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Misinformation Alone Can’t Explain Vaccine Hesitancy Among India’s Marginalised

Misinformation Alone Can’t Explain Vaccine Hesitancy Among India’s Marginalised

Workers erect scaffolding at a construction site of a metro rail station in Kolkata, July 2019. Photo: Reuters/Rupak De Chowdhuri

Mumbai: We asked Asha, who works as a house-help in the city, when she was planning to get vaccinated. She said her husband and in-laws had told her to not get vaccinated at any cost as doing so would weaken her. We reasoned with her and cited many cases of vaccinated people who were all healthy. She said she would not be able to go against the wishes of her family.

A few days later, the Mumbai government published new rules that said only vaccinated house-helps would be allowed to enter housing societies. Finally, Asha took the first dose of a COVID-19 vaccine; not doing so would have threatened her livelihood.

We recalled that similar fears had been expressed by an office peon who refused to get vaccinated, as that had led to the death of some people in his village. He said these were not rumours and he personally knew the ‘victims’. When we gave examples of the many who were healthy after vaccination, he countered: “Aap ka tika sahi hai, hamare mein zahar hai, is se garib khatam ho jayenge” (‘The vaccine for you people is fine but for us it has poison, which will finish the poor’).

The salience of this focus on faulty or poisonous vaccines is not the misinformation itself – that it is factually wrong – but that it is an expression of fear that the “system” is against them. The more we spoke with people, the clearer it became that an aversion to vaccines is driven by bits of misinformation only in a superficial sense. The truth is deeper: for those marginalised in socio-economic terms, these bits reinforce an already existing worldview full of despair and anger at a state and society that is indifferent, or even hostile, to their travails.

Such beliefs circulate inside a gigantic social “echo bubble” populated by those who feel left out.

Feeling abandoned

We scoured media reports about such reactions from people from weaker socio-economic groups, in order to perform a discourse analysis.

A group of people, in rural Uttar Pradesh, jumped into a river to escape a team of health officials because they believed the vaccine was an injection of poison.

Such is the fear of harm that could follow vaccination that, in Madhya Pradesh, a group of health workers and vaccine motivators was assaulted even while they were talking to people.

For those who are too weak to be assertive, there is just plain fear and the desire to flee – as in a video of an elderly woman trying to hide to avoid being vaccinated.

People run away from their homes whenever they see health workers, including locals, involved in the vaccination drive. There are many beliefs about vaccination causing death – if not immediately, then after a few years. Or, of it being a “deliberate” attempt to kill that are echoed in rural areas and among the urban poor.

Notions about the vaccines availed to them being toxic are common. Some even believe that local health workers receive money when people die. There is also this narrative that vaccines “induce impotence and paralysis”.

These reports indicate feelings of being hunted or preyed on by wider society, and by the well-off in particular. The vaccine was seen as a weapon rather than as a cure. And these comments, often tinged with anger, demonstrate this clearly.

Pehle apan maiya-bahiniya ke tika dilau (First get your mothers and sisters vaccinated)” – an elderly woman to a NGO worker

“When we are actually ill, none of these health workers turn up to give us medicines. Now that we are fine, they have come to inject us. We will die a natural death or from a disaster, but not from the coronavirus.” – A woman from Manjhi Tola, Laxmipur

A less aggressive version of these feelings is that they be “left alone”.

Also read: How Covaxin Trial Participants in Bhopal Were Misled

* * *

From the beginning of the COVID-19 pandemic, most steps taken by the Indian government have only deepened this sense of hostility towards the state, accompanied by experiences of intense apathy from society at large. The first evidence of this was the big lockdown, at very short notice, in March 2020. It resulted in jobless migrant workers and their families walking for days in scorching weather, even some dying en route to their hometowns and villages.

“Hardly anyone came to our aid during the lockdown, when we ran out of work and money. Who will help us if something goes wrong now with the vaccination?” This is what our local electrician said, after mentioning that he hadn’t taken a vaccine.

Even the slogan “stay safe, stay at home” is alienating for people who have to earn a living working everyday. Staying at home for this group is synonymous with hunger, debt and lost jobs. It signals a certain indifference and lack of concern.

The second COVID-19 wave brought on a graver sense of abandonment. Many people – disproportionately more from marginalised sections and rural areas – have lost their near and dear ones, to the disease as well as to the lack of adequate health services, hospital beds, oxygen, etc. There has been no dignity even in death when, in many areas, a lack of resources forced people to abandon bodies of their family members on riverbanks.

Such choices seem to have eroded most expectations that the marginalised had in India’s health system, or in fact in the government. This increasingly supported conviction, that there is no administrative machinery that will tend to their needs, even minimally, has spawned mistrust. And in this ‘us versus them’ framing, the vaccine is coming from ‘them’.

