India did not have a vaccination hesitancy crisis till the government mismanaged COVID-19
The prime minister Narendra Modi’s government has accused the opposition, especially the Congress party, for increasing vaccine hesitancy in India during the novel coronavirus pandemic. Ministers and other members of the ruling National Democratic Alliance and supporters of the government have said that the Congress tried to ridicule the Covaxin vaccine. The union government has heavily promoted Covaxin as an indigenous solution since it was developed entirely by the Indian company Bharat Biotech. It also blamed the Congress for trying to sow doubt about COVID-19 vaccines in the minds of people. In January 2021, Harsh Vardhan, who was then the union health minister, said that “vested political interests” were spreading vaccine hesitancy. A few months later, in April, he claimed that the Congress had been spreading vaccine hesitancy throughout the pandemic.
The Modi government has been quick to point out, and rightly so, that India has not had a history of vaccine hesitancy. What it has refused to acknowledge, however, is that its lack of transparency, unreasonable requirements for access and flip-flops on vaccine policy have been the largest contributors to vaccine hesitancy.
In 2012, the World Health Organisation established the Strategic Advisory Group of Experts on Immunisation and a working group on vaccine hesitancy. In 2014, SAGE working group produced a report that defined vaccine hesitancy as a “delay in acceptance or refusal of vaccines despite availability of vaccine services.” The report noted that vaccine hesitancy is complex and context specific, and varies across time, place, and vaccines. Growing vaccine hesitancy in India is a multi-dimensional problem and more complex than the conspiratorial narrative of a political sabotage of the world’s largest COVID-19 vaccination drive.
On 21 June, India administered 81 lakh doses of COVID-19 vaccines across all states and union territories— a 62 percent rise in the vaccination rate in a single day. The government and its supporters vociferously celebrated the milestone. They gave credit for this success to the revised vaccination policy that allowed free vaccination without pre-registration on the Co-Win app for all adults in state-run vaccination centres. But the government made the policy revision only after pressure from the Supreme Court, civil society and experts who questioned the inclusivity and equity of the previouspolicy under which 50 percent of vaccines were reserved for sale by private players and digital registration was mandatory.
The new policy that Modi announced on 7 June increased government procurement up to 75 percent and reserved 25 percent of India’s vaccine supply for those who could pay and chose to pay. But the much-celebrated revisions still failed to address issues of equity and profiteering in India’s vaccination programs. Vaccine access is still far from universal. Estimates show that Indian COVID-19 vaccine manufacturers continue to make profits as high as 4000 percent with the current policy.
The government’s claim of record vaccinations on 21 June also fell flat within 24 hours as data on the Co-Win app showed a significant, and possibly deliberate, slowdown in the vaccination drive just a couple of days earlier. A report in the journal Nature about China vaccinating two crore people per day for a week in June, also put India’s claim of a vaccination “world record” in doubt.
Additionally, the government’s actions that undercut confidence on COVID-19 vaccines began more than a year ago. For instance, in December 2020, while preparing for the launch of the two vaccines Covaxin and Covishield, the government had assured safety and efficacy of both. However, it allowed Covaxin to be deployed even though there was no data from its trials. Bharat Biotech released Covaxin’s phase-3 data only in July 2021, almost six months after the Drugs Controller General of India approved it. This huge data deficit would likely have fuelled vaccine hesitancy even among medical fraternity, who were the first batch of people to get the vaccine. A survey in June of doctors in Lucknow showed that some doctors preferred to wait for vaccines by either Pfizer or Moderna to be available in India.
The reasons for vaccine hesitancy are always diverse and stem from various structural and historic factors. Poor and marginalised communities have shown hesitancy to India’s previous vaccination programs, such as drives for measles and rubella vaccinations, due to a historical distrust of the health system and lack of health information. But studies have shown a gradual improvement in India for vaccination acceptance among the marginalised, as is seen by a 19% increase of vaccination coverage from 2006 to 2016.
In January 2021, the University of Michigan, in the United States, and the Post Graduate Institute of Medical Education and Research, in Chandigarh, published a study titled Demographics of Vaccine Hesitancy in Chandigarh, India. The paper, which used the standard WHO SAGE vaccine hesitancy scale, showed that scheduled castes and scheduled tribes had 3.48 times greater odds of vaccine hesitancy compared to other caste groups. The study confirmed an overall positive outlook towards India’s universal immunisation programme but found hesitancy around newer vaccines because of the fear of serious adverse effects—this concern has caused hurdles for COVID-19 vaccine drives.
