India’s race to vaccinate its villages meets with rural resistance

Outside a three-room concrete building coated in faded red paint, Neeral Kullu was waiting anxiously. The 35-year-old farmer had spent the late August morning walking across miles of jungle, dirt tracks, and lush fields to reach this makeshift vaccination clinic in Simdega, a rural district in Jharkand, one of India’s poorest states. At the entrance he was greeted by two white-coated nurses stationed at a small table laid out with syringes, Covid-19 vaccination cards, and paracetamol tablets. Still, Kullu was unsure he’d actually get an injection. The first time he’d tried, a couple of weeks earlier, fewer than five people had turned up, and he was told to come back the next day, because opening a precious 10-dose vial for so few recipients would be a waste. When he returned, a nurse told him his blood pressure was too high and sent him home again.

On this visit, Kullu sheltered under a fig tree while he waited for his turn. His blood pressure was normal, but when a nurse tried to register him on the government’s vaccination-tracking app, a new obstacle popped up: She couldn’t get a phone signal. Clutching her handset, she took five steps away. Still nothing. Then another five steps. Suddenly, a couple of small bars popped up on the screen. She could record Kullu’s shot. A few minutes later another nurse injected him with his first dose of AstraZeneca Plc’s Covid vaccine. Kullu, who wore a sky-blue polo shirt with a prominent tear at the chest, blue shorts, and rubber sandals, was elated. “The gods are supporting me today,” said the father of two, beaming.

Kullu was the latest beneficiary of one of the largest vaccination drives in the world—and one of the most troubled. Since India began distributing doses in January, the campaign to vaccinate its 1.4 billion citizens has hit snag after snag, held back first by shortages and then by chaotic distribution, confounding expectations that the country would lean on its vast and effective election-management system to ensure dispersal. Ten months later, the country finally has adequate supply, but the current challenge is arguably the most daunting: getting shots into arms across the vast, impoverished countryside, where some two-thirds of Indians—many of them—live. Nationally only 24.8% of the population is fully vaccinated, according to Bloomberg’s Covid-19 Vaccine Tracker, a rate that lags those of Indonesia and Thailand and is less than one-third that in mainland China.

The stakes could hardly be higher, both for India and for the world. Public-health experts fear that a third wave of infections could soon wash over the subcontinent, shattering the uneasy calm that’s prevailed since the end of the second, which crested in May. Then, medical resources were so overwhelmed that some Delhi parks were converted into open-air crematoriums; in the northern state of Uttar Pradesh, the bodies of victims were left to float down the Ganges. Now, with most urban residents either vaccinated or previously exposed to infection, it’s in rural areas where the virus will find the largest pool of immunologically naive targets.

These are also places where the health infrastructure is rudimentary, to say the least. The state of Jharkand, for instance, has just nine hospital beds per 100,000 people, the second-lowest total in India; in the number of nurses per capita, it ranks dead last. Such environments give the virus ample opportunity to mutate, potentially seeding new variants that are even more formidable than delta, which was first identified in India almost a year ago.

In Simdega, Shyamal Santra watched approvingly as Kullu and other local residents got their shots. Thirty-seven years old with a 6-foot frame, Santra oversees vaccination efforts in rural Jharkand for the Transform Rural India Foundation (TRIF), a nonprofit funded by the Bill & Melinda Gates Foundation and the technology tycoon Azim Premji, among other donors. The organization is helping state governments deliver vaccines across 3,800 of India’s poorest villages—many of them difficult or even dangerous for health-care workers to access.

Santra’s territory is some of the most challenging, with few roads and minimal health infrastructure. It and other regions of Jharkand are also home to the Naxalites, a loose grouping of Maoist insurgents who periodically launch attacks on government officials and security forces. Since Santra began working in the state about a decade ago, he’s twice been taken hostage by the militants, who released him only after they were satisfied that his work was serving the rural poor.

