Indian Pediatr 2009;46: 963-974
Deconstructing Social Resistance to Pulse
Polio Campaign in Two North Indian Districts
Dasgupta, $Vivek Adhish, **Kalyan K Ganguly,
Rai, Leena Sushant, Srabasti and Narendra K Arora
From the INCLEN Trust International, INCLEN Executive
Office, New Delhi; *University College of Medical Sciences and GTB
…Centre of Social Medicine and
Community Health, Jawaharlal Nehru University, New Delhi; $Department of
Community Health, National Institute of Health and Family Welfare, Delhi;
**Reproductive Health and Nutrition Division, Social Behaviour Research
Unit, Indian Council of Medical Research, New Delhi; and
for Community Medicine, All India Institute of Medical Sciences, New
Correspondence to: Prof Narendra K Arora, Executive
Director, The INCLEN Trust International, 2nd Floor, F-1/5, Okhla
Industrial Area Phase I, New Delhi 110020, India.
Manuscript received: December 31, 2008;
Initial review: February 27, 2009;
Accepted: April 28, 2009.
Published online: 2009 September 3.
Objective: To gain an insight into the phenomenon
of social resistance and rumors against pulse polio campaign.
Design: Qualitative, community-based
investigation, mapping perceptions of various stakeholders through
in-depth interviews (IDIs), focus group discussions (FGDs), non-formal
interactions and observations.
Setting: Moradabad and JP Nagar districts of
Subjects: IDIs (providers 33, mothers 33,
community leaders 10); FGDs (providers 4, mothers 8) and non-formal
interactions (156) with community leaders, parents, businessmen,
journalists (Hindi and Urdu media), mobilizers, vaccinators and
Results: A distinct machination of social
resistance and rumors against oral polio vaccine during supplementary
immunization activities (SIA) was observed in some minority dominated
areas. The pattern can be understood through a model that emerged
through qualitative evidence. Inspite of all this, most parents in
minority areas supported the SIAs. Only a few clusters from extremely
marginalized sections continued to evade SIAs, with an endemic pattern.
Through social osmosis, these rumors reached majority community as well
and some parents were affected. However, in such cases, the resistance
was sporadic and transient.
Conclusion: While the program’s focus was on
microbiological issues, the obstacles to polio eradication lie in the
endemicity of social (and/or cultural) resistance in some pockets,
leading to clustering of perpetually unimmunized children - inspite of
good coverage of SIAs at macro level. This may sustain low levels of
wild poliovirus transmission, and there can be exceptions to the
robustness of the pulse approach. A micro level involvement of
volunteers from marginalized pockets of minorities might be able to
minimize or eliminate this resistance.
Key words: Eradication, India, Pulse polio, Rumors,
Supplementary Immunization Activities (SIAs), Social resistance.
he 60th World Health Assembly urged
endemic states (including India) to engage local leadership and members of
the remaining poliomyelitis affected populations for ensuring acceptance
of poliomyelitis eradication activities. Immunization campaigns have
deeply rooted social and political dimensions in addition to their health
benefits – and this makes the situation complex. The wild polio virus 1
(WPV1) outbreak in India in 2006 (648 cases) was followed by a WPV3
outbreak in 2007 (791 cases). Majority of WPV cases were reported from two
large Indian states – Uttar Pradesh (UP) and Bihar(1). Disproportionately
higher number of paralytic polio cases have been reported among
marginalized segments of Muslim population. Endemicity in these hotspots
has been variously attributed to biological determinants like the peculiar
environmental and sociodemographic milieu of western UP (high population
density, high birth rate, poor sanitation, etc.) coupled with poor
performance of supplementary immunization activities (SIAs) with
consequent low coverage, and also to social and program determinants,
including falsification of data and resistance by the minority
While technical strategies and innovations have
focussed largely on vaccines(3,4),
social determinants of the program have not been accorded comparable
importance. Persistent hotspots marked by similar patterns of social
resistance towards the end of the eradication efforts of smallpox and
polio programs (thirty years apart) in the same states (Uttar Pradesh and
Bihar) portend that lessons of the smallpox eradication have not been
learnt and applied to the polio eradication initiative(5). In this
long-drawn eradication campaign, fatigue and burnout has been reported
among service providers; and among marginalized communities the phenomena
has manifested as social resistance with complex constructs(6-8). Lately
though, social mobilization efforts have been considerably stepped up and
reduction in social resistance to vaccination along with improvement in
the tonality of media coverage has been reported(9). However, knee jerk
reactions such as mandatory single-dose OPV administration for all Haj
pilgrims (adults and children) have added to the confusion(10).