Currently, COVID-19 vaccine hesitancy has been spreading across diverse income and social groups due to multiple reasons. The COVID-19 vaccination program has exacerbated the old causes for hesitancy or created new ones. The new causes include lack of information on vaccine safety and efficacy, a digital divide, a preference for vaccines developed in other countries, gaps in transparency for vaccine approval in India and misinformation.
One such example of a combination of factors possibly encouraging vaccine hesitancy was the rumour about the presence of calf serum in Covaxin. In September 2020, the Indian Council of Medical Research, the apex organisation in India that coordinates biomedical research, and Bharat Biotech published a paper about the use of calf serum in biological research. New-born calf serum is used for the preparation of vero cells, which are tissue-culture cell lines that are used to grow the virus, from which the antigen needed to make the vaccine is extracted. The final vaccine does not contain calf serum. The government could have avoided rumours by putting out a clarification at this stage about the ingredients of the vaccine. It did not.
By December 2020, rumours started circulating about the presence of animal products in COVID-19 vaccines. The Raza Academy, a Muslim community organisation in Mumbai, wrote to the World Health Organisation at the time and sought clarification about the presence of pig extract in the vaccine. According to one news report in March 2021, people in some districts in Haryana told local administrations that they did not want to be vaccinated because they had heard that the vaccines contained cow or pig extracts. Subsequently, on 8 June, a right to information disclosure that reiterated the use of calf serum in vaccine research was distorted to further fuel the rumours. Misinformation has continued to spread in the absence of effective communication at the local, state, and national levels.
In fact, COVID-19 vaccine misinformation has been rampant among all socio-economic categories, including urban and educated communities. The senior lawyer Prashant Bhushan, who has more than two million Twitter followers, has repeatedly tweeted his scepticism regarding COVID-19 vaccines based on poor information. India has also witnessed organised anti-vaccine movements, aided by anti-vaccine subcultures on Indian social media and messaging apps, in metropolitan cities. These movements involve people who are not just vaccine hesitant but also vaccine resistant. The vaccine hesitancy is being unsure about taking a vaccine while vaccine resistance is being absolutely against vaccination. Vaccine resistant groups have been found to be less likely to obtain information from trusted sources and more likely to organise against vaccination.
The growth of anti-vaccine subcultures is not just a sign of a vaccine-communication strategy failure but also a measure of the government’s inability to address civil-rights concerns around vaccination drives, and its larger COVID-19 management strategy.
In the United Kingdom, studies conducted using the Oxford COVID-19 vaccine hesitancy scale, which is a measure that assesses intent to take a vaccine, showed greater hesitancy was associated with socio-economic factors such as lower age, female gender, lower education, lower income, black and mixed ethnicities, not being single or widowed, not being a homeowner, not being employed full-time, not retired, a change in working conditions, and having a child at school.
In the absence of a standardised tool like the one used in the UK, India has had multiple surveys that indicate varying rates of COVID-19 vaccine hesitancy. The Centre for Voting Opinion and Trends in Election Research, better known as C-VOTER, is a polling agency that tracked vaccine data since January 2021. It released an analysis of vaccine hesitancy in June based on data from 43,032 people from all states and UTs. It concluded that there was no vaccine hesitancy in India. C-Voter’s director Yashwant Deshmukh said that India is among most pro-vaccine countries in the world. In the same month, a survey by Local Circle, an online citizen engagement initiative, of only 8,949 people predicted that vaccine hesitancy might have spread to 33 crore Indians or almost one-third of India’s population. Like the findings, analyses linked to the surveys are also varied. A survey by Prashnam, an AI-powered feedback engine, claimed digital registration as the main barrier to vaccination in the northern states. Rajesh Jain, the founder of Prashnam, was also the architect of many digital initiatives that powered Modi’s 2014 Lok Sabha campaign.
While there is a lack of reliable data on vaccine hesitancy in India, the current data on vaccines also shows that other big obstacles to vaccination are vaccine shortages and mismanagement. In June this year, the union government reiterated its commitment to vaccinate the entire adult population by December 2021. At the time, six months since the first vaccinations in India, only 5.2 crore people had been fully vaccinated and 28 crore people had received their first doses. On 22 June, NK Arora, the chairperson of the National Technical Advisory Group on Immunisation in India, said that the country was capable of administering 1.25 crore doses per day. By 16 August, more than 12 crore had been fully vaccinated and more than 55 crore had received their first doses, according to data on the Co-Win app.
