Dr Saiful Islam is a dejected man. “My head has just stopped working,” he told this reporter over the phone on Saturday evening. “I just don’t know what to do anymore.”

Islam has reasons to be despondent. He heads the directorate of health services in South Salmara-Mankachar, the district with the dubious record of the lowest Covid-19 vaccination coverage in India.

As of June 3, the Western Assam district bordering Bangladesh has administered only 3.2 doses per hundred people, shows an analysis of official vaccination data on the CoWin portal by Scroll.in. This amounts to barely one-fifth of the national average of 15.72 doses.

District officials say the abysmal numbers are a result of vaccine hesitancy fuelled by misinformation. The district immunisation officer, Dr Sirajul Islam, said: “There is this video of a foreign virologist doing the rounds where he is apparently saying that people who take the vaccine will die within two years.”

In May, a WhatsApp message had surfaced across the country where Luc Montagnier, a Nobel prize-winning French virologist, was quoted to have said that. While Montagnier is known to share an anti-vaccination stance, he did not say what was attributed to him in the viral message, several fact-checking organisations had clarified at the time.

In fact, even the Assam police had issued a statement on social media debunking the claims made in the message.

But that appears to have had little effect in South Salmara-Mankachar. From coercion to threats, nothing seems to work to convince people to get the jab. “We have organised marathon awareness campaigns,” said Saiful Islam, the head of the directorate of health services. “We have threatened shopkeepers that we will not let you open if you don’t get vaccinated. But no, nothing works.”

This is borne out by the abundant number of available slots in the district’s vaccination sites at any given time on the Cowin portal. “There have been days when we have opened upto 15 sites with capacity of 100 doses each,” said Sirajul Islam, the district immunisation officer. “But in terms of vaccinations we have never reached 400. Usually it’s around 165 to 215.”

Apart from the anti-vaccination propaganda on social media, what has further induced hesitancy is that a few people died after taking the vaccine in the district, said the immunisation officer. The deaths, according to him, were unrelated and the deceased had underlying comorbidities.

The district immunisation officer addressing a large meeting to persuade people to get vaccinated.

Awareness campaigns

A desperate district administration has resorted to organising awareness meetings at the panchayat level. While people turn up for these meetings in large numbers, it has not translated into people showing up at the vaccination sites yet.

“Just the other day, we organised a awareness meeting in Mankachar,” said Saiful Islam, the health services director. “There was a big gathering, but the next day three people turned up at the vaccination site where we had readied a hundred doses.”

As a result, even the three people who did show up also had to be turned down. “We cannot open a vial for three people,” said Saiful Islam. “We need a minimum of ten people.”

Local politicians have tried to step in – but again to no avail. “I go, tell people to get vaccinated, they listen, but they don’t finally get vaccinated,” said Aminul Islam, the local All India United Democratic Front legislator.

The state government has sent teams too to address the crisis, but has also struggled to make any substantial headway. Munindra Nath Ngatey, the state nodal officer for Covid-19 vaccination, said the district’s demography could be a factor. “It is a Muslim-majority district,” pointed out Ngatey.

Salmara-Mankachar is almost 95% Muslim. District officials say that many people cited their Ramzan fasts as the reason for their disinterest in getting vaccinated. Followers of Islam observed the holy month of Ramzan this year from April 13 to May 12. But even after Ramzan ended, vaccinations didn’t pick up.

Data from the rest of the state shows that of the 11 Muslim-majority districts among the total 33 districts, nine have coverage lower than the state average.

However, attributing low vaccination coverage to Muslim presence is complicated by the fact that barring South Salmara-Mankachar, the districts with the lowest vaccination rates are overwhelmingly Hindu. For instance, the three districts that follow South Salmara-Mankachar in the list are Baksa, Chirang and Udalguri, all with less than 25% Muslim population.

Still, the district authorities in South Salmara-Mankachar have asked mosques to broadcast vaccination appeals during prayer calls. “We have asked all imams to encourage people to get vaccinated at least twice a day while making prayer calls,” said Saifur Islam. But the response to the move – like all other efforts – has been underwhelming, he admitted.

A health worker distributes vaccination awareness pamphlets.

Scattered population, systemic neglect

District commissioner Hivare Nisarg Gautam said South Salmara-Mankachar also had other peculiar “topological” issues plaguing the vaccination drive.

A large proportion of the district’s population, Gautam pointed out, lives in far-flung chars, as the shifting riverine islands on the Brahmaputra are locally referred to. “People are scattered, it’s an almost entirely rural district,” he said. “If mobile vaccination is permitted, maybe something can be achieved.”

A view of the desolate landscape created by the Brahmaputra river in the district. (Credit: Raju Narzary)

The chars, populated largely by Muslims of Bengali origin, have some of the lowest literacy levels in the state. Health infrastructure is nearly non-existent, a consequence of systemic neglect that these areas suffer from.

Data from the latest National Family Health Survey shows that the district’s routine immunisation rates are also significantly lower than the state average. Among the 343 districts surveyed in the last NFHS round, the district is only one of two to have reported less than 80% electricity access.

Critics say that the district administration has only itself to blame for the low Covid-19 vaccination coverage. “Awareness programs at the panchayat level catering to the uneducated population began very late,” said Nazmul Arefin, the president of the AIUDF’s district committee.

Meanwhile, having run out of options, the district authorities are now resorting to ultimatums. “I have prepared a strict order for our healthcare workers,” said district immunisation officer Sirajul Islam. “That they, along with their family members, should come forward, otherwise they will have to face departmental action.” Nearly 10% of the health workers in the district are yet to take even the first dose.

Islam acknowledged that threats were not the best idea. But desperate times called for desperate measures, he said. “We have been explaining nicely for so long now.”