Remote Tribal Village Shows How To Fight Vaccine Hesitancy

Skepticism about Covid-19 vaccination among tribal villagers in Maharashtra's Melghat forest is being reversed with advocacy in the local Korku language. It's a playbook for effective communication in India's remote, tribal-dominated pockets with longstanding low immunisation coverage

COVID - vaccine hesitancy

Mumbai: Tembhrusonda village, located on the periphery of the Melghat Tiger Reserve and 80 km from Amravati city in eastern Maharashtra's Vidarbha region, appeared an unlikely setting for a video-recorded interview of a doctor speaking on public health policy. But when Chandan Pimparkar, a doctor at the Tembhrusonda primary health centre (PHC), urged viewers not to fall prey to rumours about Covid-19 vaccines, he had an attentive audience. He was speaking in Korku, the language spoken by at least 600,000 indigeneous people in central India, and one of the world's endangered languages.

Pimparkar's is the second in a series of five videos in Korku uploaded on the YouTube channel of the state Integrated Tribal Development Project's (ITDP) Dharni project office, a key element of official strategy in the Melghat region--which includes the Dharni and Chikhaldara blocks of Amravati district--to reinforce vaccine advocacy by using the local language.

A public meeting underway in Chinchkheda village early in May. PHC doctors, block-level officials and local political leaders led the meeting, clearing citizens' doubts regarding the vaccine.

Since the video-series was launched mid-April, four villages in Chikhaldara block have achieved 100% vaccination of eligible adults, tehsildar Maya Mane told IndiaSpend. Bahadarpur, Ruiphata, Chinchkheda and Kakadari, all small hamlets with an eligible population of between 85 and 150 people each, achieved the target at day-long camps in the last two weeks of May.

For the Korku villagers of the region, not only the language, but the speaker too is one of their own, and that is why the video-series helped allay long-standing mistrust of public health systems among tribals in remote areas, said Mane. Alongside a slew of other measures, such as gram sabha meetings and discussions at the village square led by vaccinated health workers, the use of Korku helped tweak vaccine advocacy to make it culturally relatable and trust-inspiring, a redesigning that doctors say will be central to reversing vaccine hesitancy among indigeneous people across the country.

Local language and culturally relatable Covid-19 vaccination awareness campaigns, recommended by both the World Health Organization (WHO) and India's health ministry, are getting under way slowly in other tribal-dominated regions across India as well, such as messages in the local dialect in rural Nashik, Maharashtra, and songs and memes in the Wagdi dialect in Banswara and Dungarpur in southern Rajasthan.

The efforts come as some tribal-dominated districts in several states have recorded disproportionately lower vaccine coverage in comparison with other districts, official data show. Further, the district-level aggregates disguise low vaccination coverage in tribal-dominated pockets, researchers in several states told us. Yet indigenous people are more vulnerable than others during the pandemic on account of their higher degree of socio-economic marginalisation, their lack of access to effective monitoring, early-warning systems and health and social services, the United Nations Permanent Forum on Indigenous Issues has said. The WHO has recommended that these groups be prioritised for immunisation in countries with low vaccine supplies.

'Corona loses and Melghat wins'

"Their homes deep inside a forest, Melghat's tribals can hardly be expected to read posters about Covid-19," said Dayaram Jawarkar, paediatrician at the sub-district hospital in Dharni, one of the first specialist doctors among the Korkus of Melghat, practising since 2005. That is how a small team came to work on audio-visual messaging, Jawarkar told IndiaSpend. Jawarkar was featured in the first video of the series, interviewed in Korku by PHC counsellor Mamta Sonkar, both sporting masks.

The sub-district hospital in Dharni is home to a 60-bedded Covid ward, prepared in record time over three days in April, to cope with the sharp rise in Covid-19 patients from the Melghat region who required hospitalisation but were unwilling to travel to the dedicated Covid hospital in Amravati city, government officials told IndiaSpend.

"In our villages, people still summon hakims and bhoomkals [traditional healers]," Jawarkar said. Modern medicine and hospitals have become accessible to Melghat's tribals only over the last three or four decades, he added. Even today, only 40% of Korkus are able to afford the travel to a city hospital and also cope with the alien milieu of Hindi- or Marathi-speaking staff, large buildings with elevators, the hum of medical equipment and, now, the sight of healthcare workers in full personal protective gear.

In Jawarkar's own village of Dhakarmal, about 15 km from Dharni, trepidation about Covid-19 vaccines was widespread. As cases and fatalities emerged in villages, the fear of the disease was matched by the fear of the injection among the healthy, said Jawarkar. Rumours flew thick and fast, first that the vaccine for health workers was different from that being administered to the general public, then that the shot led to infertility. "At one point, people believed that being infected and being administered the vaccine would both cause certain death," he said.