His team is on a race against time to vaccinate as many of Jharkand’s inhabitants as possible, traveling to distant villages on foot, by motorbike, and in rugged makeshift ambulances. Sometimes they come across settlements that have had little contact with the government for years and whose residents are understandably wary of outsiders bearing what they say are lifesaving medicines. It’s painstaking work that demands a diverse set of skills: public health with some sociology and anthropology thrown in. If a new surge arrives before widespread vaccination, “it will be more devastating than what we have seen,” Santra warns. “There’s no second option.”

When Prime Minister Narendra Modi’s government officially kicked off India’s vaccination drive in mid-January, it was with great confidence. “Our preparation has been such that vaccine is fast reaching every corner of the country,” Modi boasted shortly afterward. “We are completely self-reliant.”

On paper that assessment wasn’t entirely outlandish. Unlike almost all other developing nations, India has enormous capacity to produce vaccines domestically, above all through the Serum Institute of India Pvt Ltd., the largest vaccine manufacturer on the planet. The Serum Institute made a deal in June 2020 to manufacture a billion doses of AstraZeneca’s shot, while another domestic company, Bharat Biotech International Ltd., was carrying out final-stage trials on a vaccine it developed in-house. And while India’s health-care system is underfunded and overtaxed, the country has extensive experience with large-scale vaccination campaigns, particularly for polio and other childhood diseases.

But it soon became apparent that even with these home-field advantages, the rollout wasn’t going to go smoothly. First, India’s drug regulator surprised scientists and provided ready kindling for anti-vax conspiracy theories by granting regulatory approval for Bharat Biotech’s Covaxin shot before the completion of trials. Then it took weeks to begin large-scale distribution, haggling over pricing with the company as well as Serum. (The World Health Organization added Covaxin to its emergency use list of approved inoculations this month, helping dispel lingering doubts about the efficacy of the domestically-developed vaccine).

The result was that by the time delta infections began surging in Delhi and other cities in March, few Indians had even received a first dose. Officials scrambled to catch up, initially blocking exports—thus intensifying outbreaks in countries, including Nepal and Bangladesh, that had been counting on Indian supplies. Then they did away with all age and health prioritization for domestic doses, on the theory that these were slowing down the campaign. A chaotic free-for-all ensued, with the wealthy paying to be vaccinated in private facilities and big companies, including Bloomberg LP, sourcing shots for their staff. Everyone else who wanted one had little choice but to shuffle from clinic to clinic, chasing rumors of available supplies. In rural areas, there were often none at all.

Even in the early weeks of the national rollout, it was clear that reaching the hinterlands where most Indians still live was going to be a colossal challenge—and probably beyond the government’s scope. From the start of the pandemic, officials in poorer states have leaned on charitable organizations including TRIF for support, tasking them with everything from training staff and analyzing epidemiological data to caring for migrant workers, millions of whom returned from major cities when the economy was locked down last year.

Vaccines would be no exception, and Santra was an obvious choice to help lead the campaign in Jharkand. Although he now lives in Ranchi, the bustling state capital—and is partial to pressed dress shirts and suit trousers—he grew up in a working-class family in a small town in West Bengal. As a student in Delhi, he once struck up a conversation with a man who lived in a slum on the banks of the Yamuna, the heavily polluted river that snakes through the capital. Soon after, Santra embedded himself in the community for eight months, even joining protests against government plans to demolish informal settlements. He emerged determined to work with India’s poorest people. After a string of jobs at other charitable organizations, he joined TRIF in 2018.

Santra had been working in rural areas long enough to know that whatever the central government claimed, pulling off a vaccination program of unprecedented speed and scale, in every part of India, would be extremely complicated. For one thing, the main initial method for booking a slot was through a mobile app called CoWin—convenient for the urban middle class but next to useless in communities where few people have smartphones or a reliable data connection.

