“Tikkakaran nahin toh khadyadhan nahin.” No vaccination, no ration. Rajwanti Devi Jaiswal, an Accredited Social Health Activist or ASHA in Uttar Pradesh’s Bahraich district repeated the slogan so often that it sounded like a chant.

The district has one of the lowest child immunisation rates in India – according to the most recent round of the National Family Health Survey, only one of every ten children in the district is fully immunised.

Desperate to increase the immunisation rate, district officials are threatening to cut off subsidised food rations to poor parents who fail to get their children vaccinated. The administration is well aware that restricting a family’s access to food entitlements is against the law, but officials claim they do not intend to act on the threat.

“I know we can’t really stop any family’s ration, but the threat is helping,” said Rakesh Kumar, district supply officer of Bahraich who responsible for the functioning of the public distribution system in the district.

Kumar said that the district magistrate’s office asked his department in October in implement these measures. According to Kumar, ASHA workers like Jaiswal are supposed to report the names of families refusing vaccination to the officials in the food supply department, who in turn instruct kotedaars or rations shop owners to tell these families that they will not get their rations.

District magistrate Ajay Deep Singh said that what his office is doing does not constitute coercion. “We know we cannot deprive any family of food grains,” he said. “This is just a administrative technique we are using to pressure the families, so they don’t deprive their children from life-saving vaccinations.”

Kumar claimed that more people have started coming in to get their children immunised in the last two months since the government threatened to withhold their rations. “In the end, it is benefitting the children,” he said.

Graphic: Anand Katakam, Manas Sharma

In many districts with low immunisation rates, communities are resistant to immunisation because they do not trust the government health system. Jaiswal, who is the ground level health worker responsible for outreach on immunisations, has faced this mistrust. “The minute these mothers see us, they run away with their children in the fields,” she said.

But instead of working to gain the trust of communities, Bahraich’s administration has resorted to a quick fix. “The officers are using coercion because they have failed to motivate the community to willingly vaccinate their children,” said public health and bioethics expert Dr Anant Bhan.

Fear of vaccination

Child vaccination is a major focus area of the Indian government’s attempts to improve the health and survival chances of children. The government launched the national programme of immunisation called Mission Indradhanush in 2014.

But districts like Bahraich continue to underperform on immunisations. Health experts say the underperformance is rooted in the abysmal state of the public health infrastructure in Uttar Pradesh’s Terai region, as reported in previous stories in this series on the high maternal and infant mortality in the region. In addition, these districts have low levels of income and literacy.

Instead of improving overall healthcare, policymakers have an obsession with numerical immunisation targets, say public health experts and doctors. “The target-based approach of the Indian health system is to be blamed which forces officials at all ranks to resort to unethical means like even fudging data to show that improvement,” said Bhan.

The vaccines administered under Mission Indradhanush include the polio vaccine, the DPT vaccine that protects against diphtheria, pertussis and tetanus, and the Bacillus Calmette-Guérin or BCG vaccine for tuberculosis.

A vaccine is a weakened form of a biological agent that causes the disease that one is seeking protection against. When the vaccine is delivered into the body, it triggers the production of antibodies that fight the disease. Once produced, these antibodies circulate in the body and ward off future infection.

Since a vaccine contains a weakened form of a pathogen, it can sometimes lead to undesirable side effects. The World Health Organisation says that an “adverse event following immunisation is any untoward medical occurrence which follows immunisation and which does not necessarily have a causal relationship with the usage of the vaccine… many are simply coincidental events, others (particularly in developing countries) are due to human, or programme, error”.

Most often reactions from vaccinations are mild and clear up quickly. In rare cases, they may result in lifelong disability or even death. Both minor and major adverse events after immunisation, even if coincidental can erode public trust in immunisation, especially in communities with high illiteracy.