If the goal of polio eradication is to be achieved, the
program strategy should be acceptable to everyone concerned without
harassment and hesitation. In this context, it will be imperative that the
determinants of underlying social resistance in the endemic pockets of
Uttar Pradesh and Bihar are systematically analyzed. This is particularly
critical when younger age groups need to be repeatedly immunized at short
intervals to achieve optimal immunity. The present study was designed to
gain an understanding of the phenomenon of social resistance/reluctance
and rumours against pulse polio campaign in two highly endemic districts
of western Uttar Pradesh, namely Moradabad and Jyotiba Phule Nagar (JP
Study setting and timings
On the request of regional office of the World Health
Organization (WHO) and Ministry of Health and Family Welfare, Government
of India, Moradabad and JP Nagar districts from the highly endemic areas
of western Uttar Pradesh were purposively selected for the study. After
interactions with district level providers, review of NPSP data, and
consensus among the investigating team - Thakurdwara, Dillari, Moradabad
City, Sambhal, and Kundarki blocks from Moradabad; and Dhanaura, Gajraula,
Amroha, Rehra, and Hassanpur blocks from JP Nagar were selected. The
decision to select these blocks was based on perceptions of program
managers that these blocks demonstrated social resistance to polio drops.
The term ‘social resistance’ was derived from the providers’ and program
managers’ perspective. Data collection lasted for three weeks from
December 2006 through January 2007, which included a National Immunization
Day (7th January).
One primary health center (PHC) was selected in each
identified block for in-depth interviews (IDI) and focus group discussions
(FGDs). IDIs were held with different levels of providers, mothers of
under-5 children, and community leaders (religious, social and political).
Special emphasis was placed on interviewing leaders from different
religious groups, influential business persons and political leaders. FGDs
were held for female health workers (Auxiliary Nurse Midwives),
vaccinators, mobilizers (community-based functionaries of NGOs/UNICEF),
and mothers of under-5 children in the identified PHCs. To complement IDIs
and FGDs, a total of 156 non-formal interactions with local leaders,
Hindi/Urdu journalists, businessmen, mobilizers, vaccinators, supervisors,
and parents of children from marginalized Muslim and Hindu communities
were also conducted. Profile and number of stakeholders interviewed and
FGDs conducted in each of the two districts is reported in Table
I and II. None of the clients or providers who were approached
for in-depth interviews refused to participate. Observations were also
recorded during the field work on a National Immunization Day (NID).
Number of Stakeholders Interviewed and FGDs Conducted in Each District
||J P Nagar
A. Providers’ Interviews
| District magistrate
| Chief medical officer
| District immunization officer
| Surveillance medical officer
| Routine immunization officer
|Block / PHC Level
| Block medical officer
| Block PHC medical officer
| PHC / Addl PHC medical officer
|B. Providers’ Focus
| Health workers (female)
C. Community Stakeholeders’ Interviews
Mothers of under-five children
D. Community Stakeholders
Focus Group Discussions
Mothers of under–five children
Profile and Number of Stakeholders Participating in Non-formal Interactions
|Local Community Leaders (Muslim/Hindu)
|Parents (Muslim/Hindu; Mother/Father)
|Journalists (Hindi/Urdu media)
|Vaccinators (During NID, in booths and in the field)
Data collection and analysis
Attempt was made to search for opinions, motivations
and perceptions of key stakeholders from the district, PHC and community
levels. IDIs, FGDs, and non-formal interactions including observations
were used in the study to make an assessment of reality by synthesizing
multiple sources of information. Based on our previous work on polio
eradication programs in India(11-13), systematic reviews and other
published qualitative research studies on polio eradication, guides for
FGDs and tools for in-depth interviews were developed.
All FGDs were audio recorded and handwritten verbatim
notes were later supplemented by transcripts of audio tapes, before final
translation into English. Interviews were not audio taped; instead they
were recorded verbatim by research assistants. All interactions were held
in the locally spoken and understood language – Hindustani, and the
investigators were familiar with the local dialect, customs and culture.
