An old mistrust of government keeps Jharkhand’s Adivasis away from COVID-19 vaccines

A health worker from the Jharkhand government conducts thermal screening  of a resident of Chaite village in Namkum block of Ranchi district on 21 May 2021. PTI
30 May, 2021

Guruwari Jamuda died in Baralagia village in Jharkhand’s West Singbhum district 11 days after she took a dose of a COVID-19 vaccine. The small village is home to about two thousand people predominantly from the Ho Scheduled Tribe.  Sixty five-year-old Jamuda, who is also a member of the Ho community, developed a fever soon after she got the shot on 15 April, according to Birendr, her neighbour. The fever did not abate for days. Jamuda’s son took her to the Tata Memorial Hospital in Jamshedpur about 70 kilometres from the village, where she died on 26 April. “She was absolutely fine before taking the vaccine,” Birendr said. “Her son took his mother to a reputed hospital for treatment but could not save her.”

Jamuda’s death is one of many incidents that has deepened existing distrust of the public-health system across Jharkhand’s rural regions and among its Scheduled Tribe communities. The main reasons for this mistrust of public-health facilities and healthcare workers among Adivasi communities are the failures of successive governments to build a strong and responsive heath system. Harsh lockdowns, coercive testing and quarantining measures and delays in aid have deepened that mistrust during the COVID-19 epidemic. News of deaths and illness after COVID-19 vaccinations added to people’s reluctance to seek healthcare from the government. 

A 54-year-old Accredited Social Health Activist or ASHA—or “sahiya,” as they are called in Jharkhand—in the Khunti block got her second dose on 28 March. Soon after, she started experiencing fever, acute abdominal pain, appetite loss, weakness and breathing difficulties. “I became so weak that I could not walk 15 steps or hold my documents,” she said, and requested not to be identified. She told me she went to a doctor four days later, who gave her “an injection” for the pain and an inhaler to help with her breathlessness. However, her road to feeling better was long. 

She pegs the start of her recovery only around 10 May. Meanwhile, she treated herself with some medicinal herbs and steam inhalation. “I informed my ANM and other senior government officials but they said that they did not believe this happened due to the vaccine, and is probably because of other reasons. So, why should I go to them for any advice?” An ANM is an Auxiliary Nurse Midwife who functions as a village-level health worker and, along with an ASHA, is one of the first people that a village resident can contact in case of a health problem. 

 “She was convinced that she is going to die,” the sahiya’s husband said. “She still feels the weakness around her waist, and is unable to do a lot of physical work. Looking at her, I have decided not to take the vaccine. Several people have also died after taking the vaccine.”

Media reports about the second wave of the coronavirus in rural Jharkhand largely suggested that ignorance of rural inhabitants was the main reason for its spread. What they ignored was the long-standing failing of the public-health system in reaching out to people, especially Adivasis. 

Jharkhand is, a Fifth Schedule state with designated tribal majority areas. It is home to more than 32,000 villages where nearly 75 percent of its population resides. Ninety percent of the state’s Adivasi population resides in these villages that have weak or non-existent health facilities.  

“The health infrastructure in Dumka is in a dismal state,” Rajni Kumari, a social activist and resident of Masaliya block of Dumka district, said. “People do not approach the public-health centres or even the district hospitals unless they are absolutely desperate.” Dumka’s district hospital was refurbished into a medical college and hospital with 540 beds in 2019. In assessing the medical college’s readiness to admit students in 2019, the Medical Council of India found major problems at the facility including a 100 percent shortfall in faculty and residents, only 50 nurses instead of the required 175, low bed-occupancy of 25 percent, a blood bank whose licence had expired, no licence to show radiation safety compliance for the x-ray, and operating theatre deficiencies. 

“There are no basic facilities here and the attitude of doctors and nurses, are very bad towards the Adivasis,” Kumari said. “People prefer to take a loan and go to Durgapur for treatment, rather than to the hospitals in Dumka.”  Durgapur is an industrial town in neighbouring West Bengal, about 150 kilometres from Dumka. Kumari added that it was common practice for doctors to refer their patients to Durgapur. “The jholchap”—village doctor who is an unqualified practioner—“in my area is quite experienced and is able to perform complex deliveries. But, in cases where he feels he cannot do much, he refers them to Durgapur.” 

Healthcare deficiencies are common throughout the state. The Manika block of Jharkhand’s Latehar district has only one primary health centre, or PHC, located at the Palhea panchayat. PHCs are intended as the first points of contact between rural communities and the public-health system. The block programme officer in Manika told me that the doctor posted at the Palhea PHC usually works in the community health centre, or CHC, in Manika due to a shortage of staff. CHCs are slightly larger intermediate health facilities that serve referrals from PHCs and are one step before tertiary district hospitals. A CHC is supposed to be equipped with laboratories, x-ray machines, round-the-clock delivery facilities along with medical specialists, technicians and, nurses. The CHC in Manika has no gynaecologist, paediatrician or anaesthetist. It has no ambulance and there are only two oxygen cylinders for any exigency.

