A Remote Himalayan District’s High COVID-19 Vaccination Rate

TRam was required to climb a steep and unpaved mile downhill in order to reach the main road. It took another 90 minutes to get on the main road towards Padampuri. That’s where the only government hospital and walk-in COVID-19 vaccination center in the Dhari area—home to some 30,000 people spread across 46 villages—is located.

In September of 2018, India was still reeling from the second COVID-19 tsunami, which was primarily driven by the Delta variant. Official government statistics show that more than 400 000 Indians were killed between June 1, 2020 and July 1, 2021. However, a new report by the journal shows this number is much higher. ScienceIt was estimated that as many as 3.2 Million people died. The majority of those—2.7 million—occurred in three months, April through June 2021.

The number of COVID-19 cases dropped dramatically over the next months. Hospitalizations also remained low, even in an Omicron-driven wave 3, which reached its peak in January. It is partly due to the widespread efforts to eradicate this virus. India began to offer COVID-19 vaccines for health workers in January 2021. Then, it started offering them for older adults and people with co-morbidities. It took a while for the vaccine rollout to pick up pace, but by Jan. 30 of this year, India’s government said 75% of its adult population had received two doses of a COVID-19 vaccine.

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Ram became eligible as a septuagenarian and was therefore eligible to receive the vaccines. However, Ram initially chose not to go. He’d been unwell and felt uncertain about the safety of the vaccines. He was also wary of the trip he’d have to take to get his shots. But months of persistence by the health workers in Padampuri—and especially by his daughter-in-law, who is part of Dhari’s vaccination team—managed to persuade him. “I saw how hard she worked on this,” Ram says. “She urged me to take the vaccine, if not for myself, then for my family and the community.”

His change of heart wasn’t unusual. In this remote area that covers 30 sq. mi.—most of it rugged terrain that rises to 7,000 ft. of elevation—by the beginning of October, 100% of eligible adults had received a first dose of a COVID-19 vaccine. That equates to some 28,000 people, according to Himanshu Kandpal, the chief medical officer of the Dhari area, who is in charge of Padampuri’s medical center. The state of Uttarakhand as a whole reached that same milestone in mid-October, with all eligible adults—some 7.4 million people—receiving a first dose, usually of the Oxford-AstraZeneca vaccine, known locally as Covishield. (Those vaccinated in the very first phase typically received Covaxin, India’s own vaccine.)

While most Indian cities are now catching up, Dhari was an early success story, and continues to get people to show up—more recently, for their second doses and booster shots. Over 80% have been vaccinated in Dhari (one of the remotest places in the country), despite snowfall, road closures and heavy snowfall. Kandpal says that by the end of February, the adult population in the region will be fully vaccinated—though it’s difficult to be completely certain in a region where officials struggle to document the members of every household. Kandpal said that all eligible teens between 15 and 17 years old have received their first dose.

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Other districts in the state have had similar success, as has India’s northernmost mountainous state of Himachal Pradesh. Dhari, and other hill areas have higher rates of vaccination than places that have better healthcare infrastructure and are more easily accessible. As an example, the U.S. has 64.4% adults who were fully vaccinated on February 14th, while only 75.9% had received their first vaccine.

It is amazing that a Himalayan remote region has been able to thrive in an environment where many cities and nations have failed. It is clear that health workers are best positioned to support their local communities in times of crisis.

At first glanceDhari is an unlikely location to achieve such a milestone in vaccine success. For one thing, the Indian government made a smartphone app the primary means for booking a vaccination appointment—in a country where only around half of the population has a smartphone. Rural areas, such as Dhari, have a lower proportion.

The practicality of the situation was another challenge. “Much of the population here lives in remote areas, and it takes them so long to come to the medical center,” Kandpal told TIME in August, sitting in his office in Padampuri—the only significant medical facility for 25 miles. It is covered with faded yellow paint and can be accessed only via a flight of stairs that have been cut out of the mountainside. It is located at 5,200 feet elevation and thousands of feet lower than many mountain villages that it serves. “People have to commit to a full day to get vaccinated. That didn’t help,” Kandpal said.