The in-depth interviews lasted for 30-50 minutes. The duration of FGDs
ranged from eighty minutes to two hours. FGD of providers consisted of
8-10 respondents, while FGDs of community members ranged from 9-13
members. Issues explored in FGDs included problems and constraints of the
pulse polio program, reasons for not accessing some/all pulse rounds,
response of the administration towards defaulters, perceptions/reasons of
specific groups (e.g. geographically isolated, specific caste or
religious groups) who did not immunize their children with oral polio
vaccines, and details of rumors/boycott of pulse rounds by any group(s).
The non-formal interactions attempted to explore, capture and triangulate
some sensitive domains of information. Notes were, however, made of
non-formal interactions; the decision to include their perceptions was on
the basis of consensus arrived among the investigators that they were
internally consistent with findings from in-depth interviews and FGDs.
Qualitative data were analyzed in a stepwise manner:
free listing of responses, domain formation, coding, and analysis. Data
were analyzed separately for each category of stakeholder and then
re-analyzed to assess similarities and differences in perceptions across
stakeholders. The triangulation was done at two levels – across methods
and across respondents. The consistency indicating towards a substantive
significance (the way it is used in qualitative data) was explored.
The study adopted the grounded theory approach
to develop an inductively derived explanation about the phenomena emerging
from the data(14) instead of forcing
or testing an a priori theory(15). We began with the data
collection and allowed the emergence of relevant explanation(s). Through
constant comparison and analysis, the team inductively derived a model
that represented the phenomena. Since the enquiry involved
micro-sociological perspective, the dictum - "all is data" was followed. A
plethora of information, including some from informal interactions,
contributed to the construction of the model. This was done with the
awareness that some of the information could have been erroneously
misclassified as journalism, and even the founder of the Grounded Theory
had been a victim of such criticism(16).
Concept identification began with the first set of
interviews with district level providers. Data collection was alternated
with analysis. Open coding was initially done by opening up the text of
the interactions and subjecting them to intensive scrutiny, asking the
question ‘what is going on here’? Detailed line-by-line microanalysis was
done. Phenomena were identified from the interactions during interviews
and FGDs, and analysis of stakeholder perceptions. Properties and
dimensions of the phenomena were also identified, giving it
specificity(17). Data was weaved around phenomena by axial coding. Thus,
the major categories of phenomena began to emerge from the data. Finally
selective coding was done for construction of core categories. We reached
a point in both the districts when information seemed repetitive, and
assured that the data saturation was achieved. Memo writing was done by
handwritten notes. The theory finally arrived at went beyond mere
reconstruction of events, it was a co-construction between researchers and
participants(18). The model arrived at was reflective of practical
situations and the structural conditions that led to these problems(19).
Study team and quality assurance measures
A multi-disciplinary team comprising of program
evaluation experts, health social scientists, anthropologists, public
health specialists and epidemiologists constituted the study team. All the
team members have participated in several polio eradication program
reviews since 1997 and were trained in qualitative research methods(11-13)
in these districts and were familiar with local cultural milieu. Health
workers and mobilizers from local communities also facilitated the
Five investigators undertook the field work, conducted
interviews (formal and non-formal) and FGDs. They were assisted by four
research assistants. One investigator conducted quality assurance visits
during data collection. The entire team participated in preparation of
tools, data analysis and finalizing the report.
This study has attempted to analyze the phenomena that
lead to the social resistance and contextualize the situations in which
rumors spread. The nature and content of rumors have also been analyzed.
While there were indications on the possible sources of some of the
rumors, in the limited scope and the design of the study it was not
possible to track the sources. While the source (reported) and content of
rumors had strong religious association, the authors were sensitive to the
fact that such issues were not just of religion but of marginalized
communities in general, and intense politicization had further complicated
the situation. There were no differences in the two districts, and between
study blocks, which were contiguous.