A community health centre in Chandwa block in Jharkhand's Latehar district. COURTESY AAYUSH RANJAN

The Kuru block in Lohardaga district has no village PHCs and only one CHC, a social worker in this area told me. A block-level officer at Arki in Khunti district said that the block has only one PHC instead of the required four. The block is home to approximately 80,000 people belonging to the Munda Scheduled Tribe. The officer said that even the CHC ran into staffing trouble. For example, Arki’s CHC had no lab technician to operate the x-ray machine it received last year. Only recently, a technician from the neighbouring block of Torpa was transferred to this centre. The CHC also received a TrueNat machine, which is a device for molecular testing used to check for infectious diseases including COVID-19,  in August 2020. After a formal inauguration at Arki, the machine was shifted to the Khunti district hospital because Arki had no technicians to operate it. 

On average, one PHC in Jharkhand serves more than 90,000 people as against the norm of 20,000 in tribal areas, according to the government’s rural health statistics for 2018-19. This marks a 72 percent shortfall of PHCs in the state. Of the total sanctioned posts for specialists in CHCs and lab technicians in PHCs and CHCs, more than 90 percent and 58 percent respectively are lying vacant. 

COVID-19 spread into this underequipped Jharkhand backcountry as it did across rural India during the second wave of the epidemic. While urban centres such as Ranchi have recorded the highest number of cases, all districts showed a marked rise in the number of cases and deaths since mid April. West Singhbum, where Jamuda lived and died, recorded 12,470 cases since the beginning of the pandemic, as of 24 May. About half these cases have been in the preceding month alone. The district recorded 124 deaths of which 85 occurred after 10 April. 

Kumari, the social activist, has lived in both Dumka district, which is a scheduled area, and in Deogarh district, which is an adjoining non-scheduled area. She noted a marked difference in access to healthcare between them. “There are hardly any ANMs who are active in the scheduled areas,” she said. “The ANM in my maternal house in Deogarh, comes to the village at least once a month for the routine immunisation and spends other days at the centre. However, one can only find cows and buffaloes taking shelter in the health centre in my village in Dumka.” 

Arki has 41 ANMs at 22 health sub-centres. Only one of the ANMs lives close to her centre, while all others reside in the nearest urban settlement, a social worker in this block said. According to India’s public-health strategy, a health sub-center is expected to constantly engage with the villages and induce behavioural change towards modern medicines. However, ANMs in charge of these sub-centres often only visit for routine childhood immunisations. Lack of help from the public health system has driven people to unqualified health practitioners, Kumari observed. “People often turn to the traditional healers or local village doctors,” she said. 

Kumari told me that the Adivasi mistrust of government also came from other interactions.  “The government officials frequently cheat the Adivasis in various schemes,” she claimed. “For example, when I was working as a rozgar sevak”—–employment assistant—“in MNREGA, I saw Adivasis were charged more commission than non-Adivasi labourers. Similarly, road contracts in the Adivasi areas are often taken up by non-Adivasi contractors. Such practices have made the people wary of the government officials. It leads to a lack of trust even in the health system which is not just alien, but also imposed by the same people who have exploited them for decades. They don’t expect anything from this system.” 

Like other rural parts of India, rural Jharkhand was hit harder by the lockdown to contain the first wave of COVID-19 in 2020 than the disease itself. The lockdown resulted in disastrous consequences including food shortages, reverse migration of millions of people from cities to villages, and loss of income due to unemployment or difficulty in selling agricultural produce. In the past year, since the lockdown eased, the government has taken little effort to inform people in these rural tracts about the nature of the disease and its treatment. While the Jharkhand government did undertake messaging regarding the importance of masks, hand hygiene and social distancing—through posters, wall paintings, mobile television vans and sahiyas—it was half-hearted. A sahiya from Deogarh district said, “There were no specific coronavirus awareness campaigns, but during testing camps last year and routine immunisation programs, we were told to remind the villagers about wearing masks and maintaining social distance in public places.” 

