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India's Most 'Backward' District Lags In COVID Vaccinations Too

India's COVID-19 vaccination programme needs to accelerate, but uptake in rural areas has been low. We visited Nuh, Haryana's only Muslim-dominated district and among India's most backward, to find out why it has vaccinated less than 1% of its mostly rural population in over two months.

Indias Most Backward District Lags In COVID Vaccinations Too
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Nuh, Haryana: Meena Kumari, 29, does not speak about COVID-19 vaccination to the people she meets during her work as an accredited social health activist (ASHA) worker in Bibipur village in Nuh district in southern Haryana. "Villagers threatened me that if I insisted on the vaccination, they would stop even routine vaccinations for their children," she told IndiaSpend.

Meena Kumari, 29, an accredited social health activist from Bibipur village in Nuh district, southern Haryana, says she is finding it difficult to convince villagers to get vaccinated against COVID-19. The district, with 4% of Haryana's population, accounts for less than 1% of all vaccinations in the state.

Not a single person over the age of 60 years had been vaccinated in Bibipur, said Meena Kumari, by the time we visited in late March 2021, more than two months after India's vaccination programme began.

Even Meena Kumari, who has been an ASHA worker for 10 years, admitted that she was afraid when asked to take the vaccine a month ago, but other than a mild fever, she felt fine. Villagers told IndiaSpend they couldn't afford a day off work, should the vaccine cause fever. "I tell them that I have myself gotten vaccinated and I am still healthy," said Meena Kumari, "They say you can risk death if you want, why should we?"

Until April 4, 2021, Nuh district, with a population of approximately 1.5 million, had conducted 18,525 COVID-19 vaccinations, the lowest among all Haryana's 22 districts. Many of these were of healthcare and other frontline workers, and the uptake among others has been low, district administration officials told us.

Nuh accounts for over 4% of Haryana's population, but less than 1% of total vaccinations. The district with the second-lowest vaccination figures is Charkhi Dadri, which like Nuh is 89% rural. Charkhi Dadri's total vaccinations at 38,775, however, are more than double that of Nuh's.

Nuh's total is one-sixth of the state average, while other districts are exceeding vaccination targets. Haryana has administered 1.87 million COVID-19 vaccine doses, covering 6.33% of its projected population of 29.5 million in 2021 with at least one dose of a vaccine, as of April 4.

India has administered at least one dose of a COVID-19 vaccine to 75.9 million people--5.6% of the population--by April 4, 78 days since its vaccination programme began on January 16. Of this, 10.2 million--less than 1% of the population--are fully vaccinated with two shots. To reach its initial target of vaccinating 250 million people by July 31, India will need to vaccinate 3.5 million people per day. In the past week, India has administered an average of 1.8 million vaccine shots per day.

Once a COVID-19 hotspot, Nuh has fewer lab-confirmed cases now

In over a year since Haryana's first COVID-19 case on March 4, 2020, Nuh district had recorded a total of 1,728 cases by April 4, 2021. The district has seen fewer than 10 active cases at a time since February. All told, 30 people have died of COVID-19 in this district since the start of the pandemic. Nuh's cases amounted to less than 1% of Haryana's total caseload of 298,133 cases by April 4, 2021, and just under 1% of total deaths.

The vaccination hesitancy in Bibipur is partly because there have been fewer COVID-19 cases in this village of over 4,000, say villagers. "When there is no COVID-19 in the village, why should we get vaccinated? If they force us to get vaccinated, that is wrong. We are scared of the vaccine. We don't want to die because of it," Rassa (she uses one name), 45, a farm labourer, told IndiaSpend. We heard this sentiment often in the village.

It was not always so. In April 2020, early on in the nationwide COVID-19 lockdown, Nuh was among 170 districts identified as COVID-19 hotspot districts by the central government, one of four contiguous hotspot districts in Haryana, along with Palwal, Faridabad and Gurugram.

The district had the second highest COVID-19 seropositivity among all Haryana districts in the state government's first seroprevalence survey conducted in August 2020. Over 20% of the samples collected in Nuh were positive for COVID-19 antibodies, far ahead of seropositivity in more urban districts like Gurugram, Panchkula and Ambala. By the time of the second serosurvey conducted in October 2020, nearly 18% of the samples from Nuh tested positive for COVID-19 antibodies, the sixth highest in the state.