A mobile unit vaccinates a senior citizen in a Melghat village.

Amravati district was among the country's first to witness a sharp second wave, IndiaSpend reported in February 2021. Towards the end of March, Mitali Sethi, sub-divisional magistrate and project officer at ITDP-Dharni, had already initiated mandatory Covid-19 testing of all symptomatic visitors to Melghat's PHCs and mobile swab-collection facilities for hamlets that were reporting many cases of fever, and was coordinating with private hospitals and companies to make oxygen concentrators and cylinders available.

The video-series came next, aiming to mobilise community support for the laggardly vaccination drive. "We titled it 'Corona haartiwa, Melghat jitauva', or 'Corona loses and Melghat wins'--it caught on like a slogan," Sethi told IndiaSpend.

The videos have modest viewership numbers--few among the target audience own smartphones--but residents say non-governmental organisation workers active in Melghat have played the audio in village after village, using amplifiers. The first in the series was viewed the most, nearly 1,800 views in a couple of weeks. Along with other measures, the series helped convert the vaccine skeptics, said Sethi.

Registration of vaccine beneficiaries in Chinchkheda. A PHC doctor registered the eligible citizens using his cellphone.

A doctor took charge of registering eligible residents of each village on the central government's CoWin portal, spending a day in each village registering people through his cellphone, said Pimparkar. "Other villages are looking at these fully vaccinated villages as role models," he said. The series of village meetings and door-to-door persuasion continues in Melghat.

Slow progress of jabs in India's tribal pockets

India's Covid-19 vaccination programme was launched in January, starting with healthcare and frontline workers, a total of 30 million people. In a second phase that began on March 1, the vaccination drive was extended to include all Indians above the age of 60, and those above the age of 45 years but with pre-specified co-morbidities, a total of 300 million people.

As the second wave hit, the government expanded the vaccination programme further, opening vaccination to all above the age of 45, starting April 1. At the time, while less than 1% of the country had been fully vaccinated with two shots, some of India's most backward districts began to report hesitancy regarding the vaccine.

Eligibility was increased to all adults on May 1, near the peak of the second wave, but shortages led to many states stalling vaccination for the younger population.

Against the government's original target of 400-500 million doses by July 2021, the total number of doses administered until 5 pm on June 7 was 231 million, with daily doses crossing the 3 million mark only twice over the previous week.

Several pockets in rural India have since seen vaccine hesitancy, leading to some violent incidents, wastage of doses in opened vials and frustration for frontline workers tasked with preparing for a third wave of infections.

Vaccination underway in Chinchkheda.

In several states, some tribal-dominated districts have recorded disproportionately lower vaccine coverage in comparison with other districts, data from the Cowin dashboard show. India's tribal-majority areas outside of the North-East are listed under the Fifth Schedule of the Constitution. Tribal-dominated areas in four North Eastern states are separately listed in the Sixth Schedule. There are presently 34 fully Fifth Schedule Area districts and 63 partly Fifth Schedule Area districts in 10 states, per the Ministry of Tribal Affairs. Many of these districts are among the Niti Aayog's list of 112 most backward, or aspirational, districts, selected on the basis of poor health outcomes, among other criteria.

Many Fifth Schedule Area districts in Andhra Pradesh, Chhattisgarh, Maharashtra, Madhya Pradesh, Odisha and Rajasthan have featured in the health ministry's list of districts with Covid-19 positivity rate greater than 10% in the last three weeks. Lahaul and Spiti in Himachal Pradesh has had Covid-19 positivity greater than 10% for three weeks running.

Maharashtra and Madhya Pradesh appear to have made the slowest progress in vaccinating eligible populations in some of their Fifth Schedule areas. Further disaggregation by vaccination centres on the CoWin portal shows that several tribal-dominated talukas (blocks) have witnessed slower inoculation.

Palghar, carved out of the Fifth Schedule area district of Thane in 2014, is Maharashtra's worst performing district in terms of percentage of eligible population who have received at least one dose of a vaccine. At 15.7%, it is nearly 10 percentage points behind the state average of 24.7% coverage till June 4. The coverage is disproportionate in the district's ST-dominated blocks. While Mokhada taluka accounts for 2.8% of Palghar's population, it accounts for just 0.9% of doses administered in the district--it has a 92% ST population. A single vaccination centre at the Amba Mata Mandir in Palghar city has recorded more vaccinations (3,564 doses) than Mokhada taluka (3,482 doses) from the start of the vaccination programme to June 4. Palghar's Vikramgad taluka, also with a 92% ST population, has fared even worse--it accounts for 4.6% of the district's population, but only 0.3% of vaccine doses administered.