An NGO worker puts up posters for COVID-19 awareness in Bokaro district. COURTESY GULAB CHANDRA PRAJAPATI

The state government’s attitude towards testing and quarantining suspected or positive cases made people even more distrustful. The government declared compulsory testing for anyone showing symptoms of COVID-19. People who thought that they might have malaria or jaundice, which are common ailments in the region, but with some symptoms similar to COVID-19, started to worry about COVID-19 tests. At the time, COVID-19 patients and migrant workers returning to their villages were taken to special COVID-19 facilities or hospitals as per the mandatory institutional quarantine. “When the migrant workers were returning to their villages last year, we conducted door-to-door survey and asked people about any symptoms related to COVID-19,” the Deogarh sahiya recalled. “Based on our report, people showing symptoms were taken to quarantine centres or hospitals in Deogarh.” The mandatory institutional quarantine was both unnecessarily harsh and impractical. Eventually, when the number of patients and returning migrants increased, the government eased these rules and issued guidelines for home quarantine.

The complexity of COVID-19 testing also added to confusion and mistrust. The sahiya from Khunti block narrated an incident of a testing camp organised at Karra village in Khunti district in October 2020, where some people without symptoms tested positive. Their test results led to disbelief and arguments with the healthcare workers. When they went to Khunti for further testing, they tested negative. The sahiya from Khunti block asked, “In such a situation, how are we supposed to believe that correct screening is being conducted?” 

CHCs conducting tests largely use the rapid antigen test for COVID-19, which is a useful tool for catching positive cases quickly but has a high rate of false negatives. Official guidelines state that a person who tests negative on the rapid antigen test must get that results confirmed with a gold-standard RTPCR test. But poor messaging around testing has complicated this process. People with symptoms of COVID-19 refuse to believe that they may be infected, if the antigen test shows a negative result. “This is creating confusion amongst the villagers who are coming to the centre,” a social worker from Kuru said. “More RT-PCR kits must be made available for testing.” 

He referred to other worries that local communities had about testing. “An ID is generated for each person who gets tested,” he said. “This also makes the people sceptical of the tests as they are apprehensive of enrolling themselves in any kind of formal processes.” 

Pavitra Mohan, is a co-founder of the non-profit organisation Basic Healthcare Service and previously a senior health-specialist with UNICEF. "During COVID, there has been an increasing mistrust of people in accessing the rural healthcare system,” he said. “One of the reasons for this mistrust is the erratic nature of rural health infrastructure. For example, when people travel 5-10kms to reach a centre but do not get treated well. Even those that were accessing healthcare, have withdrawn from the system because they feel they will be penalised for being infected. This fear of penalisation comes from last year's compulsory quarantine rules which made people feel that they were being distanced from their homes. This year, similar fears have surfaced in people's rejection of vaccination.” 

All these events during the first wave created misgivings that lingered into the second wave. Government inaction added to doubts. The state government took no measures to tackle any further surge in cases after the first wave receded in October 2020. For example, it began procuring and distributing equipment such as pulse oximeters and oxygen concentrators only in April 2021, almost a month after cases had started to increase. It started distributing pulse oximeters to panchayats and anganwadis but faced supply shortages due to the sudden surge in demands. 

Jasmani Horo from Shantipur village in Khunti received the vaccine on 4 April. About ten days later, she started showing symptoms and started medications for COVID-19 prescribed by a doctor in Khunti. By 23 April, her condition had worsened with her oxygen saturation dipping to 57 percent. She was rushed to a private hospital where she died the next day. 

“I don’t think it happened due to the vaccine, because she did not fall ill immediately after taking the injection,” Sushil Boria, Horo’s husband, said. Horo’s family did everything they could to help her. What they did not know was that her oxygen levels had to be monitored closely. “We did not check her oxygen saturation at home or in the clinic during the first visit. That should have been done. We didn’t know about oxygen levels or oximeter then. Later, my son and I also tested positive. Now we have bought an oximeter.”

The state government prepared home-quarantine kits that include basic medication, like vitamin and zinc supplements, paracetamol and antiparasitic drugs for people who tested positive, but the kits are yet to reach many panchayats. With the seemingly uncontrollable second wave well on its way, administrators in Khunti and Jamtara even resorted to disseminating public-safety messages about COVID-19 through local unqualified health practitioners.

Despite the alarming shortage of staff across the state and particularly in rural health centres, there was no new recruitment in the past year. The district administration of Jamshedpur released an advertisement for short-term recruitment of more than 400 health personnel only in May 2021, in light of the surge in cases. However, the shortage of staff is compounded by the problem of healthcare workers themselves contracting COVID-19. When a healthcare worker tests positive, there is no substitute to carry on her work. A social worker from Arki said, “When an ANM tested positive in Khunti, work increased for her counterpart from another centre since only ANMs can administer the injection [for routine immunisation of children]. All the healthcare personnel are working way beyond their capacity and are exhausted with the increased pressure.”

During the second wave, the government quickly shifted focus to vaccination. With the roll out of vaccines for 18-44 year-old residents, majority of government personnel and efforts are channelised towards it. “Now we have got the training, so when we go for surveys, we try explaining to people about the vaccine,” the sahiya form Deogarh said.  