Further, while Nuh's active caseload appears low at just six on April 4 compared to the nearly 3,000 in Gurugram, this is an increase from one active case when we visited in late March, and comes as Haryana is seeing a continuing rise in cases since mid-February as India's second wave surges. Once again, Gurugram and Faridabad districts, contiguous to Nuh, are among the four more urban districts leading the rise in Haryana's caseload.

Given the high seropositivity in the district in the two surveys, could Nuh's low caseload be attributed to lower testing in the district? Not really, said Surendra Yadav, chief medical officer, Nuh. The high seroprevalence may explain low numbers of cases in Nuh, said Yadav, since those who have the antibodies would have immunity against COVID-19. He further said that the district is conducting 600-700 RT PCR tests each day but given the current low positivity rate, there is no need to conduct more tests.

"That would just be a waste of resources," said Yadav.

Haryana does not provide tests disaggregated by district in its daily COVID-19 updates. Gurguram, however, had conducted 5,021 COVID tests in a day on March 26, according to its last publicly available update. Ambala has conducted an average 730 tests a day since April 2020, and Hisar 1,060.

Nuh, in the shadow of development

Women in Bibipur village filling water from a neighbour's tap. Only 22% of households in the Mewat region of Haryana get treated water supply, according to the Niti Aayog. Women in the district spend between 3.5 and 5 hours a day collecting water.

As one drives southward out of Delhi, the scenery changes dramatically over the 65 km distance between the respective district headquarters of Gurugram and Nuh. The highrises, malls, flyovers and underpasses of Gurugram, one of India's richest cities, give way to sparse habitation and open fields of India's most backward district, where cattle share the roads with vehicles. This disparity once coexisted in the same district.

Nuh district, earlier called Mewat, was carved out of Gurugram (then Gurgaon) district in 2005. It was renamed in 2016 to differentiate it from the cultural region of Mewat that spans parts of southern Haryana, northern Rajasthan and Uttar Pradesh's Mathura district. In 2018, it was ranked as the worst among 101 aspirational districts on parameters including health, education, agriculture, basic infrastructure and financial inclusion by the central government's policy think-tank, Niti Aayog.

Despite being a less than two-hour drive from the seat of India's central government, the district remains in the shadows. Nuh is the poorest district in Haryana. The per capita income of Gurugram is 11 times that of Nuh, according to a study on inter-regional disparities in the state conducted by the Institute for Development and Communication in state capital Chandigarh for the Haryana government in 2014. There are just 19 hospital beds available per 100,000 population in Nuh, compared to over 40 in Gurugram, according to the IDC study. Just a third of babies are born in hospital and just a third of women are literate.

Nuh is largely rural and agrarian with poor gender and social indices: Just a third of babies are born in hospitals and only a third of women are literate.

Nuh is largely rural and Haryana's only Muslim-dominated district. Just under 80% of the population are Meo Muslims, an agrarian, cattle-rearing community and a listed backward class. The extent of underdevelopment in Nuh was highlighted in the Rajinder Sachar Committee report, 2005 on the socio-economic condition of Muslim communities in India. The disparities between this district and Haryana's two Backward Region Grant Fund (BGRF) districts, Mahendragarh and Sirsa, were further highlighted in a Niti Aayog-supported study in 2015. Only 24% of households in Nuh have attached latrines; in the BGRF districts, the figure is 70%. Government drinking water supply is provided to 22% of households in Nuh and to more than 50% in the BGRF districts. On ownership of seven types of assets ranging from radio sets to vehicles, Nuh lags the BGRF districts by nearly 30-50%, except for mobile phones. Only 17.4% of households have a TV set.

The role of community radio stations such as Radio Mewat, run by Delhi-based non-governmental organisation SMART, and Alfaz-e-Mewat, supported by the central agriculture ministry, has been crucial in COVID-19 messaging, Sohrab Khan, station manager of Radio Mewat in Nuh town, told IndiaSpend. Mobile phones have doubled up as radio listening tools for the nearly 80% residents who own one, according to SMART. "During the lockdown, we have never missed a day of work. We were answering queries about COVID-19, busting fake news and relaying guidelines to people," said Khan. The station is now actively working with the administration to create awareness about COVID-19 vaccination. But there is resistance in the community, said Khan.