A. An emerging model of rumors and their impact
A systematic pattern of rumors, religious edicts, and
suspicion to oral polio vaccine was observed among the poorest of Muslim
families (especially Quraishis/Ansaris/Saifis) in urban/peri-urban areas
like Sarai Pukhta in Moradabad city and Sarai Tareen in Sambhal, and with
less intensity, in some rural clusters of Dingarpur and Ratupura. There
were instances of sporadic reluctance among marginalized Hindu families
(especially Sainis/Khadgavanshis) as well. However, this seldom translated
into a significant or lasting resistance in spite of reporting occasional
incidents of coercion at the individual family level. The health workers
were largely Hindus and represented the face of the state to the Muslim
communities. Overcoming reluctance/resistance among Muslims was reported
by health workers (Hindus) to be a far more difficult task. Reports of
coercion by the administration came from marginalised Hindu communities,
including Dalits. There were occasional reports of ‘reverse coercion’
(triangulated through both provider and client interactions) from Muslim
majority areas where the health workers were forcibly asked to mark their
children as immunised (an indelible ink-mark on their fingers) without
giving vaccine. The process of generation and dissemination of rumours
leading to resistance to the polio vaccine consisted of a series of
inter-related phenomena (Box 1 and 2).
Box 1 Emerging Model of Rumors and Resistance to
Pulse Polio Campaign
Phenomenon 1 A low-profile and highly local
spate of rumors started gathering right before SIA rounds.
Phenomenon 2 The nature and content of
rumors (Table 3) kept on changing with time and locale.
Phenomenon 3 The rumors were often supported by
one or more of the following:
• Locally circulating religious leaflets and
magazines, mostly disowned by the sources (Sarai Tareen)
• Locally restricted announcements through
static and/or mobile (rickshaw bound) public address systems (Dingarpur
and Sarai Pukhta)
• Address by a religious leader inside a mosque
after a prayer ceremony (Sarai Pukhta, Sarai Tareen)
• Quasi-confirmed religious edicts, that were
often disowned by the sources (Sarai Pukhta, Sarai Tareen)
Phenomenon 4 Whenever attempts were made to
reach out for the sources of rumors, they either went incommunicado or
dissociated themselves from the episode. Public
retraction/contradiction was never seen. At best, the sources got
neutralized. By this time, the damage was already done.
Phenomenon 5 Inspite of all this, most of the
families in Muslim areas supported the SIAs. Only a few parents among
them, mostly from extremely marginalized sections, got decisively
influenced by the rumors and continued to evade SIAs. Though miniscule
at the macro level, they formed the clustered pockets of perpetually
Phenomenon 6 Through social osmosis, these
rumors did reach some economically and socially marginalized Hindu
clusters. However, in this case, the rumors did not translate into a
significant and lasting resistance to SIAs.
Box 2 Rumors and resistance: Representative quotes
• “Everytime there is a
polio day, news start spreading that the polio programme is against
Muslims. This makes me feel scared.” (Mother-Muslim, Sarai Pukhta)
• “Disquieting news are heard about these drops
whenever a polio day is approaching …. I feel like going to some other
place with my children on that day” (Mother-Muslim, Dingarpur)
• “In some places, people say that rumors
start two to three days before every NID” (Provider, Thakurdwara)
• “Our men keep talking about polio drops, and
everytime there is something new about it. Sometimes it’s about
sterility – sometimes about pig’s blood – sometimes about conspiracy
against Muslims. If the drops are good, why so much of bad news?”
• “Polio drops are made up of blood of pigs, dogs
and mice. This is the reason, why we are not giving drops to our
children.” (Mother-Muslim, Rathupura)
• “We were told in Madarsa that polio drops cause
sterility.” (Mother-Muslim, Sarai Pukhta)
• “Each time, you will hear newer and more
and more weird things about the vaccine …. They can stretch the limits
of imagination…. Last time there was a strong rumor that the polio
vaccine is prepared by the Jews and America is using them to finish
Muslims.” (Provider, Sambhal)
• Rumors keep on changing. Last time we neutralized
one type of rumor, now we face another type in this round.” (Community
• “During the last round, an Urdu magazine was
circulated in this area. In one of its articles it was said that the
polio drops contain pig’s blood and therefore are prohibited for
Muslims. The magazine was apparently published by Nadwa, Lucknow. When
contacted, the Nadwa denied any such publication.” (Community
Leader-Muslim, Sarai Tareen)
• “Lodspeakers of the mosque ask us to give
polio drops to children but the simultaneous announcements from
rickshaw prohibit us. What to do? It raises suspicion.”
