Latest Case Studies/ Human Impact

Bringing Vaccines to Millions in India’s Stigmatized Communities

With HIV, diabetes and heart disease, the transgender woman living alone in Bengaluru, India, was a perfect candidate for a Covid-19 vaccine. But she thought it would kill instead of protect her, and dreaded going to a health clinic where she might be judged for her identity.

Then she met Jasmine.

Jasmine, a 45-year-old transgender woman, also lives alone, and had survived her own bout with Covid. She listened to the woman’s concerns with deep empathy and offered to accompany her to a vaccination center set up specially to serve the transgender population. “I will stand by you,” Jasmine promised. Eventually the woman agreed, Jasmine ordered a rickshaw, and the vaccine was safely administered.

“That I could convince her made me very happy,” recounts Jasmine, who has a gentle air about her that feels persuasive. “My parents only lived to see one phase of my life. But if they could see me today, and how I support others, I know they would be proud.”

Jasmine is part of #VaxNow, a program supported by a grant from The Rockefeller Foundation to the nonprofit Swasti aimed at bringing equitable testing and vaccinations to India’s marginalized communities. Swasti, established in 2002, is focused on achieving improved public health outcomes for the economically challenged or socially excluded.

Swasti’s approach to break through vaccine-hesitancy while creating equitable access was two-pronged:

  • engage trusted community members to pinpoint key concerns and counsel peers; and
  • bring Covid-19 care to communities’ doorsteps through pop-up vaccination sites.

The #VaxNow project involved a collaboration between 353 partner organizations known as #COVIDActionCollab. The group vaccinated some 6,206,000 people across 24 states and union territories, including transgender men and women, sex workers, migrant workers, street children, people with disabilities, those in shelters, informal workers and street vendors, among others.

Participatory Approach to Designing a
Vaccine Drive

Jasmine (center) working at a transgender vaccine drive
Jasmine (center) working at a transgender vaccine drive

“Our partnership with Swasti has been a great example of quick, agile action while working through a wide-ranging public health crisis,” says Deepali Khanna, Rockefeller Foundation Vice President, Asia. “Swasti didn’t just step up to the challenge; they thought outside the box to reach the farthest corners of the communities they serve. That’s equity. Enabling access is where it begins for me.”

“As Covid-10 vaccine supplies are finally reaching countries that need them most, The Rockefeller Foundation’s Global Vaccination Initiative is focused on reaching at-risk populations,” added Dr. Bruce Gellin, Chief of Global Public Health Strategy, Health Initiative. “But you can’t just deliver vaccines to clinics. You also need to understand the community’s perspectives and invest in communication and connection—as they are in Bengaluru—to help people understand why they need them.”

The participatory process used to design the #VaxNow program was led by Dr. Angela Chaudhuri, who has logged nearly two decades of public health accomplishments in India and internationally and has worked for Swasti since 2004. She also helped create an extensive Rockefeller Foundation-supported “Covid-19 Playbook” to offer methods to meet and surpass vaccination targets.

The playbook, drawing on critical learnings from the India campaign that could be helpful globally, addresses why stigmatized and “last-mile” communities are often left behind in public health efforts, how to draw them in, the role of clinical and non-clinical staff, and various crucial decisions ranging from timing, location, advocacy materials and more.

 

“We didn’t want our program to be designed only by people who drive cars or sit behind computers,” she said. “To center equity, we gathered key champions of various communities, who spoke their lived realities. We also sought feedback from people waiting in line, or after they’d been vaccinated.”

Line for a Vaccination Drive held in a Bengaluru urban slum
Line for a Vaccination Drive held in a Bengaluru urban slum

As a result of this input, the team created multi-purposed vaccine sites aimed at meeting a particular community’s needs. “For example, the transgender population was starving,” Dr. Chaudhuri noted. “They’d lost their livelihoods in the pandemic, so we had huge boxes of food packs available at the vaccination sites, as well as a doctor to do regular checkups and someone who knew about hormone replacement therapy.”

One day, a government healthcare provider and a senior bureaucrat saw crowds at a #VaxNow site and asked Dr. Chaudhuri how she did it. Their vaccination efforts, they noted, had not been as successful. That exchange may encourage government public health leaders to partner more frequently with community groups, which would be a valuable outcome, she noted.