"People were hurt by how Tablighi Jamaat was being portrayed in the media and by government agencies," said Khan. The Tablighi Jamaat religious organisation, which held a large, pre-planned religious congregation in Delhi's Nizammudin just before the imposition of the nationwide COVID-19 lockdown, and which was subsequently accused of intentionally spreading COVID-19 across the country by the government and sections of the media in April 2020, was founded in Nuh in the 1920s. The return of over 600 Jamaat members to Nuh from Nizamuddin was attributed as the reason for the district becoming a hotspot early on in the pandemic. Incidents of religious polarisation targeting religious minorities in the district in the recent past predate the COVID-19 pandemic. "Many [in Nuh] believe the virus was not real and it is just another means to harass them," said Khan.

Overcoming immunisation challenges in Nuh

Basant Kumar, district immunisation officer, Nuh, says complete immunisation among children has improved up to 72% in the district, much higher than 13.1%, the figure in 2015-16.

"If you compare other districts and Nuh on any parameter, there are tenfold problems here, but we are in the process of making things easier for COVID-19 vaccination," Basant Kumar Dubey, district immunisation officer, told IndiaSpend.

Only 13.1% of all children younger than two in Nuh district were fully immunised under India's routine immunisation programme, compared to 65% for the state's rural districts, and 62.2%, which is the state average, according to the National Family Health Survey-4, conducted in 2015-16. (Haryana is not covered in Phase I of NFHS-5, 2019-20, released in December 2020.)

The numbers have improved much since--full immunisation had been around 48% and increased to 72% last year after four months of intense Mission Indradhanush activities, said Dubey. The mission aims to achieve full immunisation of all children and mothers. In 2021, the usual four months of Indradhanush activities had to be limited to two because of the pandemic. "The state officials even gave us the option of first completing routine immunisation activities before starting COVID-19 vaccination, but we said we will do both simultaneously," he added. There are 502 vaccinating spots in Nuh district and these villages have been provided WiFi facilities to aid efforts to register beneficiaries, he said.

The auxiliary nurse midwives (ANMs) who conduct routine immunisations in the villages were given a week of online training and told to conduct COVID-19 vaccination as well, said Dubey. However, there are hurdles--given the focus of the health services on women and children, the authorities did not have a list of those aged 60 and above years, the first age-group targeted for COVID-19 vaccination besides healthcare and frontline workers in India. The ASHAs in Nuh, as elsewhere in the country, are women from the community who are schooled till at least grade VIII, but many in Nuh struggle to read and write and hence there were problems in creating a list of elderly beneficiaires, Dubey said.

Also, while the Serum Institute of India's Covishield vaccine was delivered in 10-dose vials, Bharat Biotech's Covaxin came in 20-dose vials. While finding 10 beneficiaries before opening a vaccine pack was possible, finding 20 in a village was challenging, said Dubey. The district has thus sent back the Covaxin batches and requested that these be re-sent in batches of 10-dose vials, he said.

Contrary to what some residents told us, Dubey said there are no rumours or fears regarding COVID-19 vaccination in the community. He showed us photos and newspaper articles about health camps being held in madrassas (educational institutions), and religious leaders working with officials to advocate for vaccination.

Strong resistance and low awareness

One of the district's centres with the highest number of vaccinations is the Shaheed Hasan Khan Mewati (SHKM) Government Medical College, Nalhar. The 500-bedded hospital has been a dedicated COVID-19 care centre ever since the district was declared a hotspot in April 2020.

By April 4, the medical college had conducted about 1,600 COVID-19 vaccinations, 1,100 among hospital employees. About 500 vaccinations were of frontline workers--Anganwadi and ASHA workers, security forces and police--Kapil Sharma, assistant professor of respiratory medicine at SHKM and nodal officer for COVID-19, told IndiaSpend.

"The medical college has vaccinated 50% of the hospital staff. It is not bad considering even the Post Graduate Institute for Medical Education and Research (PGIMER), Chandigarh, has vaccinated 57% of its staff," said Sharma. IndiaSpend confirmed that about 60% of hospital staff at PGIMER, Chandigarh, have been vaccinated, till date.

Vaccine hesitancy, however, was high even among hospital staff, especially ward boys, sanitation and security workers, said Sharma. The hospital administration held meetings with all of them and motivated the supervisors to counsel their teams. The numbers improved after these efforts.

