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Rural Indians can be more isolated, mobile and vaccine-hesitant than those living in cities – but as doses are being manufactured at a breakneck pace, health officials are trying to make sure everybody gets one

Health worker Reena Jani, foreground, speaks with a pregnant patient in Pendajam village in Koraput, India, this past January before travelling to a health centre to get vaccinated. Ms. Jani works as an accredited social health activist (ASHA), a lynchpin of India's rural health-care system.Danish Siddiqui/Reuters

One of the greatest challenges facing India’s vaccination drive, the largest in the world, lies in reaching the remotest corners of the country before the pandemic does.

India is now seeing more than 100,000 new COVID-19 cases a day, up from 10,000 in February, and is hurriedly mobilizing rural communities in an immunization push – expanding medical facilities, deploying mobile vaccination camps and getting local health care workers to tout the safety and efficacy of vaccines.

But rural residents are often scattered across the countryside, working as day labourers, making it hard to track them down. Vaccine hesitancy is more prevalent than in urban centres. And people in small, remote villages often believe they are safe by virtue of geography – or the local deity.

“India is a vaccine manufacturing hub with a record of delivering large-scale immunization ... so everybody had a high expectation from the COVID-19 vaccination drive, and it hasn’t yet lived up to the potential, as the daily vaccination rate is far lower than it should be. It is slowly picking up,” said epidemiologist and public-health expert Chandrakant Lahariya.

A health worker displays an AstraZeneca dose, manufactured by the Serum Institute of India, before administering it to an elderly person in Gauhati last month.Anupam Nath/The Associated Press

On a recent weekday morning, a dozen women gathered at the child-care centre in Dongra, a village about three hours from Delhi. A large white banner on the wall announced that a “COVID-19 Vaccination Awareness Campaign” was under way.

“Reach out to your community, coax your neighbours, tell them about the benefits of getting vaccinated and how it will help their immunity,” exhorted Shyam Lal, a program officer at the Society for Public Education, Cultural Training and Rural Action (SPECTRA), a local organization.

Low turnout at vaccination camps in rural areas has prompted Mr. Lal’s team to hold frequent awareness drives in villages across Rajasthan state’s Alwar district.

Such initiatives are now being employed across the country, with millions of rural health care workers enlisted to spread the word and exhort people to get the jab.

Last month, Prime Minister Narendra Modi directed all states to step up vaccinations in remote rural and tribal areas as the country was gripped by a severe second wave.

Public-health officials worry that this time the virus is sweeping across smaller cities, inching closer to rural areas that lack health care infrastructure robust enough to manage an outbreak.

Ms. Jani got a lift from Koraput to the health centre from a neighbour with a motorcycle. When she first learned she was to be vaccinated, she says she wasn't worried, but then she heard a rumour: 'Someone told me that people are fainting, they are developing fever and some are dying after taking the injection.' Nevertheless, she went to get her shot.Danish Siddiqui/Reuters

After a staggered approach earlier in the crisis, the Health Ministry plans to vaccinate 300 million people by July. Almost 80 million doses have been administered so far, and on April 1 the drive was expanded to include everyone above the age of 45.

But it is unfolding differently in urban and rural areas, with a clear class divide. In cities, the affluent have been relatively enthusiastic to register for vaccination appointments on a centralized, government-run portal. In rural areas in the states of Haryana and Uttar Pradesh, however, even with on-the-spot registration and walk-ins, some news reports peg turnout at just 8 per cent to 13 per cent, compared with more than 40 per cent in urban areas.

In some states, such as Gujarat, superstition has gotten in the way. In one case, 50 villages reportedly refused entry to public-health officials because the villagers believed the local god would protect them from the disease.

Access is a significant issue, too. Mobile vaccination camps are trying to address this problem, but the day in early March that a camp was held in her village, Ismailpur in Alwar district, 84-year-old Phoolpati Devi couldn’t make it.

“My son was away at work, as we didn’t know about it in advance, and I can’t get there on my own as my eyes are too weak,” she said.

Her other option was to get the jab at the community health centre about 10 kilometres away. That’s too far, she said, so she will wait for the next mobile vaccination camp to come to her village, which could take another month.

People wait in line for vaccinations at a medical college in Allahabad, Uttar Pradesh, on April 6.SANJAY KANOJIA/AFP via Getty Images

In the neighbouring village of Tehtra, meanwhile, a vaccination camp was in progress at the local primary school, which is surrounded by sweeping fields of mustard and wheat.

“Last evening, we received a notification on our phones from the health supervisor that the camp will be held tomorrow. We didn’t have much time to prepare, so we immediately began going door to door informing everyone in our village that the elderly can avail of the free vaccine between 10 and 5 p.m. Many were not willing to get it done due to vaccine hesitancy,” said community health worker Resham Yadav.

Announcements were also made on loudspeakers. It took a fair bit of counselling and coaxing to get 70 of 200 eligible residents to turn up for the jab. One of them, farmer Sundar Lal, 74, said many of his neighbours were afraid to get vaccinated. “They are suspicious, so would rather not take the risk, especially when there are hardly any cases of infection in the village,” he said.

Rahaman Khan, 62, said his friends refused to come along because they believe COVID-19 is a city disease. “It’s also harvest season, and people are busy working in the fields. They can’t afford to miss even one day’s earnings. There may be more enthusiasm once farm work slows down in a few weeks.”

As states employ a variety of strategies to increase vaccination coverage in remote areas, timely communication is key, Dr. Lahariya said. “Large-scale vaccination programs have to factor in such obstacles, and misinformation campaigns are challenging. Informing people of the benefits, the side effects – and that there is still a chance of being infected after vaccination – is important, while addressing rumours and managing expectations through front-line workers and mass media.

“We need to speed up vaccination everywhere. Two-thirds of India is in rural areas, so unless we vaccinate that population, we will never be out of the woods.”

Ms. Jani leaves Mathalput Community Health Centre after getting her shot.Danish Siddiqui/Reuters

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