On June 22, 11-year-old Muhammed Afsad of Kondotty village in Kerala’s northern district of Malappuram died after contracting diphtheria, a highly-contagious though preventable disease. Afsad, who had complained of throat pain and breathlessness, was first taken to a local hospital and then to Kozhikode Medical College, where he passed away.

Doctors at the hospital said that they had never seen such a case before. “The boy’s entire lymph nodes were swollen when he was brought here,” said a doctor who treated Afsad, who did not wish to be named. “The bacteria had spread at an alarming rate throughout his throat up to the trachea. We immediately put him on oxygen support and life-saving drugs. But we just couldn’t save him. This surely could not have happened to a person who was vaccinated.”

Though Afsad’s mother said that he was vaccinated, she has no records to prove it. Neither did her son have an immunisation card or a progress report on his health, which his parents would have been given by state health services if Afsad had indeed been immunised.

Afsad’s father, a fisherman, has no idea about immunisation. Afsad’s brother is 18 years old, and he has no vaccination records either.

Preventable death

Diphtheria is a highly-contagious preventable disease that has largely been eradicated in the developed world. Most of us are vaccinated against it during childhood. In all, between six weeks and five years of age, children get three doses of the DPT vaccine against diphtheria, pertussis and tetanus and two boosters.

Afsad's is one of two recent deaths due to diphtheria in Malappuram, where large gaps in immunisation coverage are emerging.

The Kerala State Commission for Protection of Child Rights has said that the deaths were an unacceptable violation of children’s rights and is set to seek an explanation from the state government over the circumstances leading to what the quasi-judicial body calls a “completely shocking situation” that has put the lives of thousands of young children at risk.

Children are immunised at a very early age when they cannot decide whether they want to be vaccinated, said Shoba Koshy, chairperson, state commission for child rights. “Somebody has to exercise the child’s right at that age,” she said. “And if the people, who have been called on to exercise that right, are not doing it, it becomes a very serious matter. It is leading to death or damage to a child…when the child did not make that choice. This is just not acceptable.”

More than 26,000 children between the age group of two and seven years are yet to be immunised in Kerala while a staggering two lakh children are partially immunised. Malappuran along with Kasargode are among the districts with the lowest immunisation rates – less than 50%. All these children, including infants, need to be immunised at the earliest.

The fear of vaccines

Malappuram, a Muslim-majority district, is infamous for diphtheria-related deaths in earlier years too.

It is not uncommon for illiterate or ill-informed parents to refuse to vaccinate their children against common preventable diseases in many parts of India, and even the US, due to rumours that vaccines have harmful side-effects. However, this resistance is particularly strong in Malappuram, where health workers have battled for years to convince parents to vaccinate their children.

Health workers say the response to vaccination programmes in this district is predominantly one of fear and mistrust.

Giving an example of the kind of resistance faced by health workers, one such worker said that she was greeted with a closed door at a house in Tirur village. When she announced that she had come to conduct vaccinations, a woman shouted through the window that the man of the house was in the Gulf and would only return a month later. “We don’t take such decisions alone,” the woman told the health worker.

When the health worker said that, in that case, she would return in a month, the woman told her not to bother. “We don’t need your medicines,” the woman said. "So please do not come back. You please leave now."

Immunisation workers say that as they move from house to house seeking to vaccinate children under the government immunisation programme, this is the usual response they get in Malappuram.

Most of them say a misinformation campaign has led to a fear psychosis, which is turning parents against vaccinations.

Messages sent via WhatsApp and Facebook are helping spread the fear of immunisation among locals here. “America has sent drugs to India to control the Muslim population. So beware,” reads one such message. Another talks of how immunisation is against Islamic traditions. There are others that talk of the so-called terrible side-effects of vaccinations.

Dr Renuka, who has been spearheading the immunisation drive in the district, said the people behind the anti-vaccine campaign included self-proclaimed naturopathy healers and quacks, who did so for personal gain.

“This resistance is because they have been made to believe that the vaccine can cause more harm than help them,” said Dr Renuka. “For example, when we introduced the Rubella vaccine [against German measles] for young girls, the rumour was spread that it was an American vaccine devised to make Muslim women infertile. Such rumours can be very damaging among a highly sensitive population.”

Where does the buck stop?

Thirty kilometres from Kondotty village, the little town of Tanur is mourning the demise of Mohammed Ameen, 15, who also died of diphtheria last month.

His parents say that he was immunised at some point, but Ameen was only given the initial shots, and not the booster, which means that he was partially immunised.

The tragedy that struck Afsad and Ameen should have opened the eyes of those resisting immunisation for their children. But in Malappuram, the social stigma surrounding immunisation is deeply entrenched. It doesn’t help that the Jamaat-e-Islami, an influential Muslim organisation, is believed to be leading the anti-vaccine campaign within the local community.

Zainuddin Ayamon, who runs a business in Malappuram, has three children, and is a loyal Jaamat worker. He said that the onus was on the government to allay the fears of people regarding vaccines. “The problem is the inability of the government to answer the concerns of the people,” said Ayamon. “There is a lot on the social platform [social media] which says vaccination is bad. We have so many worries and concerns about the safety of these medicines. If this is a government-driven initiative why is the government not coming forward to allay our fears? Without that, people will not cooperate.”

Ayamon has vaccinated only the oldest of his three children. The other two, aged seven and five, have not received any vaccinations whatsoever.

Similarly, the two children of Abdul Hameed of Tirur village are not vaccinated either. “I have seen children who have taken vaccination dying in front of me,” said Hameed. “Many others have become crippled. Why should I let my children take the risk? Otherwise the government should give me in writing that these vaccines are safe. There is a huge business angle to this vaccination drive and we are not guinea pigs.”

The Jamaat was unavailable for comment on this issue, despite several attempts to reach its leaders.

Limiting the damage

Prompted by the two deaths last month, and with two more children undergoing treatment for diphtheria at Kozhikode Medical College, the state government launched an all-out vaccination campaign in Malappuram in the last week of June.

Four municipalities and 44 gram panchayats are working on a war footing to vaccinate children across the district. The remaining ones are expected to join the drive soon. On June 25, 1,496 children were vaccinated across 26 camps in the district, and at the end of the month, that figure stood at 8,200.

“Resistance levels are certainly coming down,” said Ummer Farook, district medical officer, Malappuram. “But there are still a lot of people who are not willing to vaccinate their children. It is a very tough job but we are determined to ensure that vaccination reaches every house in the district.”