Kapil Sharma, assistant professor of respiratory medicine at Shaheed Hasan Khan Mewati Government Medical College, Nalhar, and Nodal Officer for COVID-19, said the institute had vaccinated 50% of its staff for COVID-19.

Sharma said when COVID-19 cases were many, people were scared of the virus, but as the numbers fell, they stopped worrying about it. Now that there is a second wave, people may now start coming for vaccines. "We can't vaccinate the patients admitted if they are not eligible; if their attendants are eligible, we inform them about the vaccine, but most attendants are younger, so that is rare," said Sharma.

At the medical college's vaccination centre, a few medical students were getting registered to get the vaccine when we visited. Manjula (she uses one name), a staff nurse at the vaccination centre, told us that they register the eligible beneficiaries and verify them when at least 10 are ready for vaccination. "This way there is no wastage" of vaccine vials, she said.

While those above 60 can get the vaccine on showing their Aadhaar card, those over the age of 45 with comorbidities needed a certificate from the Civil Hospital to get the vaccine until April 1, she said, adding that such enquiries had been very few.

Things were not looking different when we visited Marora Primary Health Centre, 25 minutes by road from Bibipur. Ravi Dutt, a multipurpose health worker, had been sorting vaccine ice-boxes when we arrived. Only 20 of 520 new Covishield vials had been used in the previous four days, he told IndiaSpend.

"The uptake has been slow especially in Muslim villages, where many believe a rumour that taking the vaccine may impact fertility," he said. Family planning is seldom practised in Mewat for cultural reasons, nor is female foeticide, according to the Niti Aayog study from 2015, giving the district the highest child sex ratio of 906 females per 1,000 males among all districts in Haryana, where the average child sex ratio is 830. COVID-19 vaccines had been given to ANMs along with other routine vaccines for children, but they were facing a hard time convincing villagers, said Dutt.

Not all Nuh villages averse to COVID-19 vaccination

There was no visible trepidation about COVID-19 vaccines among the villagers that IndiaSpend met in Jajuka village in Nuh. Most of the eligible villagers we spoke with were aware about the vaccines--a vaccination camp had been held in Jajuka's local co-operative bank a week before our visit.

Villagers here too had been hesitant, but had changed their minds after an awareness programme, said Sohrab Khan, in which Radio Mewat had participated.

"If the vaccine is available, I will go get vaccinated," said Soraj Singh, 77, who owns a small general store in the village. He said he had seen the prime minister take the vaccine on TV. "I know there are no side-effects of the vaccine. It will protect me from getting COVID-19," he told IndiaSpend.

Anganwadi helper Kusuma, 55, said there is willingness in her village to get vaccinated for COVID-19.

Kusuma, 55, an Anganwadi helper who herself got vaccinated, said there is willingness in Jajuka to get vaccinated for COVID-19. There was a queue outside the bank to get vaccinated, but not enough vials. "I went to get the vaccine but they said they only had 40 vials available and they will come back when they get more vials," said farmer Maman Singh, 59.

This kind of support is something that Meena Kumari, the ASHA worker from Bibipur, would love to get. "I wish they [government] would come with us and help convince the people that this vaccine is safe and will in fact protect them from COVID-19," she said.

Countering stigma, denial in socially marginalised communities

The more marginalised a community, the more vulnerable it is to disease and less likely to come forward for treatment, said T. Sundararaman, global health coordinator, People's Health Movement, and former executive director, National Health Systems Resource Centre, when asked why vaccine hesitancy differs between villages in Nuh district. "The same applies to COVID-19 and its vaccine," he said. Even with India's routine immunisation programme, vaccination has dropped among vulnerable communities, IndiaSpend reported in October 2020.

It is the government's responsibility to reach out and engage with communities. It can do so by increasing awareness and prioritising vaccination in high-risk groups like butchers, shop-keepers, sanitation workers and others, he said. Combining routine immunisation activities with COVID-19 vaccination as Nuh is doing may not be advisable, as it puts tremendous pressure on the ANM, who may find it difficult to focus on separate groups of beneficiaries.

In Nuh, where health infrastructure is already low, it is not enough to depend on people's willigness to seek out COVID-19 vaccination alone, said Sundararaman. A combination of poor education, poverty and marginalisation of a community has led to stigmatisation and COVID-19 denial in Nuh; the government will have to do the hard work of engaging with people here about the importance of getting vaccinated, he added.

(Lesley Esteves co-wrote and edited this story.)

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