The other bottlenecks were obvious. India’s government spends just 1% of the country’s gross domestic product on health, far below the 10% that is the global average, according to the World Bank. While cities such as Delhi and Mumbai boast well-appointed private hospitals, care in rural areas is provided by a creaky network of public clinics, with too few staff to administer so many doses on a compressed schedule. Reliable electricity is often a luxury, as are refrigerators, complicating any attempt to distribute temperature-sensitive vaccines in a country where summer temperatures can push past 40C (104F). Previous vaccination efforts had also encountered this worrying problem: Many people simply never return for their second shot, particularly if they live a long distance from a clinic.

Santra’s team got started in January, initially targeting larger, better-equipped communities, using them as bases for extending supply lines deeper into the forests that cover much of Jharkand. They’ve now assembled a network of about 100 staff and volunteers, administering as many as 20,000 doses each day. But almost a year in, the work isn’t getting much easier.

The hub for vaccine distribution in Simdega, the rural district where Kullu received his first dose, is an old, four-room outbuilding at the local hospital. It’s run by a staff of just three, who were trained on video calls by state health officials. “We are lucky to have three people,” one of the trio, Akhilesh Prasad, said during a recent visit. “Other places have fewer.”

In part because India has so few deep-freeze facilities outside of urban centers, it isn’t using the mRNA vaccines produced by Moderna and the Pfizer-BioNTech partnership, which both must be kept at subzero temperatures. The range for the AstraZeneca and Bharat Biotech inoculations is from 2C to 8C, meaning they can be stored in a standard pharmacy fridge. The facility in Simdega has two, which are connected to backup diesel generators, since the area typically gets only 18 hours of electricity per day. For added insurance, Prasad keeps plenty of ice packs on hand.

Around 9 a.m. in the morning, a pair of vans arrived to collect the day’s vaccine allocation for smaller communities. A worker jumped out from each vehicle, presenting Prasad with an authorization letter for the volume of doses required. They matched the numbers he was already expecting, thanks to a government vaccine distribution app and a WhatsApp group that local health-care staff use to coordinate. After recording the shipment in a pair of notebooks, Prasad handed over 5,000 doses—4,000 of Covishield, the Indian brand name for the AstraZeneca shot, and the rest from Bharat Biotech—placing them in coolers lined with ice packs, along with boxes of syringes and blank vaccine certificate cards.

One of the vans departed for a small health center in Kurdeg, roughly 30 miles away, a two-hour drive on narrow, rutted roads. Santra arrived around the same time as the shipment, greeting TRIF’s volunteers and asking how their work was going. The clinic boasted a brand-new refrigerator exclusively for Covid vaccines, making it the last stop in the “cold chain” that Santra and his team had helped design. But many of the vials needed to travel farther. Those logistics would fall to Spikar Kujur, 31, and Salmon Tappo, 35, whose motorbikes were parked outside. They would courier the doses to their destinations in blue plastic coolers, navigating dirt tracks to reach settlements that have no connection to the road network. There, nurses would actually inject them into arms in village clinics or in schools. Before sunset, Kujur and Tappo would ride back to Kurdeg to return any unused vials. They each earn 90 rupees ($1.20) for the day’s work.

Public-health workers haven’t always been welcome in such communities. That’s partly because of vaccine hesitancy, particularly in places that are sufficiently on the grid to have access to the internet—a boon in many respects but also an extremely efficient vector for disinformation. It’s also a function of long-standing distrust of anyone connected to the state. The Indian government’s five-decade-long counterinsurgency campaign against the Naxalites has killed thousands of civilians, and the movement, which remains formally committed to a peasant-led revolution, enjoys broad support in some remote areas despite its own record of human-rights abuses.

Santra prefers to have his staff move around on motorbikes, which attract less attention from locals and the militants than big, modern cars, but keeping a low profile doesn’t always make a difference. On one of his team’s early trips to a particularly remote settlement, residents were waiting to pelt the visitors with rocks if they didn’t turn around. In another area nearby, a vaccination worker was attacked with a scythe. After these incidents, Santra concluded that his only hope was to get help. “We realized change in attitude was not possible without local leadership,” he explains. “Community volunteers are the key.”