In Madhya Pradesh, several tribal-dominated districts have vaccinated well below the state average of 22.4%. The fully Fifth Schedule area districts of Mandla, Jhabua and Barwani, with ST populations of 58%, 87% and 69%, respectively, and the partly Fifth Schedule area districts of Chhindwara, Siddhi and Khargone with ST population 37%, 28% and 39%, respectively, all lag the state average. These districts have vaccinated between 14% and 18% of their population with at least one dose, compared to the state average of 22.4%. Other non-Fifth Schedule tribal-dominated districts like Alirajpur (ST population 89%) and Anuppur (ST population 49%) also lag the state average, with 19.1% and 18.4% of their population, respectively, vaccinated with at least one dose.

In Chhattisgarh, 10 districts have recorded less than the state average of 35% coverage with at least one dose for their 20-plus population. Four of these are fully Fifth Schedule areas, another three are partial Fifth Schedule areas. Of the remaining three, Narayanpur has a 77.4% ST population and Kabeerdham/Kawardha has a 20.3% ST population.

Urban-rural divide

District-level averages in many of the Fifth Schedule districts reflect the high Covid-19 immunisation coverage in their urban parts, say local activists. India's ST population is almost entirely rural.

Grassroots organisations in Odisha and Jharkhand have reported that vaccination drives are still only starting off in remote areas and adivasi pockets, Tushar Dash, an independent researcher on adivasi communities and forest-based livelihoods based in Bhubaneswar, told IndiaSpend.

Odisha has seen a more mixed performance in Fifth Schedule areas. Mayurbhanj district, a fully Fifth Schedule area, shows only 18.1% of its 20-plus population vaccinated with at least one dose till June 4, compared to the state average of 24%. It has received a little over 4% of all doses administered in the state, while it accounts for over 6% of the state's population. Koraput, another fully Fifth Schedule area, and Sambalpur, a partly Fifth Schedule area, have seen above average performance of 31% and 37% single-dose coverage, respectively. The latter is the state's fourth most urbanised district, with a nearly 30% urban population.

In Chhattisgarh's Raipur district, home to the capital city and also a partially Fifth Schedule area where less than 30% of the eligible population has received at least one dose, the rural-urban divide is sharp, say local activists.

Yogesh Jain, a public health physician and paediatrician who co-founded the Jan Swasthya Sahyog in Bilaspur, Chhattisgarh, told IndiaSpend that the level of current vaccine hesitancy in India's remote pockets is "mind-boggling", and that he hasn't seen such fear of a vaccine or public health measure in the past despite marginalised communities' long-standing mistrust of state-run amenities.

One reason for the hesitancy is that messaging regarding the vaccine was injudicious from the start, said Jain. "We told people, take the vaccine and you will be protected from the disease, but this is nonsense." Instead, there should have been clear messaging to say vaccination would protect citizens from serious illness but this was never attempted, he said.

Also, the vaccination programme began during a lull in the pandemic, but had already run into chaos and shortages just when the second surge hit, by when the probability of being infected was higher even for those who had taken a shot.

Jain said many who went to take a shot may have been incubating the disease or were asymptomatic, and if they came down with symptoms soon after and tested Covid-positive, they would simply blame the infection on the vaccine. "So the myth developed that the vaccine causes disease, and some of these patients who died later would be seen as killed by the vaccine," he said.

Tribals in Jharkhand, served by only marginal levels of public healthcare, extensively relied on traditional medicine to treat Covid symptoms, Sanjay Bosu Mullick, an activist with the Jharkhand Jangal Bachao Andolan (JJBA), told IndiaSpend. Many died, untested and untreated for Covid-19, "but many were also cured either because of their immunity or because something they consumed alleviated their symptoms, leading to the belief that traditional medicine is sufficient protection against the disease". This, coupled with instances of fatal Covid infections among those who had received one dose, has sharpened vaccine hesitancy across tribal areas of Jharkhand, said Mullick.

JJBA's activists from 14 districts have sent feedback that people in remote tribal pockets are still very wary of taking the injection, said Mullick. The government is, meanwhile, trying various means of persuasion including through religious leaders and tribal chiefs. "At other times, the government does not recognise the tribal system of administration, but right now they're trying all means of exerting influence on those who are hesitant to take the shot," Mullick said. "But it is too late."

In Jharkhand, fully Fifth Schedule district Sahibganj and partially Fifth Schedule district Godda bring up the rear of vaccine coverage, with 13.9% and 15.5%, respectively, of their 20-plus population receiving at least one dose, against the state average of 20.5%. Three fully Fifth Schedule districts are among the top five in vaccine coverage for their 20-plus population, but two of these, East Singhbhum (home to Jamshedpur) and Ranchi have large urban populations, 55% and 43%, respectively.