Pop-Up Sites Used to Vaccinate Millions

Hareesh BS, Swasti’s Associate Director with 18 years of experience working with the transgender and sex worker communities, helped lead the implementation of the vaccination drive in Bengaluru, the capital of India’s southern Karnataka State with a population of just over 13 million. He coordinated about 170 people who vaccinated 123,000 city residents from May 2021 through April of this year.

Woman in Urban Slum getting vaccinated

What that meant practically, he said with a laugh, is that “I was organizing chairs, counselling clients, cleaning up the venues—doing everything except giving vaccinations, but only because I wasn’t trained for that.”

Some 25-30 people staffed each pop-up vaccination site, registering patients, overseeing the process, helping maintain social distancing, administering vaccines, and providing counselling. Even obtaining permission to use school or religious centers as vaccination sites for a day was time consuming—only one out of every ten places they approached agreed.

Transgender Woman Receiving a Vaccine in Bengaluru

Reaching Out to Sex Workers and Slum Dwellers

Pushpalatha helped lead the effort to reach out to Bengaluru’s sex workers. In her 20s, she was a nanny for an Indian family living in Kuwait. When that position ended, she returned home and searched for a job a year without success before a neighbor introduced her to sex work.

In 2003, she and three other sex workers founded the organization Swathi Mahila Sangha to improve the lives of her community’s members, and a year later they partnered with Swasti.

Now 58, Pushpalatha was working as an HIV project director when the Covid lockdowns began. As part of this project, she provided counseling during the vaccine drives, which began later in the day to accommodate sex workers’ schedules. She is proudest of the moment when she noticed two women enter a site, look around, and start to back out.

“I stopped them. I reminded them of all the ambulances carrying dead bodies. I said this is the only weapon you have to save yourself, your family and your clients. I said if you have any problem, you can call our hotline. Also, we will give you a kit with pain pills in case you get a fever,” she recalls. “Finally, they agreed. I am very, very proud when I think of that encounter.”

Although Bengaluru is among the top four wealthiest cities in India, some 16% of the population also lives in slums. Asha, 32, a mother of three, is among those. As part of this grant, she worked within her community to support Covid education and encourage vaccination.

Asha, who works at an incense packaging factory, recalls how happy she felt after persuading a fearful diabetic coworker to get vaccinated. “Many people who live and work near me don’t have documentation, or don’t know who to approach, or are simply afraid,” she said. “We have to help, because vaccination is the only way out of Covid.”

Out of a Challenging Background is Born a Community Leader

Jasmine’s challenging personal journey prepared her for the work she does now. Born in Shimoga District in southwest India, Jasmine realized at age five that, although she presented as male, she identified as female. Her feelings were both clear and confusing: in grade school, she preferred playing with the girls, and when she reached high school, she wanted to wear nail polish and makeup, and realized she was attracted to boys.

Everyone, including her parents, indicated that these feelings were wrong. She faced teasing and bullying. As she was raised in a small town, she found no one like her, and felt deep loneliness. The mocking—and sometimes worse—continued when she entered college, so eventually she dropped out.

Image is a photo of Jasmine.
Jasmine

She began to consider suicide but then found someone with whom she had her first relationship. When his family objected, and Jasmine’s parents died within six months of one another, she moved to Bengaluru.

There, she had a roommate who soon moved out, leaving her unable to afford the rent. She began working in a temple as a janitor in exchange for food. Then she became a sex worker, making a meagre salary of about 8000 rupees a month—but at enormous cost. She describes, for instance, a time when a client came with several companions who had all been drinking, and they raped her, forcing her to have unprotected sex multiple times.

One day, sitting in Cubbon Park in central Bengaluru, she was approached by someone from Samara Society Yeshwanthapur, a sexual and gender minorities rights nonprofit that partners with Swasti. This chance meeting marked a turning point; Jasmine began visiting the Samara office, where she was eventually hired to clean and run small errands for 800 rupees a month.

She went on to become a peer educator, an outreach worker and finally a community counselor, where she now makes as much as she once did as a sex worker. And eight years ago, she underwent gender-affirming surgery.

“We appreciate the outreach to the transgender community during Covid,” Jasmine said. “But people should know we are like any other human beings, and equal in front of the law. If they started accepting us, then we could live respectful lives like anyone else.”

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