TRIF began recruiting what Santra called “change sisters”—one or two women in each community tasked with winning over skeptical neighbors. They went door to door offering basic information about the vaccines, trying to answer questions and dispel rumors.

An important part of their work and that of TRIF’s other volunteers is to gain the trust of religious leaders, who in places with few secular institutions are often sources of authority. After the day’s shipment of vaccines arrived in Kurdeg, Rupesh Kumar Mishra, a Hindu priest wearing a knee-length white kurta and a thick layer of golden sandalwood paste on his forehead, stood outside his temple with a megaphone in hand. “Greetings to fellow fathers and mothers, brothers and sisters,” Mishra called out in the local dialect of Odia, a language spoken in parts of eastern India. “Corona vaccine is very important to save ourselves from corona infections. You have to reach the nearest vaccination point to get the shot.” At a mosque nearby, Imam Mohammed Hossain Raza put out the same message, as did priests in the local churches. Meanwhile, drivers trundled around in motorized trishaws, announcing through a loudspeaker that vaccines were available.

Bit by bit, villagers were making their way to mobile clinics. At one, set up in an eight-room school, two teachers’ desks had been pushed together to serve as a registration point. From there it was just a few steps to another table, where a nurse briskly administered injections. Under a mango tree outside, Santra’s team had set up a couple of photo booths, where recipients could take a post-shot portrait. Some of the younger villagers set the photos as their status images on WhatsApp, providing motivation for their friends and family to also get inoculated. At least, that’s what Santra hoped.

In May, Baba Ramdev, a yoga guru with a huge national following, delivered a message that enraged members of India’s medical community. “One thousand doctors have died even after getting both doses of the vaccine,” Ramdev said during a yoga session, which was broadcast live on Twitter. “What kind of doctors are they, if they could not save themselves?” Later, he said he didn’t plan to get vaccinated, because he would be protected by a “double dose” of yoga and ayurveda.

Ramdev’s claim about dead doctors was completely false, but combined with other statements by the guru and a vast gallery of other vaccine skeptics, both religious and secular, who reach Indians through social media and village rumor mills, it illustrated a serious problem. While national polls indicated that by April a clear majority of citizens were willing to get a Covid shot, poor, rural populations tended to be much more wary. A survey conducted around that time by the Self Employed Women’s Association, a union with more than 1.6 million members, most of them small-scale farmers, found that just 17% planned to get themselves and their families vaccinated.

Some of the factors driving vaccine hesitancy in India would be familiar to anyone who’s studied the phenomenon in the U.S. or Europe. QAnon and its offshoots, for example, have spread around the globe. Other conspiracy theories have been filtered through the unique sectarian politics of the subcontinent, becoming more potent in the process. Modi’s Hindu-nationalist Bharatiya Janata Party is mistrusted by many Christians, Muslims, and members of other religious minorities, and some see vaccinations as part of a larger plot to politically and economically marginalize India’s minorities—or even eradicate them entirely.

In a predominantly Christian village called Rengarbahar, Santra encountered intense hostility to his team’s efforts, amounting almost to a boycott. “Modi wants to kill us,” one resident told him. “They have different vaccines for themselves, and the ones that are being given to us will either make us impotent or kill us.” One of his volunteers, 28-year-old Surekha Kumari, had a similar experience in Chadrimunda, deep in the Jharkand forests. At first, people she approached there were “abusive and hostile,” she says. “They started telling me that if something happens to them after taking the vaccine, I’ll be responsible for their deaths.”

Santra and other public-health workers have had to get creative to overcome pockets of resistance. After learning of the level of skepticism in Rengarbahar and Chadrimunda, volunteers began knocking on doors every morning, politely but relentlessly urging people to get the shots. To make that easier, TRIF began setting up a larger number of small, local injection sites, reducing the distance residents had to walk. And, Santra says, “we realized that if someone has fever in the night after the vaccine, people can’t be taken to a hospital or seen by a doctor in these far-off places. So we made it a policy to distribute two paracetamol tablets” to everyone receiving a shot. “These things helped.” By mid-August almost every adult in Chadrimunda had received at least their first dose; in Rengarbahar, the figure was around 70%.