By depending exclusively, and for a considerable time until recently, on the CoWIN platform to make vaccination appointments, India’s massive rural and/or illiterate population has been led to believe that the vaccination drive is tailored for the urban, educated elite.

Conspiracy theories and fatalism

People search for meaning in everyday experiences, and a persistent struggle in daily life rendered harder by the pandemic, has paved the way to religious fatalism, superstitious beliefs and conspiracy theories.

One set of studies has shown that “social exclusion is associated with superstitious/conspiratorial beliefs.” This is the way in which people develop “explanations” for why things are the way they are, through a psychological mechanism called ‘meaning-making’. Beliefs like ‘vaccines for the poor are poison’ or that ‘state agencies want to eliminate us’ or ‘make us impotent’ help people make sense of their powerlessness, and find a modicum of control through the conspiracy (“I don’t want the vaccine” being an assertion of control).

Research into why and when such conspiracy theories find traction suggests two relevant cardinal principles.

First, “negative emotions that constitute the psychological origins of belief in conspiracy theories include anxiety, uncertainty, or the feeling that one lacks control”. This works even more effectively if the “perceivers consider the implicated authorities as immoral”.

Second, “social motivation is to protect against a coalition or outgroup suspected to be hostile. This outgroup typically has some threatening quality, such as power (e.g., politicians; managers) … which reinforces people’s suspicion towards these groups”.

Indeed, many marginalised sections of society strongly feel that they lack control over their lives, consider authorities to be unjust and think in terms of “us” versus “them”.

An extreme form of superstition is religious fatalism. This is not unexpected in a deeply religious society. The worship of a “corona goddess”, much like the worship of ‘Shitala Mata’, considered the goddess of smallpox, is a case in point. Devotees offer prayers to the deity to save them from her wrath, and these temples have attracted large crowds.

It is easy for people to fall upon such “solutions” as they evoke hope and a sense of control through prayer – in an otherwise dark world. Nevertheless, it is tragic and telling that there are vast sections of the population that feel more “in control”, leaving their lives in the hands of gods rather than those of the state.

Also read: India Donated COVID Vaccines to Afghanistan, But Hesitancy Has Left Many Unused

Inclusion and calling out misinformation

In this context, simply calling out misinformation and rumours can work only up to a point. For many who resist vaccination, attitudes towards the vaccine are related to their survival and safety. And attitude theories suggest that these attitudes are strongly held, and thus hard to change. If state agencies don’t become less hostile and less alienating, and whose schemes don’t become more inclusive, campaigns centered on facts and rationality will find poor traction on the ground.

Creating genuine inclusion is hard in highly unequal and hierarchical societies, however. And even then, financial assistance in the form of cash transfers to marginalised and vulnerable groups would be essential to their survival. Providing material assistance would be a clear way to demonstrate that the state cares. Opening up vaccination appointments to walk-in registrations is a good step in this direction. Another such could, and should, be the rapid and visible rejuvenation of public healthcare centers.

Awareness campaigns will work only in such an ethos. There should be large-scale, customised publicity campaigns that debunk misinformation, convey the dangers of COVID-19 and connect – in a reassuring manner – with currently alienated social groups. Vaccine awareness publicity, with the energy that was seen earlier in the Pulse Polio and the Swachh Bharat campaigns, is missing.

First, deftly packaging facts and figures – done honestly, without fudging – about vaccine safety, minor side effects, possible complications, etc. is more important than sensational and loud headlines.

Second, the credibility of the sources disseminating this information is important. Local doctors and influential people should be roped in to spread relevant information in regional languages and dialects.

Third, advertisements on radio and TV should become commonplace, and stress the need and advantages of vaccinating oneself – instead of focusing on highlighting government achievements. Some states have already started using folk music and nukkad natak (street plays) to spread awareness. We need posters, billboards and announcements through loudspeakers mounted on vehicles moving through villages and towns.

Concentrating public messaging campaigns on digital media will alienate more than it will mobilise. In this universe, misinformation spreads largely through word of mouth, aided only occasionally by WhatsApp forwards sent by those fortunate enough to possess a smartphone and a data connection. This is not the Twitterverse, so simply publishing smart tweets would be pointless – except, of course, for the favourable optics on social media.

And coercive measures like meting out corporal punishment to or putting skull-mark posters on the unvaccinated – and it is usually the poor and the marginalised who are victims of such punishments – will only reinforce the existing sense that the state and society are out to belittle them.

Anurag Mehra teaches engineering and policy at IIT Bombay. His policy focus is the interface between technology, culture and politics. Anshu Deshmukh is a psychologist and student counsellor, and works in the field of mental health.

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