Shreya Agoramurthy with Mukesh Kapila

Tackling COVID-19 has shown humanity at its best, be it through speedy innovations by scientists, sacrifices by families, or in numerous acts of kindness by health, humanitarian, and social workers.  But, for all the talk of global health solidarity, theSars-CoV-2 coronavirus has also shown the worst side of humanity by deepening policy-driven inequalities all over the world.

With the arrival of COVID-19 vaccines, the balance sheet has tipped ever more firmly on the side of officially – sanctioned collective selfishness. Some 82% of all vaccine doses so far have gone to people in richer countries, and only a dismal 0.3% to low-income countries.

So how to cope with the unfairness all around us that is not going away any time soon? Moan and groan, or rant and rave? I asked Shreya Agoramurthy to share an alternative insight.

Around 900-950 million adults in India are eligible for vaccination and 11%  have been vaccinated so far. This says little about who is actually getting jabbed and where. The urban-rural vaccine divide struck me when I heard of friends and family in big cities getting double vaccinated (many months ago) in contrast to those in my village.

India’s internal divides matter

The urban-rural gap or rich-poor divide within developing countries may cost them much more than overall low vaccine coverage and a prolonged pandemic. The virus mutation risk is much greater when groups with different proportions of immunised people live close together. With urban areas getting higher vaccine coverage compared to neighbouring rural areas (and no movement restrictions), further waves of infection are inevitable.

With some 70% of Indians living in  rural areas, urbanites are almost twice as likely to get a COVID-19 shot. With vaccines now available privately for those who can afford to pay, the divide has entrenched. Is this because rural areas have fewer vaccination centres, lesser awareness, more vaccine hesitancy, shortage of supply or a combination of all?  

Rural realities 

To better understand  ground realities, I rang up my uncle in India. My father and his siblings were born and brought up in the small village of Melapoothanur in Nagapattinam District in the southern state of Tamil Nadu. Before moving to Singapore in 2009, I enjoyed going to my village several times a year. I taught in the school and helped my family run a free medical-eye camp. While COVID-19 restrictions stopped that, we remain connected with the village and people. My parents helped to revive the village school and led vaccination awareness campaigns, remotely from Singapore.

My uncle, V. Ramakrishnan manages an agriculture business in Melapoothnur. He is a trusted community leader who has run the village for four decades, tackling daily challenges that concern everyone, including, now, COVID-19. He shared his insights on the barriers and enablers to the local vaccination programme. Echoes of his story from a remote  little village in India will resonate up and down the land, and even other continents. 

Early in the pandemic, villagers feared getting tested for the virus. So, when the first vaccination camp was set up a few months ago, the villagers also dreaded getting the vaccine. He says that these reactions were due to fear and ignorance. Health workers elsewhere have confirmed that many don’t want the vaccine because “they fear that they will die if they take it”.

This is augmented by misinformation and poor misunderstanding of benefits and risks. The death of a popular actor and campaigner soon after taking the vaccine stirred huge and long-lasting  hesitancy. Moreover, rumours that alcohol must not be consumed by vaccinated individuals deterred people from coming forward. Government-led pro-vaccination campaigns struggled to communicate properly or to reach the remote interior. Villagers had no credible forum to seek answers and clarifications.

To my surprise, vaccine supply was not an initial constraint in Melapoothanur. During the first camp, precious vaccines were wasted when many villagers did not turn up. But when the second wave of infections rolled in and loved ones started dying, people began to recognise the seriousness of the situation.

Severely affected families stepped forward to get jabbed, which led to others joining. The ripple effect was amplified via organised community leadership and participation to increase understanding. Local trusted volunteers led door-to-door campaigns. Community leaders collated and addressed common concerns, liaising with government or panchayat (village council) officials. Positive word-of-mouth stories from vaccinated individuals reassured the villagers in Melapoothanur.

This collaborative, community approach changed the local mood; 200 villagers queued up for the second vaccination camp in contrast to just 20 in the first. As of August 2021, some 20% had been double vaccinated, and around 90% of over 18s in the village had got their first dose and are soon to get their second.

Although vaccine supply tightened, this temporary constraint was well tackled by panchayat officials and timed perfectly with ongoing community campaigns, so as to maximise uptake of what was available. During this period, the whole of India was battling it’s second wave amid national vaccine shortages, people gasping for breath, funeral pyres burning night-and-day, and shocking headlines around the world.

Melapoothanur has fought back against ignorance, apathy and neglect through the strength of its community and local leadership.  Unfortunately, other rural areas who don’t have this combination are far from such a happy ending. Rural vaccination centres remain quiet, people continue to fear side-effects, and grapple with all types of misinformation.

Urban wedge

In some states, vaccine supplies are limited in rural areas while cities take the lion’s share. Even there, vaccine sales from private hospitals mean limiting supplies to the poor.

Divided by income and class, vaccine gaps in urban areas demand a differently tailored approach. A major challenge concerns the millions of digital have-nots or illiterates that cannot navigate the digital registration requirement for a vaccine appointment. Low-income people may not own an internet device or are unfamiliar with new platforms such as the Co-WIN booking system. There are reports that the poor are paying smartphone-owning  intermediaries to log-in for them: modern India’s enterprising version of olden times when the illiterate hired professional letter-writers to communicate for them.

These obstacles are more marked in urban areas because inequalities there are in such sharp juxtaposition, and the environment for survival can be callous or harsh.  While rural places have their own challenges, they appear to have more social capital and also benefit from decentralised services led by district governments and panchayats who come from the same region.  Can the impersonal, burgeoning metropolises of India – and those who run them – learn from the villages?

The ongoing COVID-19 vaccination saga shows that inequalities are a life-and- death matter. But we have always known that. The reality is that correctional policy prescriptions and their practical application are easier proclaimed than implemented, whatever your political, economic, or social beliefs.  

Meanwhile, recognising that externally-driven levelling-up is unlikely to happen any time soon, liberates people to take matters into their own hand. This happens in different ways in different contexts whether in India or other countries, and whether rural or urban.

But they all rely ultimately on the same notion of shared values and collective organisation with, if you are lucky to get it, enlightened local leadership.