• “Mosque attenders were told to resist the
polio program. A sealed edict came from Saharanpur. It was told in the
post-prayer address that the whole program is against Muslims. Since
than no one from the mosque is available for comments. Many people
have tried to contact them.” (ISM Practitioner, Sarai Pukhta)
• “25% Muslims do not give polio drops to
their children. And out of these, 90 % are not giving it because of
religious edicts.” (Community Leader-Muslim, Sarai Pukhta)
• “In September 2006, there was announcement from a
mosque that polio drops contains pig’s fat.” (Provider, JP Nagar)
• "Religious leaders don’t retract or contradict
their statements. At best they can be asked to remain silent. With
great difficulty, I contacted the Imam Saheb. He said that I will stop
discussing this topic any more – but refused to retract. The damage
was already done." (Artisans’ Union Leader, Moradabad)
• "After such addresses or announcements, no one
contradicts. How can anyone contradict the truth?" (Father-Muslim,
• "Imam Saheb is not meeting anyone after that
address. Poor people have faith in him and whatever he has already
said stays in their minds." (Community Leader-Muslim, Sarai Pukhta)
• "All these rumors and leaflets keep on
circulating and many parents are worried. However, only a handful of
them get convinced so much so as to resist the program. Majority of
the parents give polio drops to their children." (Community Mobilizer,
• "Barring some clusters of Quraishis, rumours do
not translate into resistance. However, the anxiety is widespread."
(Mother-Muslim, Sarai Tareen)
• "These pockets of perpetual resistance are very
small but unless we are able to reach them we would not be able to
eradicate polio." (Provider, Sarai Tareen)
• "Some Hindu areas also get influenced by such
rumors. Mainly the scheduled cast people. But the resistance to polio
drops is very temporary thing in Hindu areas." (Provider, Rehra)
• "Resistance is very rare in Hindu households.
Sometimes poor people start asking about the rumors but it is always a
transient phenomenon." (Provider, Thakurdwara)
• Jatavs were initially scared of the program.
There were rumors about impotence. When they saw that everyone is
giving drops to their children - they also joined." (Father-Hindu,
• "Resistance in Hindu localities is unheard of. Inspite of rumours,
Sainis have always been supporting polio program." (Father-Hindu,
B. Possible factors sustaining social resistance /
The model presents a set of necessary conditions for
the rumors to be generated and spread. However, it was important to
explore and attempt to explain how these phenomena are sustained. The
content of rumors appeared to represent different concerns of Muslim
communities (Table III). They also indicated that in the
current geo-political environment, health behavior of communities might be
influenced by unrelated non-health events. We present a set of additional
conditions that have probably been responsible for sustaining social
resistance in these districts for a considerable length of time.
Nature and Content of Rumors
|Negative effects of vaccine
causes shortening of penile length even in children.
starts showing its negative effects even after 2 doses.
Undesirable constituents of the
contains pig’s fat/meat.
is pink in colour because of pig’s blood.
is prohibited (Haraam) for Muslims because of some evil ingredients.
different vaccines are being used for Muslim populations.
Muslims are being specifically targeted through an American
vaccines have been manufactured by the Jews, and the US machinery is
using them to finish Muslims.
|Haj vaccination policy
Saudi government is interested in getting the adults vaccinated. Why
then the international authorities are specifically targeting our
Suspicion and Cynicism
generally no one cares for us. Why are they so much interested in
getting our children immunized by this particular vaccine?
sudden and intense involvement of WHO and other international agencies
speaks for itself. There must be something fishy about it.
The social divide and mutual mistrust amongst religious
Among the marginalized Muslims, the elite of their
community often appeared to have little credibility - and even a
professional or a well-to-do businessman was considered a part of the
elite. The middle class that could have acted as an interface - and a
critical section determining the behavior of the community, was largely
missing. Level of cynicism was so high in some of the extremely
marginalized sections of minority that they even considered civil society
as an intruder. Metro-based minority institutions were perceived as the
Muslim mask of Western influence. IEC (Information, Education and
Communication) attempts by Muslim celebrities and metro-based Islamic
institutions were seen with suspicion, and were unlikely to have the
"If you really want to do something, you will have to
involve volunteers from Qureshis and Ansaris. See, there is no middle
class in Muslims. Ordinary Musalman says that well-to-do people in their
community have a double face. You keep on depending on Jamia-Shabana etc.