The task now is to ensure that everyone returns for the second. Federal rules stipulate that Covid vaccine doses be administered 12 to 16 weeks apart, so many people in Jharkand are only now becoming eligible. (Initially, the gap was imposed to stretch supplies; it’s been maintained partly because studies have shown that a longer break might produce superior immunity.) But residents may not be as motivated this time around. A first-shot certificate has become a de facto requirement for accessing many welfare programs in the state, including a food-rationing system many families depend on. There’s no equivalent incentive for the other dose.

Modi met with officials in districts with low vaccination coverage this month and urged them to pick up the pace. The country also plans a campaign titled Har Ghar Dastak—“a knock on every door.”

In the communities where she works, Kumari is trying to keep track of everyone coming to the end of their mandatory gap, then nudging them to get to a clinic. But as with so much else in India’s experience of the pandemic, the problem is one of scale. “People have to be self-driven to take the second dose. That’s not easy,” Santra says. “Surekha doing it in one village, out of her own efforts, won’t solve that problem for the country.”

Sushant Gaurav, a tall, lean local-government manager, strode confidently into a brightly lit meeting room in Simdega, apologizing for being a few minutes late. The 15 or so people waiting—doctors, local bureaucrats, and staff from TRIF—stood up respectfully to greet him. As the deputy commissioner of the district, Gaurav ranked as a senior official, and he was bearing important news: He’d received an assessment from the federal government that a new surge of Covid cases was likely to begin soon. Even more alarming, he said, scientists working on the response believed that children, who remain ineligible for vaccines in India unlike in the U.S. and Europe, would be among the worst affected.

The group began going through an update on local preparations. Two pediatric intensive-care units under construction in the area were still essentially shells, with insufficient medicines and too few staff. Most of the district’s ambulances were rickety converted vans, unsuited for heavy use. Gaurav promised that the government would find some new vehicles and quizzed the public-health managers about testing capacity. “Our preparation should be good to ensure we do not let it become a wave this time,” he said.

No one can say whether India’s next crop of Covid cases will be as deadly as the last—a national trauma more severe, in terms of the sheer scale of suffering, than any on the planet since the start of the pandemic. New cases peaked at more than 400,000 per day in May, ultimately pushing India’s official death toll past 461,000. (Given the state of record-keeping outside large cities, that figure is certainly a drastic undercount.) Some studies of sero-prevalence—the number of people in the population who have Covid antibodies—suggest that the majority of Indians have already been exposed, which could restrain its spread. But even under the most optimistic assessment, hundreds of millions remain vulnerable.

Santra is trying to make the greatest possible impact in the time he has left. On a sweltering day in Chadrimunda, he looked on as a group of teenage volunteers, trained by TRIF staff, gathered at a raised platform in the town center used for public meetings. An elder named Ram Chandra Nayak had brought a nagra, a goblet-shaped drum made from buffalo leather, and began tapping it rhythmically—a traditional method of summoning villagers to a gathering. In this case, it was to watch the teenagers do a series of skits. First, some of them played health-care workers, answering common questions about vaccination. Then they acted out the procedure at a clinic, an attempt to demystify the process of getting a shot. In that vignette, one of the teens was dressed as an old woman, with a tattered white sari and a wooden walking stick. “I’ve heard,” she said theatrically, that the vaccine “will kill us, and women can’t have children if they take it.” Another performer replied with some epidemiologist-approved common sense: “Look at these people. They have all taken vaccines. Has anything happened to them? Corona can kill you, but vaccines will save you.” Persuaded, the skeptics queued up to take their simulated shots. A moment later the players formed a line and took a bow. Bloomberg