Hema Devi is well aware of how hard that can be. The 45-year old farmer trekked uphill for a mile from Thiroli to Dhanachuli, a larger village, in July. Before she could get her turn, the camp ran out of vaccines. She waited hours before getting it. “I hear about people not taking the vaccines in the cities, and I am puzzled,” she says. “They don’t even have to climb a mountain or negotiate broken roads. They also don’t have to think of who’s going to cook dinner or lunch if they are stuck at the camp—they can just order food on the phone.”

She tried it again on Aug. 2. On that day, she woke up before sunrise to clean and cook and then take her goats and buffaloes to the grazing area. Then, she set off along with two neighbours and her husband. Devi and her husband were able to join different lines when they reached Dhanachuli. The line for men was much shorter, with most of them—including Devi’s husband—there to receive second doses, while most of the women had yet to receive their first.

This disparity persists across India due to the difficulties in finding time for childcare and housework. According to India’s official vaccination website CoWIN, as of Feb. 14, a total of 1.67 billion vaccine doses have been administered in India: 49.5% to women and 50.5% to men—a gap of some 38 million doses.

Indeed, when Devi’s husband received his first dose in July at the primary health care center in Padampuri around an hour’s drive away, she couldn’t go with him because of home responsibilities. “It would have taken the whole day, and who would have taken care of the children and the housework?” Even on the day Devi finally received her vaccine, she rushed home after registering at the camp, to cook lunch and tend to the livestock while her husband saved her spot. Just in time to get her shot, she ran back. “I didn’t want to miss out this time too,” she says. “If we run out of vaccines, you never know when we will get it next.”

Devi wasn’t alwaysShe was so excited to receive the vaccine. She was scared at first, like many Dhari residents TIME interviewed. “We heard stories of infertility and deaths,” she says. “But then we saw people taking it and they were OK. Also the health workers came to the village and explained and encouraged us. They are one of us, so we trust them.”

These workers are fortunate to have a long history. Dhari’s health care workers consist mainly of local women who are trained to teach in their community as ASHAs (accredited social health advocates) or to work for the government as nurse midwives (ANMs), to serve as first points of contact between the community, the state and the healthcare system. In India, in particular in rural areas of India, community workers play a vital role in spreading the Pandemic. In Dhari, this well-earned trust led locals to buy into the idea that they needed to get vaccinated to protect themselves and their families against COVID-19—even if it meant trekking hours through steep terrain.

The success of Dhari’s COVID-19 vaccination campaign was also built on years of outreach within remote communities, especially among women and children, notably through India’s robust universal immunization program that reaches around 26.7 million newborns and 29 million pregnant women each year. The program depends on an extensive network of primary and district health centers as well government workers and community volunteers. It’s also credited with the country’s incredibly successful polio-vaccination campaign, which began in 1994, when India accounted for around 60% of global polio cases. The task of vaccination of 170 million under-5-year-olds twice annually required the dedication of millions of frontline workers. India declared polio-free two decades ago, in 2014

India’s immunization program for children may be “a well-oiled machine,” says Rajib Dasgupta, who heads the community health program at Jawaharlal Nehru University, but the system still needed to be adapted to deploy COVID-19 vaccines to adults. Kandpal, his 13 ANMs team and 46 ASHAs met with Dhari village leaders to discuss how to improve the immunization infrastructure. This was done to deal with the issues of travel and lack of mobile phones. First—and long before most areas in India began doing so—they decided to send out mobile teams to villages because not enough people were coming down to the two walk-in centers. Although the program included a door-to-door follow-up campaign, it was significant scaling up to reach the whole adult population. These new mobile teams were capable of trekking into the mountains to get closer to isolated communities, where they established pop-up vaccination sites designed to get more shots into arms—both for those people who already want it and those who aren’t so sure.

