Even as India dispensed a “record” number of Covid-19 vaccinations under its new vaccine policy, effectively doubling its previous count and surpassing over 8 million vaccine doses a day on June 21, liberal tropes about “vaccine hesitancy” and “rural mistrust” in medicine continue to circulate in the media, scientific and political discourse.
Exhorting “Rural India” to comply with global biomedicine, such tropes often frame health as a civic duty and vaccines as a public good against which rural “vaccine hesitancy” threatens to undermine global and local responses to the pandemic.
However, such tropes also enact a pernicious erasure and vilification. Not only do vague, liberal notions of the “civic” and the “public” symbolically exclude those living in structural conditions of socio-cultural and economic vulnerability, they also end up framing rural India as the very paradigm of causality and culpability for the spread of epidemic disease and destruction.
In neoliberal, global health regimes it is common for the responsibility of ailing health systems to be shifted onto the afflicted. Rural regions, apart from being historically underserved. are also easy to cast into imagined geographies of blame.
This creates an enduring stigmatisation, surveillance and objectifiction of “rural culture”, “rural behaviour” and “rural health”, which become fixed as static epistemic categories by urban health bureaucracies and the urban citizenry (and netizenry), whilst failing to be explicated commensurately in epidemiological discourse.
The “epistemic injustice” arising from such situations hinges precisely on the categorical fixation of “the rural” as a harmful social fact and the violent and wounding burdens of blame and condemnation “rural India” must bear as a result.
What is alarmingly absent from the Indian state’s paranoid framing of “vaccine hesitancy” and “rural mistrust” is both the attention and commitment to recognise and remedy deep rooted structural determinants of health. The classist and casteist blame placed on rural individuals, communities and entire, vibrant socio-cultural lifeworlds neglects historical factors and decouples analyses of power from local disease dynamics.
Equally, the diversion of public health foci from structural factors is part of neoliberal epidemiological research designs as much as of local political processes.
Two recent studies of viral epidemics shed light on these complex dynamics from a global health perspective and can help India derive crucial lessons during its own public health emergency. In a recent study of Ebola conducted by Harvard physician-anthropologist Eugene Richardson, narratives of local “mistrust” against the ebolavirus and vaccinations were analysed from the Democratic Republic of Congo.
According to Richardson, static notions of “native mistrust” (including tropes such as the Congolese “did not believe Ebola was real”) were deployed not only by international media but also by established journals like The Lancet and the British Journal of Medicine.
For Richardson, “attempt[s] to isolate phenomena like ‘trust’ and ‘belief’ as measurable facts simplify complex social, political and epidemiological dynamics into fungible units that are easy to comprehend”.
However, this ignores that “mistrust is not an unprovoked phenomenon” and “may serve as a practical way of engaging with the history and ongoing effects of atrocities inflicted” on communities i.e. slavery, (post)colonial extraction, structural adjustment and stratification.
In other words, mediatised notions of “mistrust” are structurally embedded in community decisions of “eluding depredations.” Richardson also notes how epidemiological research designs relegate local claims of health as “outside the domain of ‘evidence-based’ global health research or action”.
In the context of HIV/AIDS, globally renowed infectious diseases doctor and anthropologist Paul Farmer critically analyses “geographies of blame”, delineating the racialised distribution of paranoia, fear and discrimination against marginalised communities like Haitians, blamed by (white) American scientists, popular culture and politics for being carriers of AIDS.
Despite rural Haitians who later became the vanguard of international AIDS control, their cultural beliefs in sorcery and “violent voodoo rituals” were wrongly used to manufacture stigma and define Haiti’s distrust in modern biomedicine.
In his latest book Fevers, Feuds and Diamonds: Ebola and the Ravages of History, Farmer turns to the West African Ebola epidemic (2014-’16), drawing attention to continuing epidemiological racism. The “drive for a dominant narrative” by global health imposed highly biased epidemiological information, creating a “control over care” paradigm for Ebola and its sufferers.
Both Farmer and Richardson argue that health emergencies reveal the underlying limits of epidemiological models of infectious disease transmission, which serve not as forecasts but as means for setting epistemic confines on understanding why people take certain decisions with respect to biomedicine.
They also significantly limit the ways people’s plural lived experiences, identities and structural encounters with violence and harm outweigh momentary “silver bullet” approaches like vaccination or medication.
In the Indian context, epistemic constraints of epidemiological data (or even its absence thereof) interact with deeply held socio-political biases of scientific and civic communities, bureaucracies and institutions, which actively delimit the state’s and the public’s ability to imagine alternatives to the way the pandemic is patterned in everyday life.
Human rights failings, moral injuries and racialised discrimination against the most vulnerable must be traced to their structural conditions, impoverished data and representations.
What lessons must India learn? First, Indian health metrics need to be “epistemically reconstituted” and nuanced to reflect not just spatial or age-based categories but socio-cultural and politico-legal gradations like caste, class, gender, ethnicity and religion. Such data must be public.
Second, public health research must parameterise historical and everyday structural forces determining people’s adaptive-cognitive dispositions rather than amplifying harmful explanations like “mistrust in medicine” commonly attributed to rural regions.
Third, the phrase “vaccine hesitancy”, which has stigma built into its very foundations needs to be discarded; hesitancy towards vaccinations is part of broader vaccine-related decision-making in which rural communities need to be mobilised as partners in finding solutions and not blamed as victims, miscreants and culprits.
Fourth, Indian public health needs to be structurally overhauled to promote systemic and epistemic redistribution in which the stories, evidence and “thick data” of vulnerable communities guides targetted, evidence-based interventions.
Fifth, India’s local response to Covid-19 must heed lessons from other global epidemics. Scientists, epidemiologists and the state must incorporate valuable socio-cultural nuances in policy-making, to ensure epistemic-intersectional health justice.
Nikhil Pandhi is a doctoral candidate in medical and cultural anthropology at Princeton University. A Rhodes Scholar, he ethnographically researches global health and the structural and social determinants of health in India.