At 5 am one day in October, 45-year-old Roshanara rose from her bed for her morning prayers. A few hours later, she began her daily rounds of Islampur, a village in the Khatauli tehsil of Muzaffarnagar in Uttar Pradesh. Roshanara is a Community Mobilisation Coordinator in Islampur and her job is to convince and remind families to vaccinate their children regularly.
Roshnara is spectacled and sunburnt and her wrinkles add a few years to her age, which is an asset in her cause. Armed with a detailed register of the vaccination histories of all children under five she makes her rounds taking special care to counsel those with newborns about the importance of giving their children “do boond” – the two drops of the polio vaccine.
“People believed they would become sterile if they took the drops,” said Roshanara, recalling the violent opposition she faced when she first began working in the community in 2003. She recalled an incident in a neighbourhood called Nayabadi where her team of seven had been given a target of clearing 10 XR cases, XR being code for those who resisted the oral polio vaccine.
“One woman pushed me against the edge of a cot when I asked if I could meet her children,” she said. “I threatened to call the police because she was behaving like this. That time I scared them into immunising their five children.”
Roshnara and other Community Mobilisation Coordinators in Muzaffarnagar say that their work is easier now, at least when it comes to convincing people to get vaccinated against polio.
In 1990, as part of an international campaign against polio, the Indian government committed itself to eradicating the disease by the year 2000 and instituted national and sub-national immunisation days supplemented by awareness campaigns. Uttar Pradesh was one state that reported pockets of resistance to the vaccination programme. In 2001, the region reported 80% of all cases in India and more polio cases than any country in the world. The statistics were accompanied by reports of communities, mostly Muslim and Dalit, resisting the oral polio vaccine.
A few kilometres away from Islampur at Chandbagh, a group of men met at Dr Mohammad Athar’s tiny clinic to discuss the immunisation programme. Mohammad Naem, an important opinion maker in his neighbourhood, was present amongst doctors, lawyers and maulanas. Naeem used to staunchly oppose vaccination.
“How else was I supposed to react?” Naem asked. “We didn’t have any basic health facilities and then suddenly these people showed up with these expensive medicines. Why were they handing these out for free? It is not like they were our relatives.”
Naem’s reservations reflect the perceptions amongst underserved communities that have had little faith in public health mechanisms. These communities associate free health services with family planning campaigns that they are suspicious of since they believe these target minority populations. Health workers and auxiliary nurse midwives administering oral polio vaccines also promote family planning and deliver contraceptives. Minority community suspicions were also stoked by remarks like those allegedly made by Varun Gandhi in 2009 about the “need to pick them [Muslims] up, one by one, and sterilise them”.
“People wondered why someone who wasn’t unwell should take medicine, especially when there were no immediate, visible results,” Mohommad Jahangir explained. “Many also wondered why the drops had to be taken repeatedly.”
Battling belief
The Community Mobilisation Coordinators also had to contend with matters of faith and the belief that paralysis was the result of a curse rather than a disease.
“The CMCs had a tough task because they had a target to meet, and they had to convince people to consume a substance which they were highly suspicious of,” said Jahangir.
Realising that illiteracy and lack of access to information were major hurdles, a consortium of organisations called the CORE group assisting the polio eradication programme initiated a communication strategy. This strategy aimed at creating awareness and altering parental attitudes in areas like Muzaffarnagar where children were susceptible to polio.
Funded by USAID, NGOs working in the space of community health spearheaded the polio project with Project Concern International taking the lead in Muzaffarnagar. Teams of Community Mobilisation Coordinators were formed with individuals from these communities. A group of about 17 coordinators, each of which kept records of 500 village households, would report to block mobilisation coordinators who in turn were answerable to a district mobilisation coordinator.
“They were trained to carry out basic Information Education and Communication activities like individual counseling, focused mothers’ meetings, how to maintain records and how to store and administer the vaccine,” said Tauquir Alam, district mobilisation coordinator at Khatauli.
On the ground, however, these women were left to their ingenuity and fortitude. With over sixteen years of experience, Roshanara has many cards up her sleeve. “In the simpler cases, we remind people that they have to take the drops when they go on a haj,” she said. “Sometimes, we take the drops ourselves to show that it is safe. There are also many who vaccinate their daughters but not their sons and then we remind them that it is our daughters who will give birth to sons. If it’s OK for the girls then it’s OK for the boys.”
Community Mobilisation Coordinators also have to establish trust with local families and this meant getting involved in other aspects of their lives. “I helped set up bank accounts, helped people procure ration cards,” said Roshnara. “Some weren’t receiving their pension, so I helped with that. If someone’s husband was beating them up, I helped them get justice. If there were health issues I accompanied people to the hospital, even if it was at 2 am.”
Roshnara also had to invest a lot of time and patience, especially with the XR cases. She once had to get acquainted with a couple who had five daughters and were refusing to get their newborn son immunised. “Over a period of three years I became their friend and not once did I mention polio,” she recalled. “This was possible because they weren’t in my area, and I was helping out with tough cases in other parts of Kathauli. Once I had the chance, I told her that my four sons had been vaccinated. I assured her that nothing would happen to her son if she did too.”
The very night that the boy got his polio drops, his parent observed a tremor in his leg. Roshnara rushed him to the hospital where the doctor told the boy’s parents that the child would be safe because he had been immunised.
“The boy is now 12 years old and I get so much of love and respect from that family,” said Roshnara.
Convincing settled communities to immunise their children is one tough battle, but there were also people harder to reach. At the dumping ground behind his shop in Sheikhpura, Iqbal the barber sees nomads make camp as they travel north from Barabanki. Iqbal saw some of the nomads affected by polio. He attended meetings with maulvis and doctors to learn about the polio vaccine and help convince members of the nomadic groups to get their children immunised.
“The nomads and many of my relatives had misconceptions,” he said. “The nomad women hid their children under their ghagras and Seema [the Community Mobilisation Coordinator] would have to pull them out. I told them to take the drops, nothing will happen.”
“Winning the support of the maulanas was perhaps our biggest achievement,” said Hari Om, block mobilisation coordinator in charge of Kathauli. “A declaration from the local mosque has far more credibility than announcements on the radio, posters and hoardings. Maulvi sahib is very supportive and any declaration is only a phone call away.”
Naem, a resident of the more urban Chandbagh, also eventually agreed to let his 24 children, nieces and nephews get vaccinated. “It was the educated people in our community who were important,” he said. “We listened to them because we trusted them and if something went wrong we could also catch them.”
Hari Om is thankful that while earlier people would chase immunisation workers away with sticks and brooms they now inquire about when the teams will visit their areas next.
The goodwill towards health officials and vaccination teams was also confirmed in other ways as during the the 2013 riots, Hari Om recounted. He was among the team conducting a health camp on one of those turbulent days when suddenly the shops began to close and there was a curfew. It had also started to rain and the team, consisting entirely of Hindus, was getting anxious in the Muslim area.
“The doctor and Naem both went out, got drenched but they returned with a vehicle and dropped each of us home,” said Hari Om. “The gesture sent an important message to the CMCs and ANMs as well.”
This reporting project has been made possible partly by funding from New Venture Fund for Communications.