Jiber Ahmed resides in Bahraich but works as a carpenter in the neighbouring district of Balrampur. An ASHA worker convinced Ahmed to allow her to administer the BCG vaccine to his son a few months ago. The boy developed a blister on his arm where the vaccine was injected under his skin, and then came down with fever. Both are known side-effects of the BCG vaccine and almost always subside on their own. But Ahmed was not told to expect fever or a blister, so he grew alarmed. “I took him to chancy (a quack doctor from West Bengal), who opened the blister and removed the pus inside it,” recalled Ahmed. “You should have seen it. The child was crying in pain and there was so much pus.”

He now tells others in the village to avoid the vaccine, which he thinks “nearly killed his child”. He has also decided to stop paying attention to ASHA workers. “I listened to her, and see what happened,” he said, holding his two year old boy who has a visible scar on his right arm.

A child in a village in Bahraich district, Uttar Pradesh. (Photo: Priyanka Vora)

“These families have seen the adverse effects of vaccines and not the benefits,” said Dr Sylvia Karpagam, a public health specialist. “They will act on what they have seen. So their resistance against the vaccine is completely understandable.”

Public health experts like Karpagam point out that fear of vaccination and poor immunisation rates reflect the government’s failure to inform and educate people about the benefits of vaccines.

And indeed, even grassroots health workers who are supposed to bring people in for vaccination and Auxiliary Nurse Midwives who administer vaccines receive little training on how vaccination works or how to explain the process in largely uneducated communities.

Laxmi Shrivastav, an Auxiliary Nurse Midwife working in Balrampur, frequently sees people’s concerns up close. One day in November, she sat on a cot in a vaccination booth in Lokhava village. Under the Mission Indradhanush programme, health officials set up such booths in the houses of aanganwadi workers. Families are asked to bring children up to the age of six to the booths to get vaccinated as per a set immunisation schedule.

At a vaccination booth in Balrampur district. (Photo: Priyanka Vora)

As each child came forward to be vaccinated, the ASHA worker cautioned the family that the child might get a blister. “Foda aayega, par darna mat,” she told the child’s parents. There will be a blister, but don’t worry. Once the blister dries, it means that the vaccine is effective.

But although she has been an Auxiliary Nurse Midwife for more than 20 years and is a permanent government employee, Laxmi Shrivastav is unable to advise parents on what they should do if their children start crying incessantly or are visibly uncomfortable after being vaccinated. “Woh humko pata nahin,” she said. I don’t know about that.

Neither ASHA workers nor Auxiliary Nurse Midwives receive training under the immunisation programme on what advice to give in such situations.

“I agree there is a problem,” said Dr Archit Shrivastav, who is in charge of Babaganj community health centre in Bahraich. “Their training is mostly focused on how to prepare reports and not on the science of vaccines, or even how to handle the side-effects.”

Low literacy, few health facilities

Low rates of immunisations in pockets across India are often traced back to a combination of factors. The first is low literacy.

In Bahraich and Balrampur, only a third of all women are literate. These means that most women with children who need to be vaccinated need to be given more information and counselling about the process and benefits. Instead, outreach on immunisation is sorely lacking.

A second factor is poor access to general health services. When Ahmed’s son developed a blister after getting the BCG vaccine, Ahmed was forced to go to a quack doctor because the closest community health centre was closed and no government doctor available there at night. The district hospital was about 40 kilometers away. A government doctor who knew about the side effects of the BCG vaccine may have allayed Ahmed’s fears and prevented the unnecessary and painful procedure to remove the blister from the boy’s arm.

Moreover, health workers are often reluctant to vaccinate a child who might be sick or malnourished for fear that if there is an adverse reaction, the family will hold them responsible. Many children born in villages of Bahraich and Balrampur are malnourished. Like Shivpal, son of Lokhava resident Manju. When Manju walks into the aanganwadi worker’s home with Shivpal, the aanganwadi and the ANM Laxmi Shrivastav exchange glances. Shivpal weighs only 3.5 kg at three months instead of at least 6 kg. His legs are thin like sticks.