The discovery of new mutated variants of COVID-19 demands that vaccination rates be as high as 90 percent of the total population to break chains of transmission and stop further mutations. Carolina Darias, Spain’s health minister announced this month that the country is aiming for 100 percent vaccination rates, with countries like Canada and Ireland also following suit. India has a lot of catching up to do to come close to required vaccination rates.
“We need to do our daily work, maintain our social life, open schools, businesses, take care of our economy; we will be able to do all this only when we are able to vaccinate at a fast pace,” VK Paul, chairman of the National COVID-19 Task Force, said to Doordarshan in June. The pressures to open the economy, and meet the deadline of December 2021 for universal vaccination have resulted in several local administrations taking various measures focusing on mandatory vaccination.
In an order on 29 May, the Tamil Nadu government urged all industries to get their employees vaccinated within a month. Worker unions and company managements in the state conducted awareness campaigns since the administration did provide support to address vaccine hesitancy. The unions also asked for two paid leaves for workers to encourage vaccination, citing international examples. The Tamil Nadu government’s order is in line with the union government’s stand on voluntary vaccination, but some states are pushing for compulsory measures. The Meghalaya state government ordered mandatory vaccination for businesses, shopkeepers, vendors, and cab drivers. This led to a backlash against district administrations. The Meghalaya High Court then scrapped the government’s order on the grounds that it violated people’s fundamental rights. The judgement called into question similar orders passed by other state governments announcing compulsory vaccination for businesses, street vendors and linking social-welfare benefits such as work under the MGNREGA, and ration from the public distribution system with vaccination status.
Implementation of such coercive measures shows India’s health authorities have failed to learn lessons from previous vaccination drives where such measures have been used. Forced vaccination in India’s smallpox programme in the 1970s affected people’s trust in the health system in the long term, as historian Paul R Greenough observed. Addressing vaccine hesitancy through communication and not through coercion is not only epidemiologically necessary but also a moral imperative to save lives.
India’s national, state, and local governments have tried to engage with COVID-19 vaccine hesitancy. In December 2020, the central government launched its COVID-19 vaccine communication strategy that included addressing vaccine hesitancy among eligible populations. Under this strategy, local administrations were asked to undertake various measures such as organising street plays, community outreach programmes, and roping in ASHAs to tackle vaccine hesitancy in communities. Some of these strategies have shown successes in small pockets.
For example, Indiaspend reported on how health officials in the tribal district of Melghat in Maharashtra used audio-visual tools and community meetings under its “Corona loses and Melghat wins” campaign to effectively address vaccine hesitancy. Before the campaign, the administration was vaccinating only 50 people in a day. This increased up to 800 in a day after various information, education and communication, or IEC, methods were used. In Odisha, the government gaveeach village welfare committee Rs 10,000 to distribute IEC material on vaccines. But a lot more needs to be done to counter vaccine hesitancy across India.
In its current version, the government’s COVID-19 vaccine communication strategy faced several operational and structural problems. Operationally, capacity building at national, state, district, and sub-district level for communication management was disrupted due to the second wave of infections. It is likely that stakeholders such as health department officials, front line workers, district officials, NGOs and youth organisations were deployed in more urgent COVID-19 relief work.
The communication strategy also places an outsize emphasis on citizens changing their individual and group behaviour instead of targeted interventions by the government. The strategy was jointly developed by the health ministry along with the country’s top immunisation officials, social and behaviour change communications consultants and experts. It shows that the focus of the communication strategy was on the optics. For example, even though vaccine hesitancy was widespread among healthcare workers during the initial phase of vaccination, the government’s messaging was about India’s developing a vaccine in record time. This was the message splashed across posters published in February by the bureau of outreach and communication.
The key messages around vaccine hesitancy in the strategy document show an emphasis on the government’s preparedness and the safety of the vaccines. But concerns such as the vaccine’s side effects, impact on women’s body, fertility and functioning are not addressed adequately. These gaps are now widely visible across India. News reports in June indicated growing hesitancy among rural women in Bihar and Kashmir. The government’s emphasis on behaviour change also ignored structural challenges to vaccine access such as digital access to register for vaccination, high vaccine prices, vaccine shortage, earlier existing vaccine hesitancy and distrust of government activities around public health in some communities. These challenges cannot be overcome with a few days of behavioural change training. The strategy puts the onus on individuals to get vaccinated instead of on the government to help people get vaccinated.