… nothing will happen. They don’t even listen to me." [Artisans’ Union
"Celebrities don’t mean anything in this place. Poor
people don’t have any faith in the educated section of their own
community. Educated and rich people are seen as westernized and
untrustworthy." [Urdu Journalist, Sarai Pukhta - echoed by several
Class strata so different, yet looked alike during SIA
The poorest of the poor and the rich behaved similarly
while evading SIAs. Both of them defeated pulse polio rounds in their own
ways. However, the rich got their children’s routine immunization (RI)
through private practitioners while the children of poor households were
often left out of even the RI as they were primarily dependent on weak
public health services. This probably was one of the most critical reasons
for the apparent difference in the incidence of WPV and other vaccine
preventable diseases (VPDs) among the two strata.
"People in Budh Vihar and Sarai Pukhta behave similarly
on pulse days. Both of them avoid polio drops. However, the rich go to
private practitioners for routine immunization. The poor are neither going
for routine immunization nor receiving pulse polio drops" [Provider,
Moradabad City - echoed by several Providers]
Weak healthcare infrastructure
The state of public health services in these districts
was poor. Indeed many respondents expressed their dissatisfaction at the
lack of primary health care services. PHC medical officers voiced their
frustration about their inability to deliver routine services on account
the frequent SIA rounds. The question "why only polio?" while delivery of
routine health services remained dismal, was uppermost in the minds of the
"OPDs get shut. CHC has staff, but additional PHCs may
have problems. Give medicines today and then . . . after six days. People
are already troubled with one month cycle (rounds of pulse polio)."
[District Level Provider]
Politicized issue and tutored stakeholders
There was intense grassroot politicization of the
issue. Leaders, especially in minority areas, had more than one
stand/front on the issue, and they used them depending upon the addressee.
Attention overload had tutored most of the stakeholders, including
parents, in diverse ways. Even a non-utilizer client was likely to be
aware about ‘what is politically correct/safe to say’, regardless of the
ground reality. Evidence available ‘on the record’ was vulnerable to miss
some highly significant aspects of the truth.
"This place is visited by so many people that everyone
knows what to say and what not to say. If you are an outsider and move
with a notepad, no one will speak the truth." [Practitioner of
Indigenous System of Medicine, Sarai Pukhta - echoed by several Community
"Politicians speak in two languages – so people have
also learnt that. If you really want to know what’s going on …. stop
taking interviews and engage people in heart-to-heart conversation."
[Urdu Journalist, Sarai Pukhta]
Children held hostage between parents and state in some
extremely marginalized pockets
Linking acceptance of the vaccine to developmental
issues was becoming increasingly common. These issues, ranged from supply
of essential goods in public distribution shops to construction of roads
and bridges, and were raised by both Hindus and Muslims. As a rural Muslim
mother put it, "Polio is your concern, not mine"– the program was thus
perceived as the "government’s need". The acceptance of the vaccine was
being used to negotiate with the state machinery for developmental issues
including road construction, basic sanitation, donations, loans, and even
"Some people think that this is a government
program……and if it is opposed, the state will do something for us."
[District Level Provider, Moradabad]
"They have understood that it is our need – not
theirs. So they are twisting our arms to get things done. They also use
their children as captive in this bargain. They want us to make roads,
clean garbage, arrange for arms license etc. This has created numerous
difficulties for our day to day working." [Provider, Thakurdwara -
echoed by several Providers]
"Every week you people (read outsiders) are at their
doorstep. Anyone will use this situation to his advantage. By keeping the
children inside on polio day, poor people are increasing their bargaining
power. You just forget about them for one or two rounds . . . the
resistance will decrease." [Community Leader-Muslim, Sarai Pukhta]
The phenomenon of rumors and resistance to OPV has been
periodically reported by various partners of the program and
researchers(20,21). The content of rumors represented multiple layers that
probably reflected different concerns and segments of the fearful
communities. Eradication and ongoing programs need to have complementary
approaches. Often, the eradication campaign are more visible while the
primary health care activities do not function well(22).
Such contradictions provide fertile ground for social resistance to
repetitive activities like immunization. Earlier Pulse Polio evaluations
done by INCLEN Program Evaluation Network (IPEN), and a published
component of present study have documented community fatigue because of
repeated immunization rounds(8, 11-13, 23). The experience of the smallpox
eradiation programme clearly indicated that eradication was not purely a
biological or technical exercise. Patterns of social opposition to
smallpox immunization were reported from the same states - Uttar Pradesh
and Bihar, and other areas during the 1970s(5).
Immediate needs such as food, security and employment
are likely to take priority over other nationally and internationally set
goals and programs, when scarce resources find competing interests(24).