Holding the needle in her hand, Laxmi Shrivastav steps down from her cot to inspect the child’s thin legs. She hesitantly decides against vaccinating the child. “He is too thin,” she said. “If something happens to the child, I will be blamed.”

There is no actual evidence that vaccinations cause worse reaction in undernourished children. Dr T Jacob John, who is a paediatrician, virologist and epidemiologist at Christian Medical College in Vellore, said “I am not aware of any data to show adverse events following immunisation for any vaccine, are more frequent or more severe in undernourished children than normally nourished children.”

However, Karpagam points out that India needs a systematic study to check whether there might be such a difference. “Children who are immunity compromised and malnourished might react differently to the known adverse reactions, which as per our knowledge are mild,” she said.

Challenges for ASHA workers

Health workers face myriad challenges in trying to get children immunised. In Bahraich and Balrampur, many children are born at home and miss vaccinations that they would have got immediately after birth, had they been born in hospitals. “Suddenly, we get a child who is six months old and the mother is not even sure if the child is vaccinated or not,” said Laxmi Shrivastav. “If he was born at home then we assume he was not vaccinated. But that means we have to give him multiple injections.”

Health workers are wary of giving a child multiple doses of different vaccines in one go to make up for the ones missed earlier, fearing a greater chance of adverse side effects.

“Yes, there is a fear about giving multiple vaccines,” said Archit Shrivastav. “We need an expert to tell us what to do in such situations.”

Auxiliary Nurse Midwife Laxmi Shrivastav immunising a child at a vaccination booth set up inside the anagwanwadi worker's house. (Photo: Priyanka Vora)

ASHA workers also have to deal with communities where people migrate for work. Banjara Dera village in Balrampur is populated by Muslim families who travel to neighbouring Nepal for work. This makes it difficult for ASHA workers to monitor pregnant women and ensure immunisation of newborns. Rabiya Khan, who is the ASHA worker for Banjara Dera, also notices disdain among health workers for Muslim communities. “It is true that Muslims are reluctant to vaccinate their children but if you explain it to them, they agree,” she said. “But people [health workers] consider them animals, so nobody talks to them properly.”

ASHA workers are also under immense pressure from the health department. Khan, who is credited with improving immunisation rates in Banjara Dera village, was once threatened with being fired. “We told her if she didn’t improve the coverage, we will fire her,” said her superior. “Since then the immunisation rates have gone up.”

Detrimental in the long run

Public health experts argue coercing people into getting immunisations is counter-productive in the long run. Sustained improvement in immunisation rates requires that communities be educated to seek vaccinations voluntarily. The extreme step of threatening to withhold rations is a sign that the public health department has failed to explain the benefits of vaccination. Ultimately, they warn, the punitive policy could backfire, increasing distrust of the government and making it more difficult to encourage people to adopt a wide range of healthy behaviours.

“Parents should willingly vaccinate their children, not under some fear,” said Karpagam. “In such a situation, parents might start lying about the immunisation status of children, which will be a bigger disaster.”

If parents are not forthcoming about their children’s immunisation, it will be difficult to estimate how many children remain vulnerable to common childhood diseases and the risk of an outbreak.

Even the government’s ability to track the problem could suffer. “When there is pressure and targets, there will be some fudging of data, which will be a major setback,” admitted a senior official from Ministry of Health and Family Welfare.

But the real victims will be children, who could suffer for their rest of their lives. John argues that vaccine-preventable diseases occur when the body and brain are developing fast and any interruptions in growth due to falling ill during the first five years of life can have long-term effects. “The arrest of growth takes time to recover from, leading to stunting in comparison with peers,” he said. “School performance also suffers setbacks, and is bad for both physical and cognitive development.”

He then pointed out that Uttar Pradesh has not only worse health indicators than much of India, but also has lower educational achievements. Calling for increased investment in public health, he added, “It is time we understand that social development will lead to economic development – a lesson Uttar Pradesh has to learn.”