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Kandpal’s team also added fully equipped ambulances to the mobile teams in case of adverse reactions to the vaccines, a data-entry operator to register the villagers on the government vaccine app, and a pharmacist to hand out acetaminophen and advise people on what to expect after their shots. Kandpal created a WhatsApp group with village chiefs and local health workers. The WhatsApp group posted weekly vaccination schedules so village heads could contact villagers. “COVID taught us to think out of the box. The systems it forced us to create will go a long way in the future too, to cater to this population,” Kandpal says. “We have taken an existing but old resource and modernized it.”

September 4, 2009, nurse-midwife Renu Sharma—a member of Kandpal’s team who has been working with the Dhari population for 13 years now—traveled with a team of health care workers from Padampuri to the remote village of Aghariya. She was greeted warmly at Aghariya. After knowing many of the women, who had been vaccinated years before, she called them by their names and told them that COVID-19 was available at camp.

Before the arrival of Sharma and her team, the nearest place for Aghariya residents to get vaccinated was the camp in Dhanachuli—a tough journey along an unpaved path that could be particularly treacherous whenever rains loosened the rocks and soil. That’s why Sharma and her team decided to set up a temporary pop-up vaccination site in Aghariya. The line to get vaccines grew rapidly and they were soon overwhelmed.

Sharma observed three older men sitting in the clinic’s pop-up vaccine clinic all day while she administered shots. She approached the men during a break in their activity. “Bubbo, have you registered?” she asked, using a local term of respect meaning grandfather. They rebuffed. “No, no, we came here just to see what’s happening,” one said. “We don’t want to take the vaccine.”

Undeterred, Sharma continued to press: “Look at me, bubbo, I was one of the first ones to take the vaccine. Has anything happened to me?” she said. Others in the village had also received shots and said they had not suffered any serious side effects. Finally the men gave up. Sharma, beaming with pride, marched the men to the registration table and returned to her station for another dose of the vaccines. “Sometimes you have to persist with them a bit,” she said. “I have had to persist for days and weeks with some people.”

Sharma reviewed her village list and compared them with those who were vaccinated. She found the names of three elderly and disabled people with mobility issues who she knew couldn’t make it to the camp. After grabbing a bag containing supplies and vaccine doses, Sharma walked her team to the homes of their clients. It was only a few minutes walk from where they were vaccinated. An official door-to-door vaccination policy would only be announced by Prime Minister Narendra Modi in another two months, but Sharma’s prior work had taught her that sometimes you need to meet people where they are.

Health workers like Sharma know well the challenges in the smaller communities they serve, whether travel difficulties or household commitments—a kind of knowledge and intimacy that is impossible in bigger cities. The Aghariya camp was the perfect place for Sharma to remind mothers attending routine vaccinations for their children that COVID-19 should be obtained for them. “You have to be mindful of the community’s sentiments,” she says. “We don’t push too hard. It takes some time. Sometimes they ask me, other times I insist. But they know I mean well.”

Sharma and other women like her have worked hard to ensure that vaccines were distributed to remote communities in the final months of 2021. Hema Devi, who got her first shot in August, was able to get her second in December—though she still had to make the long trek from Thiroli to Dhanachuli. As an Omicron-fueled wave of COVID-19 patients began to sweep the country, she was glad that she got it.

Several weeks later, India’s COVID-19 cases are on the decline, and state governments are reopening schools after long hiatuses. Dhari is another area where hospitalizations and cases are falling. Health workers in Dhari continue to work to administer booster shots for adults as well to fully vaccinate children aged 15-17 years old. Although hospitalizations are down and cases have fallen, Dhari’s health workers are working hard to fully vacinate all 15-17-year-olds as well as give booster shots to adult patients. Sharma says it’s much easier this time than with first doses because there’s a much greater understanding of the need for them. Villagers have “watched the news about the booster dose on television and have been coming up to me asking about it,” she says. “They understand the importance of the vaccines in keeping the whole community safe.”

Devi, for example, understands that it is worth the effort to be vaccinated. “If I could, I would urge everyone to take the vaccine. Don’t think of yourself; think of your friends and family and your community,” she says. “If you are safe, they are safe; the world is safe.”

—Eloise Barry/London reporting

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