The developmental issues used as a bargaining point should be seen in this
light. It raises a fundamental concern of felt needs versus
epidemiological needs, and it demonstrates that the top-down vertical
approach is ill-equipped to address the plethora of local political,
social and economic conditions. On one hand, this calls for reforms in the
choice of programs that address local health priorities; on the other,
program managers have to engage in advocacy (to a reasonable extent) to
articulate developmental needs and aspirations of local communities. The
field of development communication can make a meaningful contribution in
The qualitative evidence generated in this study
suggests that while program managers and academics concentrate on
microbiological and other technical issues(10-11), the critical missing
link to eradication may lie in resolving challenges of social
implementation of available interventions. In these situations, the
overall coverage at the district or block level might look good in spite
of harboring less visible clusters of perpetually unimmunized children.
Such clusters, though miniscule when seen at macro level, may sustain low
level of transmission of WPV- more so with relatively low levels of RI
coverage. Despite 97% coverage in Netherlands, several outbreaks of
poliomyelitis occurred in the last three decades, among clustered
unvaccinated persons(25). The
phenomena of resistance/reluctance result in vulnerable subjects being
clustered (most of them located in extremely poor sanitary conditions, and
therefore, with increased environmental exposure) and provide the critical
mass to allow sustained WPV circulation. Thus, there can be exceptions to
the robustness of the pulse approach. The program will have to minimize or
eliminate the clustering of perpetually un-immunized children as a
critical strategy for what is termed as ‘end-game’ in this global
initiative. Our analysis from two WPV endemic districts of western Uttar
Pradesh suggested that a systematic social resistance to SIAs exists, and
demands to be addressed proactively – with required sensitivity.
As described earlier, marginalized Muslims perceived
Muslim celebrities and metro-based Islamic institutions as outsiders. IEC
attempts by them probably had relatively less than the desired impact.
Seemingly, this was yet to be fully appreciated, even by the program
managers - although the SM Net supported by UNICEF initiated a wide range
of innovative social mobilization strategies with several positive
outcomes(26). Marginalized Muslims
often sought involvement of their own volunteers in micro-planning. A need
for evolving area and locality specific participatory methods for
resistance reduction was felt across different parts of the study area.
Ongoing engagement with major Islamic seminaries and schools was welcome,
but the same process would be necessary to be pursued with local level
religious and social leaders, with equal respect and seriousness. The
feeling of ‘otherness’ needs to be minimized before we can expect optimal
acceptance for any government sponsored program. In this context, the PHC
doctor is uniquely placed to facilitate such processes. However, s/he can
claim legitimacy only when effective and responsive public health services
are delivered on ground.
The methodological approach adopted in this study was
useful to deconstruct some of the phenomena linked to the
resistance/reluctance observed during polio eradication campaign in
endemic districts of North India. In the given context, we faced the
challenge of coping with an unstructured reality(27). While it is
impossible to begin research with no preconceptions, this exercise was
conducted with ‘a more rather than less open mind’(28). There is a bias in
social research in favoring ‘underdogs’ and drawing attention to social
inequities(29). We drew upon ‘Other’(30) while addressing class
differentials within the same (minority) religion to distinguish between
parental/group responses to routine immunization and SIAs. Our explanation
may be a partial one, with limited explanatory power. The strength of this
work lies in its attempt in unravelling social determinants in WPV endemic
districts where social mobilization strategies have changed almost as
frequently as technical strategies, none of them relying on credible
evidence. The present model needs to be validated in other locations with
similarly placed societies and program situations.
Lastly, we need to re-examine the scope of the concept
of ‘social resistance’. Does it include ‘cultural resistance’ by default?
Or we need to be little more discreet about these two seemingly distinct
phenomena? Science places certain realities that cannot be understood or
addressed without liberating ourselves from our training of political
correctness. The endemic resistance against polio eradication program,
witnessed in this study, refused to be totally explained by socioeconomic
marginalization alone. Contents of some of the rumors indicated that the
phenomenon had a distinct share of cultural resistance as well.
Contributors: RD, SC and NKA: Concept, design,
acquisition of data, analysis, interpretation and writing of manuscript;
KKG, VA and SR: Conception, design, acquisition of data and analysis; and
LS and S: analysis and critical revision of manuscript.
Funding: South East Asian Regional Office, World
Health Organization, New Delhi, India.
Competing interests: None stated.
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