On January 6, Chaggan Bhujbal, Maharashtra Food and Civil Supplies Minister, said the state government might consider denial of rations for the unvaccinated. "Since there are few who are not taking their shots for no valid reasons, we may be compelled to deny them rations, especially in districts where the vaccination figures are very low," he said. For him, the threat of ration denial could help improve the pace of vaccinations, and help us all deal with the wrath of this unrelenting pandemic. Bhujbal is not alone in this, state and district officials from most parts of India seem to be in agreement. So much so that even the Indian Medical Association had recommended this a day after an official order to this effect was made by Bandipora (Kashmir) district officials all the way back in April last year.
While the country grapples with new records on daily spike in Covid-19 cases fuelled by the Omicron variant, data shared by the Union Health Ministry on January 13, 2022 showed the cumulative vaccination coverage has crossed 155.28 crore. India had hoped to fully vaccinate the entire population by the end of 2021. Yet, data showed that only 64 per cent of the country’s adult population was fully vaccinated and around 90 per cent had received the first dose. At that time, vaccinations for children were not in the cards then, and neither were the booster shots.
With credible scientific research and evidence having established that vaccines help ameliorate the severity of Covid-19 infections, the best way forward is to provide affordable and accessible vaccines for all as soon as possible. Most Covid-19 deaths were of unvaccinated people, which clearly indicates the urgency to complete the vaccination drive. What is concerning, however, is the threat of denial of rations as a disincentive to push for better vaccine coverage. Pushing the already marginalised further into penury and starvation with such threats harks to a familiar narrative of blaming victims for their plight.
Sylvia Karpagam, a public health doctor based in Karnataka argued that rations are basic existential requirements of people, and the public distribution system (PDS) in most states is already a pathetic and dismal condition. It only progressively worsened during the pandemic and unplanned lockdowns. "Several states are not pulling their weight to ensure that people's food entitlements are being met. Instead of proactive responses there, with these 'no vaccination, no ration' plans, the government is choosing to further burden and punish communities for what are, in reality, systemic failures. If there is a low uptake of any vaccination, then questions have to be raised on the reasons for this, rather than just coercing people." she said.
Reports from the states
In December, oral instructions were given to ration shop dealers in Adilabad, Asifabad, Nirmal, Mahabubnagar, Narayanpet and Gadwal districts of Telangana to not link ration to vaccine certificates. Srinivas Kodali, a researcher with Free Software Movement of India working on data governance, found that there are no known cases of denials yet. "They did ask them to get the vaccine, else their PDS will stop from next month. In that meantime with Omicron approaching, the state did try to proactively promote vaccinations by sending ASHA workers door-to-door. But, there are instances of the Telangana police conducting cordon searches to get un-vaccinated people vaccinated. This use of police force in a healthcare exercise is a new practice that people need to question."
In November, the Madhya Pradesh Food and Civil Supplies department issued an order stating that PDS beneficiaries will not get rations without proof of vaccination. It stated that the PDS shopkeepers should ensure the vaccination of all eligible members, and "if they are not vaccinated, the shopkeeper has to ensure counselling sessions at nearby health facilities. The shopkeepers should also provide a list of non-vaccinated and those beneficiaries, who have taken only the first dose, to a nearby hospital every week." But, Sachin Jain, a right to food campaigner based in the state confirmed with on-ground activists that no such disentitlement has happened so far, fortunately.
Jain believed that it was unlikely that such orders would be implemented anymore. "People are willing to get the vaccines on their own, especially now that they have been made affordable and accessible," he said. He recalled that there have been times when their group of activists had successfully reached out to district administration officials in vaccination camps in parts of Panna and Satna where the vaccines were not easily accessible at the time.
A complex set of reasons and realities
"What needs to be addressed is that vaccine hesitancy in the population in rural areas has changed over the last many months. Earlier, the fear was either for medical concerns like AEFIs or social concerns like women being apprehensive of not being able to cater to household chores after the vaccine. Now, some are concerned that vaccines themselves lead to Covid-19 infections," he explained.
Yogesh Jain, a Public Health physician who has conducted extensive workshops addressing vaccine hesitancy in rural Chhattisgarh, also echoed the same sentiment. "Vaccine hesitancy in India is nothing like the hyper-individualised ideological anti-vaccine movement in the USA," he said. His observation was that when vaccines were first rolled out here, the misinformation and myths caused a lot of chaos. For him, the ideal solution should have been better public health messaging coupled with provision of adequate paracetamol tablets at vaccination centres everywhere. “Once people could save themselves from the side-effects, they could have been role models for others who had apprehensions about getting the vaccines."
In June, a Gram Panchayat near Jabalpur, Madhya Pradesh, the threat of losing out rations for not being vaccinated reportedly soon led to an uptake in vaccination. A similar uptick was noticed in Raisen - people reached vaccination centres in large numbers to avoid the risk of losing out rations and wages, but the centre ran out of doses and left them waiting.
The seemingly popular consensus is that since people would choose food over not getting the vaccine, but a carrot and stick policy that jeopardises people's right to food is not the answer that shall save us. "This is not just about people’s right to food and right to a dignified life, but also about enabling their ways to make informed choices about their health and well-being," said Dipa Sinha, a Right to Food campaigner based in Delhi. In June, the RTFc issued a statement against such disincentives, "Such linking of access to entitlements under various government programmes with immunization status is unacceptable. The right to food campaign believes in provisioning of these entitlements, unconditionality. While people need to be encouraged to get the vaccine, the focus for achieving this must be to increase the availability of free vaccines and provide information and support services to people."
Sinha pointed at another crucial point in this discourse: "Unlike other diseases which required vaccinations, the visibility and severity of Covid-19 is far too different. Especially after the second wave, people are scared and do want to avert these risks. So, the hesitancy towards vaccinations did reduce over time after it was made affordable and accessible." What then remains to be examined is why did some people not get their vaccines yet.
She recalled that her domestic help hailing from Jharkhand lost all her identification documents sometime around June 2020. "Initially, she was quite apprehensive of getting vaccinated, but that changed when she saw others including my family being healthy after getting the doses. By then, however, she was unable to get the vaccine because she had no identification documents." she said. Many strings were pulled and many months were spent trying to help her get a voter-ID to help her get vaccinated as recently as November 2021. Another domestic help in South Delhi also suffered a similar problem - a Nepal-born individual who had no Indian identification document of her own while her husband had somehow managed to get his papers sorted for their everyday lives in the city.
What these cases illustrate is that often broad overarching vaccine policies involving disincentives and denials of public entitlements do not take into account contexts and specificities of people who might indeed want to take the vaccine but have not been able to get the same. Nor are they based on evidence-based science and public health practices and ethics. The possibility of ration denials for the unvaccinated then only disregards the dignity of their lives in the most callous way imaginable in these unprecedented times.
"Building trust is key to vaccine success. In the absence of that, using such coercive tactics as linking with essential services is unacceptable," said Karpagam. The ethical way forward then involves facilitating informed choices and improving accessibility and affordability to public health messaging and services.