The government has aggressively pushed for social and behaviour change communications in many areas of social and health communication strategy in the last few years. The Economic Survey in 2018-19 recommended behavioural economics as a valuable instrument of change in India, citing the success of social and behaviour change communications in the Swachh Bharat Abhiyan. However, independent assessments of the scheme have shown mixed results of such interventions aimed to promote use of toilets. Many residents, especially the elderly continued to practice open defaecation despite having toilets in areas declared open-defaecation free in Lucknow and Mumbai. In 2017, the UN Special Rapporteur on the human right to safe drinking water and sanitation Mr. Léo Heller noted that “many, including government officials, expressed doubts that behaviour change can be done in a short time period and would be sustainable in the long term for all those recently ‘converted’ to using toilets.” These learnings from the Swachh Bharat Abhiyan should have been integrated in the government’s COVID-19 vaccine communication strategy.
As India accelerates COVID-19 vaccination across districts, it is important that the vaccine communication strategy does not remain limited to touting the government’s supposed achievements. The current wave of communication activities around the vaccine reflects the government’s eagerness to claim the success of vaccination drives, while actively ignoring vaccine hesitancy and its own shortcomings. Both Kendriya Vidyalayas and the University Grants Commission were instructed to put up “Thank you PM Modi” banners across campuses and vaccine sites on 21 June. Advertisements on the radio continue to claim “free vaccination for all” despite the fact that 25 percent vaccines in India are being sold in the private sector.
Globally, vaccination programs have been celebrated as a collective achievement of scientists, frontline workers and governments as opposed to individual success. Joe Biden, the president of the United States, had given a call for a national month of action in June to mobilise the entire country to make it easier for everyone to get vaccinated. This included directing national organisations, local government leaders, community-based and faith-based partners, businesses, employers, social-media influencers, celebrities, athletes, colleges, young people and thousands of volunteers to enable mass movement for voluntary vaccination.
As opposed to this, the Indian government’s public relations blitz about “India’s world record in vaccination” on 21 June, which Modi declared as Yoga Day seven years ago, worked well to grab the headlines but did little to address issues of vaccine hesitancy and lack of access among vulnerable groups. The government is more focussed on generating short-term spikes in vaccination rates than on targeted communication to enable vaccination for all. It needs to identify groups vulnerable to vaccine hesitancy and take the time and effort to communicate the importance of getting vaccinated.
The government also needs to identify vaccine-resistant groups and actively educate them on vaccines rather than turning them hostile through penal action. Systemic identification of resistant groups is important and targeted communication needs to be created to engage with them. One way to approach this problem is to develop a vaccine hesitancy scale along the lines of UK’s Oxford Covid-19 Vaccine Hesitancy Scale, which has been used by its National Health Services to obtain data on vaccine hesitancy. This would help to understand multidimensional issues leading to organised vaccine resistance among the population.
The government’s current strategy disproportionately focuses on “building positive public discourse” around vaccines, which is mentioned 24 times in the document in various contexts. This can hinder communication around adverse events following immunisation or AEFIs, which is an untoward medical occurrence after immunisation that is not necessarily caused by the use of vaccines. District administrations and health departments need to employ better communication on AEFIs and better reporting so that people who develop AEFIs are not neglected. The health ministry’s national media rapid response cell can be roped in. The NMRRC was established in January 2021 at the health ministry for early identification of any misinformation or rumours and countering that with correct information. It can be used to provide real time updates about COVID-19 misinformation to district collectors.
The district administration can then deploy various locally relevant mediums and messages to fight such misinformation. A digital media-heavy communication strategy may not be effective in districts with low digital penetration. More thrust on mediums such as community radio needs to be deployed in such cases. The ministry of information and broadcasting’s network of 316 community radios across India are playing a crucial role to manage COVID-19 across 28 Indian states. Many community-radio networks have been creating programming on COVID-19 appropriate behaviour and fighting misinformation with little to no government support during the pandemic. This network needs to be strengthened and deployed to fight vaccine hesitancy in local languages and contexts.
Minor successes of India’s COVID-19 vaccination drive cannot be used to hide the central and state governments’ mistakes, especially during the second wave of the pandemic. The communication must focus on people’s health rights and vaccine education not just behaviour change.