The administration is conducting vaccination camps, mobilising and sometimes even compelling the people to take the vaccine.  “Last year I was assigned the duty at testing camps in the village but this year tests are happening only in the CHC,” the social worker at Khunti said. “All village-level camps are on vaccination, despite stiff resistance to the vaccine by the villagers.” 

This resistance to the vaccine is a result of reports of people dying even after getting vaccinated. A sahiya from Arki block said, “When the government rolled out the vaccine initially, several people came forward for the first dose and did not require much convincing. However, after taking the first shot people fell ill and experienced symptoms like body ache, fever, and loss of appetite. Now, the same people are refusing to take the second dose.” News of death or illness spreads quickly among Adivasi communities, which have close ties. The government has done little to allay these fears that have built around deaths and illness after vaccination and to build trust amongst people.

“There was nobody to clarify and counsel the people,” Ranjan Kanti Panda, the health and nutrition lead at Transforming Rural India Foundation, said. Panda has worked in the state for more than 10 years. “They had no access to basic medication or drugs either. This not only hampered their day to day work, but also led to lack of confidence in the system.”

The state government responded to the resistance to vaccines with coercion. “We were being pressurised by our seniors not to distribute ration to those who were refusing to take the vaccine,” the Khunti sahiya’s husband, who is a ration dealer, said. “When senior officials came to talk to the villagers, the villagers said that they will not take the injection even if it meant withdrawal of ration. However, after this meeting, the officers ordered the dealers to distribute the ration.” The social worker in Arki said, “In essence, the focus on vaccination is leading to a denial of any comprehensive action on COVID-19, especially in controlling its spread.” The Jharkhand government only recently announced a state-wide door-to-door survey to map people with symptoms, confirmed positive cases and COVID-19 deaths in an attempt to contain the spread of the disease. 

The sahiya from Deogarh worried about her duty to bring people to vaccination camps. “When the vaccination camp will be held, it will be our responsibility to mobilise people and bring them to the camp,” she said. “But I don’t know how will we manage because almost everyone in the village, including educated people, have already refused to take the vaccine.”

The sahiya from Arki said their only tactic was to try and explain the benefits of vaccination through the gram pradhan­—the village head. “Only 10-12 people turn out at the camps every day and we don’t achieve our targets,” she said. “But still, we can only explain it to them as we have to live in the same village and people will hold us responsible if anything goes wrong.”

“There is an immediate need to regain the trust of people,” Mohan of Basic Healthcare Service said. “It is important that healthcare workers go back to the people without any agenda. They must speak to the people and explain the nature of disease as well as the need for vaccination. It is important to demonstrate the care and assure them that, ‘we are there for you’ in case something happens, and not just during the pandemic but also afterwards.”

Doctors in rural Jharkhand give people the same post-vaccination advice that people anywhere in the world are given. “We keep the people under observation for 30 minutes after taking the vaccine,” Seema, a doctor from Manika said. “It is important to eat healthy and take multivitamins to boost one’s immunity.” But in these parts, that advice is almost impossible to follow. In large parts of rural Jharkhand, people lack proper nutrition and safe drinking. Women have to often walk several kilometres to find water. 

Jharkhand is one of the sates with highest prevalence of malnutrition amongst women and children. According to the fourth round of the National Family Heath Survey conducted in 2015-16, less than seven percent of the children between six and 23 months receive adequate nutrition. More than 70 percent of children between six and 59 months are anaemic. In May 2020, a five-year-old Dalit child in Latehar district allegedly died of hunger because her father, a brick-kiln worker, had been unable to earn any wages during the lockdown. People often depend on hard physical labour including farming and manual labour under the national rural employment scheme for their livelihood. 

The gaps in public health measures against COVID-19, including vaccination, have largely been due to failures of successive governments to take a comprehensive approach to health that include people’s social realities and engagement with grassroot health workers. “It is imperative that the government engages in a dialogue with the people and acknowledges their reservations regarding testing or vaccination, instead of dismissing them,” Jaykishan Godsora, a social worker in Jharkhand, said. “Any incident of illness or death in the village must be investigated and conversations on post-vaccination care must be made more commonplace. Along with the vaccination, it is the responsibility of the administration to ensure care and consultation for those showing any side effects.” 

Panda said that the government had to make concerted confidence efforts with the community. “The government has constituted a panchayat level task force with ASHAs, anganwadi sevikas, panchayat mukhiyas and others,” he said. “However, there continues to be a lack of convergence amongst them, and all the burden falls on the sahiyas and sevikas. It is important to increase communication and create an ecosystem with greater community engagement.”