Not very long ago, family planning dominated health system allocations and priorities in India and resulted in much harassment for grassroots health workers and the rural folk. It turned into a target-chasing, at times compulsive, exercise. The corollary was the undermining of trust in the public health system, which would often lead to people avoiding contact with health facilities for routine health services.
Meeting targets
Such trust is indispensable for large public health programmes to function optimally, particularly in cases like COVID-19 vaccination. But the primeval tendencies of the Indian public health system often antagonise such trust. These tendencies entail that a public health problem is seen merely as a function of input deficiencies, which can be overcome by pouring in more resources, manpower, and policies. The rich processes involved in translating these inputs into outcomes, which are deeply entwined with local contexts, are largely dismissed. They also result in benevolent objectives turning into ruthless targets which are to be met at all costs and reduce subtle activities like community sensitisation into simplistic information-education-communication exercises.
There is every reason to expect these primeval tendencies to kick in and play foul in the COVID-19 vaccination drive. There are signs of vaccine hesitancy in India. Crucial junctures like a pandemic provide a window for communities to express distrust of otherwise long-established interventions like vaccines. For the government, failing to act with finesse in such situations could produce spillovers into the post-pandemic period and affect normal routine immunisation. More importantly, a desperate and overbearing approach to ensuring vaccination, coupled with deficient trust among communities, can lead to avoidance of public health facilities by many, which could be disastrous.
Further, there are certain factors that make us particularly vulnerable to the peril of vaccine hesitancy during the pandemic. While routine immunisation is well-entrenched, COVID-19 vaccines are prone to suspicion as they are new and abrupt entrants. The unprecedented scale and speed of their roll-out, and the media reporting of adverse events that are often spurious, add to the suspicion. One of the biggest neutralisers of vaccine distrust are the visible improvements in disease prevention, and the equally visible damages when communities reject vaccines. These are unlikely to work substantially in the immediate term. The emergence of newer variants which predispose to vaccine failure and breakthrough infections can also endanger trust.
Such crises also provide opportunities for traditional and folk medical practitioners to reassert themselves by attempting to discredit modern medical principles. These practitioners constitute influential hubs within many communities that may make or break a public health programme. Further, certain factors could prompt our public health system to regress to an instinctive top-down approach driven by desperation, including an imminent third wave, an anticipated increase in vaccine supplies in the near term, and the pressure to vaccinate as many as possible in the shortest time. Vaccine hesitancy may not necessarily emanate from a distrust of science but from government motives which may be miscommunicated.
Acting prudently
Apart from community involvement, contextualised action, and transparency, eloquence and responsibility in public communication, the government should rein in an instinct of regressing into ‘target mode’ even at the highest moment of desperation. This is necessary, though not sufficient, to safeguard public trust and prevent community alienation.
There is a need of active thinking on avenues to incentivise vaccination beyond pecuniary subsidies, particularly for the rural sections. This would include removing disincentives that accompany reduced physical access, overenthusiastic drives on certain days that result in subsequent shortages, etc. Given that more than 38 crore vaccine doses have already been administered, there is a case for disseminating success stories through locally appropriate media, while not cutting back on honest, solemn and tactful reportage on adverse events.
Positive messages and reinforcements for vaccination have to be aired from the several quarters that command respect and trust of the community. In this regard, there is a strong case for engaging with members of traditional and folk systems despite any potential resistance from them. Lastly, there is a strong case for effectively utilising the services of social science professionals. They may have a pivotal role in navigating the many nuances involved in community mobilisation that are often invisible to medical professionals and other technocrats.
Soham D. Bhaduri is a physician, health policy expert, and chief editor of The Indian Practitioner.