Recapturing faith

Back in 2019, when it was still uncertain what force the next influenza pandemic would gather, the WHO called vaccine hesitancy one of its top 10 challenges for the year. A vaccines advisory group of the WHO identified "complacency, inconvenience in accessing vaccines, and lack of confidence" as the top reasons for hesitancy, and added that community health workers would continue to be the most trusted influencers of vaccination decisions.

For India in 2021, this means locating traditionally vaccine-hesitant groups and those newly diffident about the Covid-19 vaccine in particular, and then to devise granular, location-specific and community-specific strategies to build credibility for the world's largest vaccination programme.

Why is this urgent? For the nearly 900 million Indians, or 65% of the population, who live in rural areas, vaccination is critical. By early May, almost half of all new cases were in predominantly rural districts, even as cases began to stabilise in the big cities, indicating a wider dispersal of infections and penetration into rural India.

No data are available on how vulnerable tribal communities are to Covid-19, the extent of infection spread and which regions could be prioritised for vaccinations, said Dash in Bhubaneswar. This is because of lack of access to testing and treatment for tribal communities, with a "visible absence" of temporary medical centres for quarantine and medical care at the panchayat level, while several such centres set up earlier during the first wave of the pandemic are now closed, said Dash.

The historical neglect that rural public healthcare, and India's indigenous people in particular, have suffered, shows up in poorer health indicators compared to non-tribal communities, and a greater burden of morbidity and mortality. Among other major ailments, tribals bear a disproportionate burden of India's tuberculosis cases. More than 45% of tribal children below five years of age are underweight, and less than 56% of children under the age of two are fully immunised, according to the National Family Health Survey-4 (NFHS). STs have the worst immunisation rates among all social groups in India, NFHS data show.

The Union government's own protocol for containing the surge in rural and tribal regions, released mid-May, drew attention to the need to tackle vaccine hesitancy in order to achieve high vaccination coverage.

On June 4, in a letter to Union minister for tribal affairs, Arjun Munda, 20 independent researchers and representatives of organisations working on tribal rights called for, among other livelihood-related measures, special testing and vaccination drives in adivasi areas. Covid-19 infections have been reported by members of at least 21 particularly vulnerable tribal groups, said the letter, signed by representatives of Campaign for Survival and Dignity, Jharkhand Jangal Bachao Aandolan, Van Panchayat Sangharsh Morcha and All India Forum of Forest Movements. The letter has been reviewed by IndiaSpend.

Not just organisations working on health, but all civil society groups including women's collectives, self-help groups, trade unions, farmers' groups and others, will have to work on Covid immunisation messaging over the coming months, said Jain in Bilaspur.

"There is a need for larger engagement of civil society partners because in the clinical desert that most of rural India is, huge and very serious consequences will follow for the people in coming years," he said. Unlike the peak and trough in urban India's Covid cases, remote pockets will see cases plateauing for a while, he said, adding to the burden of already-broken public health infrastructure for non-Covid care.

The mass media methods applied until now for vaccine and Covid-care messaging will simply not work, as already proven, in rural India, he added, recommending granular meetings of about 20 people in villages and hamlets, "talking about the science, which is beyond the capacity of an impersonal state". This is the only way to recapture faith in a key public health intervention, he said.

The Melghat playbook

With four villages now established as 'model villages', the latest in Melghat's video series takes viewers into one of these, Bahadarpur, featuring an Accredited Social Health Activist (ASHA), a local politician and villagers lounging outside their homes with their children and goats. Speaking in Korku, they tell viewers that they're perfectly healthy after getting the shot.

A meeting underway in Pipadari village of Chikhaldara taluka.

Chikhaldara tehsildar Maya Mane visits homes in a village in Melghat to convince residents to take the vaccine.

Chikhaldara tehsildar Maya Mane herself attended village meetings before the camps were organised. "I told them I could travel and attend a small meeting without fear because I am already vaccinated," she told IndiaSpend. The persuasion by talathis (revenue department village officials) and police patils (village police officials) of these villages played a key role, she added.

Barely a month ago, almost nobody was willing to get vaccinated and doses in the vials were going to waste. The Korku videos shared on WhatsApp started an important conversation in these villages, said Mane.

Before the videos were released, PHC counsellor Mamta Sonkar spent hours every day, almost begging villagers to get tested, treated or vaccinated. "For the first time, the villagers were flatly refusing. They've never rejected my advice before," Sonkar told IndiaSpend. Villagers would give her names of others from neighbouring hamlets who died despite going to hospital, and then no amount of reasoning would move them. It took a village, and community mobilisation through culturally relatable measures, to reverse the trend, she said.

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