In New Delhi, the countdown to a vaccine has begun. Last week, the Narendra Modi government announced that it was planning to vaccinate 300 million people against the coronavirus by June. The same week, three different Covid-19 vaccine developers – Pfizer, Oxford-AstraZeneca and domestically developed Covaxin – applied for emergency authorisations so their vaccines could be used immediately. But even though approvals won’t be given until the vaccines pass a series of safety protocols, Modi has said India is just weeks away from starting its inoculation drive. At the heart of these moves is a country grappling with a core question: how do you vaccinate 1.3 billion people? For an answer, the example of Pratibha Shirke could offer some insight. For 32 years, Shirke has walked long distances, climbed mountains and crossed rivulets in Raigad district, a little more than 70km away from India’s gleaming commercial capital, Mumbai. The 56-year-old is one of the thousands of auxiliary nurses and midwives (ANMs) that form the first point of ground-level contact in India’s health care system. ANMs, among other their other tasks, are the vaccinators who drive India’s massive Universal Immunisation Programme (UIP), one of the largest health programmes in the world. Under the UIP, women like Shirke are tasked with administering a total of 18 vaccine doses – from the Bacillus Calmette-Guérin (BCG) vaccine meant to protect infants from tubercular meningitis and disseminated tuberculosis, to the oral polio vaccine and the tetanus and adult diphtheria vaccines for expectant mothers. India eyes China’s one-child policy, but some see Hindu nationalism Each year, government data shows that nearly 157 million people, from newborns to expectant mothers, receive vaccinations through about 10 million inoculation sessions conducted by workers such as Shirke. She and her army of vaccinators will play a key role in distributing the Covid-19 vaccine – in India, 90 per cent of vaccinations are done through the government and the remainder through the private sector. Shirke’s task is not an enviable one. With a bare-bones team of four, she is in charge of vaccinating nearly 1,500 children across five neighbouring villages – a year-round job. The five villages are spread over 30 sq km, 10 times the area of New York’s Central Park. Some villages are as far as 12km away from each other. Local officials said that in some areas, there were barely any roads, so vaccinators had to carry their doses in ice boxes and trek up the mountains for over an hour. Shirke’s job starts even before a child is born. “As soon as there is an expectant mother, we start tracking her health, in general, but specifically her vaccinations.” Such scrutiny comes for a reason. The medical officer of the region, Dr Preeti Karvande, said that anaemia was common here, especially in hamlets where tribal communities lived. When a baby is delivered, Shirke swings into action. In her long register, filled with neatly drawn columns in blue ink, she maintains a studious record of each newborn’s vaccination cycle – which doses are taken, when and which ones are left to be administered. Across India, local authorities like the one Shirke works under often create a fixed schedule for vaccinations. For instance, at the Primary Health Centre in Mohili village, a blackboard has a printed schedule for the vaccines. This centre finishes all its monthly vaccinations within the first two weeks, with days fixed for each village. The advantage with such a system is that villagers know when to expect the vaccinators. But the system also has a backup just in case. A day before vaccinators reach the village, another group of workers, the Accredited Social Health Activists, better known as ASHA workers, show up. “We visit the homes of those children or expectant mothers who are due for their vaccine doses and remind them to come to the village centres where the vaccination is slated to happen,” said Seema Dhabade, an ASHA worker in the nearby village of Mothe-Vengaon. India vaccine giant eyes emergency licence despite efficacy questions UPHILL TASK Despite having the nuts and bolts in place, immunisation drives in India can often be a process fraught with many challenges. Over three decades she has worked as a vaccinator, Shirke has realised that the key to successful immunisation programmes is not the planning, but the people. “It finally boils down to whether those you are seeking to vaccinate trust you or not,” she said. “If they don’t trust the vaccinator, they won’t want to take the vaccine.” Early into her career, she realised this the hard way. Trekking for several kilometres, she would go to a tribal hamlet in the mountains in the Raigad district only to encounter parents who would refuse to allow their infants to be vaccinated. I realised that the way to bring the mothers on board was just to visit them and spend time with them while they cooked. Pratibha Shirke, health worker Slowly, Shirke recalled, she started dropping in for casual visits, for chats that would turn into invitations for meals. “I realised that the way to bring the mothers on board was just to visit them and spend time with them while they cooked.” But parents are often so fearful of the side effects of the vaccinations that Shirke must face their fury. “I used to often face abuse by mothers, because they used to blame me for their child falling sick or having an illness, even if it had nothing to do with the vaccination,” she said, adding with a smile: “One gets used to these things.” What complicates the situation further in a country as diverse as India is the constant battle to avoid societal conflicts over vaccinations. Dr Chandramuni More, the health officer in Karjat, a town in Raigad district, said that last year the Muslim community had reservations about taking the newly introduced measles-rubella vaccine. “So, we had to talk to local clerics in the mosques around and ask them to help us convince the community that the vaccine was safe,” More said. Such community education imperatives hold important lessons for India as it embarks on one of the largest vaccination drives in the world. Modi, speaking earlier this month, said that political leaders should help dispel rumours around the vaccine lest unfounded claims derail the fight against the virus. In the same speech, he called India’s vaccination network “vast and experienced” and said the country was “far better than several countries in this regard”. Nidhi Choudhari, the Collector of Raigad district, agreed and said lessons from ground-level health workers would be important when the Covid-19 vaccine was finally approved for distribution. Such routine cycles of immunisations had revealed some of the problems in achieving universal vaccination, the senior-most bureaucrat in the region said. Detective, ambulance driver: the Indian women breaking gender stereotypes “One major lesson is that due to migration from such rural areas to urban areas, a section of the population misses out on vaccinations. So, that is one aspect we will have to focus on.” For now, even as the Indian government fine-tunes its vaccination plans, it has indicated that frontline health workers might be the first ones to receive a shot, as early as within the next few weeks. On the ground, the army of vaccinators led by the likes of Shirke is ready and raring to go.