Tamenglong, Manipur: Dr Sunil Kamei, the district immunisation officer for Manipur’s Tamenglong, stood within the town’s small medical office complex and looked at a 16-seater mini bus with trepidation. The mini bus was to take nine members of the district’s health team to and from a vaccination site, Sanglungpang village, 21 km away from the headquarters. Dr Kamei wasn’t so sure the vehicle would make it.
“Twenty one kilometres isn’t much, but when you look at the condition of the roads… these cars have to be able to take a beating,” he told ThePrint.
The few broken-down cars in the small parking lot of the office complex are a testament to the conditions under which the district’s health team works to vaccinate its population. The only ‘pakka‘ roads are found in the district headquarters. The rest of the district has no smooth, black-topped roads to speak of. The only routes are carved out by earth diggers, or are roads that were built decades ago and have since fallen into disrepair.
But poor roads are just one part of the problem.
“This is Manipur’s remotest district. We have problems with manpower and infrastructure. It takes us double the time and cost to get somewhere, and we do it with half the workforce,” Kamei told ThePrint.
These problems, along with vaccine hesitancy, have cost the district’s Covid-19 vaccination drive greatly. Tamenglong is among the five worst-performing districts when it comes to Covid-19 vaccination coverage — with a population of 1.56 lakh (2011 Census), it has managed only 12,169 first doses as of 9 July.
The matter becomes more urgent when put in the context of Manipur’s Covid-19 situation. Though active cases in Tamenglong are low — 60 — Manipur has recorded a positivity rate above 10 per cent for over a month now, indicating the disease is likely to spread further.
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Cash incentives, work orders to fight vaccine hesitancy
ThePrint tagged along with the health team to Sanglungpang, a village located off the Tamenglong-Khongsang highway, connecting the district to Imphal, and the entire exercise took over 10 hours. Six of those hours were spent in travel, waiting for earth diggers to push aside debris from two landslides, and waiting for a storm to pass before making a safe return back to the headquarters.
The highway, a 38 km-stretch whose renovation is only halfway complete, is punctuated by long stretches of muddy and rocky marsh, made worse by the monsoon season. Monsoons affect the region for six months a year. In places where the road narrows, the edge of the road forms a steep precipice.
Travelling through risky or otherwise non-existent roads is now a routine affair for the health team and the district administration.
“This is one of the better routes,” R.K. Rita, an auxiliary nurse midwife (ANM), told ThePrint, indicating the highway. “The other day, we went to a far-off village that took four hours to reach one way. The car broke down and we had to push it through the mud.”
For all of this effort, only 77 people out of 733 showed up to get vaccinated at Sanglungpang.
“There’s wrong news and propaganda holding people back from getting vaccinated. Initially, we were hesitant too, but after the doctors and nurses came and explained to us the benefits of the vaccine, we told them to set up a camp,” said the village’s former secretary, Taduanlong Gonmei.
Some members of the health team end up visiting villages more than once, first to conduct a kind of orientation programme to convince villagers to come forward. At other times, the health department returns to a village because not enough people showed up to get vaccinated the first time around.
“People weren’t cooperative when I would persuade them to take the vaccine. They said it was a means to control the population, and no matter how much I tried, I wasn’t able to convince them otherwise,” Gaibangnei, Sanglungpang’s ASHA worker, told ThePrint.
In most villages, where no car can go, healthcare workers walk up to 5 km at a stretch to administer the Covid vaccines. Otherwise, they manage with whatever little space is made available. After finishing at Sanglungpang, the team briefly put up a makeshift vaccination camp at a bus stop off the highway for a handful of villages nearby, even as sheets of rain came pouring down.
“Even if there are a few people, we will stop to give them the vaccine,” Dr Kamei said.
The most number of doses Tamenglong has been able to administer in a day is 629 on 30 June. Since then, vaccinations have averaged 303 a day (1-8 July).
Deputy Commissioner Armstrong Pame says he’s doing everything in his power to push people to get vaccinated and help the medical team — including organising resources for the district hospital, ensuring a steady supply of vaccines, and reimbursing any amount for the damaged vehicles trudging through the rough terrain.
Pame made vaccinations compulsory for all vendors and businessmen seeking to reopen their shops. He also offered a Rs 50,000 cash incentive to villages that manage to get the highest vaccination turnout rates. More controversially, he is issuing NREGA work orders only to villages that have 50 per cent or more vaccinated members, and will also make vaccination an essential criterion for entrance into the district’s bank.
“Some of my methods may seem harsh, but it’s the only way to get people to come forward and get vaccinated,” Pame told ThePrint.
“In the next 15 days, we will have vaccinated a large chunk of our population. I’m certain of it,” he said.
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Sparse infrastructure
Much of the healthcare infrastructure in Tamenglong was put together over the last month and a half. Oxygen concentrators and solar panels for electricity were donated by several NGOs, and, at Pame’s request to the state government, 10 new doctors were stationed at the lone district hospital in May.
The hospital doesn’t yet have an ICU, which is currently under construction, as is an oxygen plant that was installed last month.
The state government also gave the district one more ambulance, increasing its tally to six.
However, three of these ambulances are currently in the workshop awaiting repairs, damaged by the road conditions. Spare parts are hard to come by in Tamenglong, which, already marooned by its poor connectivity to the rest of the state, is further isolated by the current lockdown in the district (certain parts of Manipur, including in Imphal, are currently under a Covid lockdown).
“The district administration has supported us greatly. But we’re still lacking in some very basic infrastructure. We don’t have a blood bank or a dialysis machine, and we have only one anaesthetist for the full district,” Dr G. Majachunglu, the district’s chief medical officer, told ThePrint. “We’re forced to refer cases to Imphal, but this is also a risk given the time it takes to go there. Now even Imphal tells us not to send anyone because their beds are full.”
Stretched across 4,391 square km, the district has only three functional Primary Healthcare Centres (PHCs), one in each sub-division. Gaibangnei, the ASHA worker, said she sometimes walked pregnant women to the closest PHC, or even the district headquarters, to help them if transport could not be arranged.
Data from the National Family Health Survey 4 for Tamenglong shows that last-mile delivery of healthcare services, as well as access to healthcare institutions, is weak in the district.
For instance, just 32.3 per cent of mothers received postnatal care from healthcare personnel within two days of delivery as compared to the national average of 62.4 per cent. Similarly, only 33.3 per cent of institutional births were recorded in the district, compared to the national average of 78.9 per cent.
“Usually when patients come to us from the villages deep in the hills, they come in a serious condition and we have to treat them on an urgent basis. Very few actually end up coming to the hospital because it’s so far,” Dr Neison, a paediatrician at the district hospital told ThePrint.
The long distances have also led to greater vaccine wastage on some occasions, because the vials were kept in ice boxes for periods longer than what is stipulated. Tamenglong has an average wastage of 5.8 per cent, according to the district health department.
“We need much, much more to treat people and deliver vaccines more effectively. But under these circumstances, we’re just doing the best we can,” Dr Majachunglu said.
(Edited by Manasa Mohan)
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