaccines administered to a healthy person may lead to occasional side-effects like fever, body aches, etc. Add to that rumours about deaths post-vaccination, and it may not be so easy for people to get convinced about the vaccines.
Responses to vaccines must also be discussed and analysed in conjunction with and in comparison to uptake of other health care services by a particular population. Addressing vaccine hesitancy in rural India would first of all require health systems to be honest and transparent. Create awareness, let people know how vaccines work, how they help prevent a disease, what are the probable side effects and how they can be managed. Health authorities need to be comfortable about people raising questions, while providing them answers as best as possible. Moreover, it’s important to be patient with them. In most cases, it would take time before they change their minds, if at all. Being cognisant of local cultural sensitivities and working with trusted intermediaries is important in this effort.
Sustained and meaningful efforts need to be made to build trust, gain confidence of communities and meet their expectations. This would also require seeing them as equals, treating them with dignity and acknowledging their fears. To do this, governments and the health functionaries will need to break out of their conventional notions and beliefs around people’s healthcare-seeking behaviours and understand and address their fears and apprehensions. They will also need to rethink and alter their communication strategies and move beyond ceremonial awareness drives and campaigns to interventions that are truly engaging and which make the communities feel important and valued.
Even more crucial is to engage communities in planning, execution and monitoring of health care services at all levels. Create fora where they can freely convey what they want and how they want it to be delivered, where they can share how they feel about government policies, programmes or services and where they can hold people and systems accountable for gaps without the fear of being subjugated. Also, governments at both Union and State level must commit to investing more on health care and prioritising primary health care services. Quality health services in all aspects, and not just in sporadic efforts such as pandemic vaccination campaigns, should be delivered. Once we establish these, we might start seeing communities respond favourably and supportively to public health efforts.
(Chhaya Pachauli is associated with Prayas, Chittorgarh, and Jan Swasthya Abhiyan and works on public health issues. Anant Bhan is a researcher in global health, bioethics and health policy.)