Everyone, everywhere has the right to the highest attainable standard of health. But we don’t have to look too far to be reminded of how many people living in South Africa are left behind due to our failures to ensure not only timely and appropriate healthcare, but also the underlying determinants of health.
Our track record is pretty deplorable and the ambitions of Universal Health Coverage feel further from our reach than ever, as demonstrated by ongoing public health crises, including: the Life Esidimeni tragedy; the fight to provide compensation for poorly paid (former) mineworkers living with silicosis across southern Africa; the ongoing struggles of people criminalised for selling sex when trying to access healthcare; the shameful Digital Vibes corruption allegations; and the current efforts to overcome the backlog in access to cancer treatment owing to, among other factors, the tragic fire at Charlotte Maxeke Hospital which appears to have been the result of poor occupational health and safety measures.
And the national response to Covid-19 — particularly our vaccination strategy — is no different.
Amplification of inequalities
People living and working on the margins of society — physically and socially — remain the most affected by our public health failures, and — as the past 18 months have clearly shown us in the most painful ways — this is mirrored in the context of Covid-19. We know the pandemic has amplified the stark inequities that characterise South Africa and the world, most recently illustrated by vaccine inequity related to access globally, continentally and nationally.
Of the 4,695,719 individuals who had received at least one vaccine dose in South Africa by 21 July 2021, 34% (1,599,581) have medical aid (representing a fifth of the population who have medical aid), while only 6.09% of the uninsured population — those reliant on the public health system — had been vaccinated. The total percentage of people in South Africa on medical aid is just 16%. We believe this is because more supplies than needed have been sent to private sites, while the number of people without insurance are also being restricted from getting vaccinated at those sites, with priority given to members.
Details of this are only now emerging, hence the urgent need for the government to indicate the supply allocations of each and every vaccine site in the country. There is a national roll-out — private vaccine sites should not be privileged in the programme.
Additionally, for all people living in South Africa, the Electronic Vaccination Data System (EVDS) for vaccine registration is in fact becoming a barrier to getting vaccinated, which explains why so many people over 60 have also not yet registered on the system and why some provinces are now taking “walk-ins”.
Leave no one behind
Covid-19 remains a public health emergency of international concern. The International Health Regulations — a binding legal framework — clearly outline that a state must implement public health interventions to address any health emergency. This should include access to vaccinations for all at risk and in need.
However, with no oversight mechanism, the effectiveness of the regulations is limited. Regardless, for any vaccination programme to be effective, we must vaccinate everyone if we are to reach the level of population immunity needed to break the chain of transmission — and fast. The spread of the Delta variant makes this even more urgent.
The speed at which the third wave has swept across the country demonstrates, in real time, why we cannot wait to act. Where there’s a safe vaccine and where there are people at risk, we must vaccinate. This is Public Health 101: leaving anyone behind leaves us all behind.
And this includes upholding the president’s promise to “make the vaccine available to all adults living in South Africa, regardless of their citizenship or residence status. We will be putting in place measures to deal with the challenge of undocumented migrants so that, as with all other people, we can properly record and track their vaccination history. It is in the best interests of all that as many of us receive the vaccine as possible.”
While aligning with the African Commission’s resolution and the Joint Guidance Note on Equitable Access to Covid-19 Vaccines for All Migrants, which emphasises the importance of an inclusive response to the pandemic that includes all refugees, asylum seekers, displaced persons and migrants, our response is far from inclusive.
The role of a dysfunctional immigration regime
An increasingly restrictive and dysfunctional immigration regime in South Africa that disproportionately affects black African non-citizens, as well as widespread incompetence and corruption within the Department of Home Affairs (which has on numerous occasions been found to be in contempt of the Constitution), means that many migrants and asylum seekers in South Africa struggle to access valid documentation.
These challenges have been compounded by the closure — in some cases the illegal closure — of a number of refugee reception centres. Those that had remained open before the pandemic have been closed since March 2020. This has left those hoping to apply for or renew documents to deal with a poorly designed online application and renewal system instead. With the permit extensions granted during lockdown due to expire at the end of July, and no plan in place to prepare for this, further challenges are anticipated.
Home Affairs itself admits that it faces an insurmountable backlog of asylum claims and other applications. Due to its increasingly ineffective and dysfunctional systems, many non-citizens find themselves rendered undocumented by the very state system through which they seek to regularise their stay. This is unacceptable and the lack of political will by the state to fix the system is nothing short of xenophobic.
Language like “illegal” and “illegality”, and that used by government officials claiming that those without documents are undeserving of basic rights — including access to healthcare and the vaccine — highlights the cruelty of such a system.
Acting Minister Kubayi has not only perpetuated the short-sightedness, xenophobia and Afrophobia of health ministers who have preceded her in terms of understanding movement and migration as a determinant of health, but, critically, seems to have missed a Public Health 101 briefing as part of her rapid induction into the world of pandemics. While tweeting about the “coffee generation” getting vaccinated, Kubayi — who is bound by the prescripts of the Constitution and the decisions of the National Coronavirus Command Council — appears to be out of her depth.
On 23 July 2021, the acting minister was asked by the media how people without state-issued documentation — including an estimated 12% of South Africans without identity documents — can register in the country’s vaccination programme which is only possible through the EVDS.
Shockingly, Kubayi responded that, contrary to the president’s promise made in February, she would “have to get guidance in terms of the unregistered because we are dealing within the government systems and provision of services. We follow the laws of the country. So you have to be a documented person in the country. If you are undocumented it means you are illegal in the country. So it’s a different case. We have responsibility to those who are known to the state, by the state.”
In a situation where the foreign embassies of wealthy nations are vaccinating their own citizens here in South Africa, we urgently need to vaccinate everyone at risk, as recommended by the World Health Organization and other expert bodies, to achieve global immunity. Fuelling anti-poor foreigner sentiments with public statements like this goes against all globally accepted principles of public health risk and need. It is also contrary to guidelines for an effective pandemic response in which clear statements outlining the importance of including everyone — including refugees, asylum seekers and migrants — have been made by the African Commission, the International Organization for Migration, the UN Refugee Agency and the International Labour Organization.
Urgent need for firewalls
We know our frontline healthcare staff are overstretched and the priority is processing as many adults as quickly as possible through vaccination sites, even walk-in sites.
The best way to ensure healthcare workers can meet their responsibilities to patients under the National Health Act, including in relation to the reporting and treatment of Notifiable Medical Conditions (Covid-19 is a “category 1” Notable Medical Condition), is to ensure they are not asked to act as immigration officials. Denying care, including life-saving vaccines, to people will only further burden the healthcare system and the responsibilities of healthcare workers down the line as Covid-19 outbreaks continue among communities who are unvaccinated by a state strategy of only vaccinating “its own” (and those with papers).
We need a legal, policy and humanitarian firewall that will protect all people without documents. We need to ensure people are willing to access vaccination sites without fear of being arrested or harmed in any way. Given the violence of the past weeks, we do not need to unnecessarily add more health risk to the system by turning people away from vaccine sites.
Basic public health logic maintains that we need everyone in our country to be vaccinated so that we can mitigate this pandemic — and for this reason we also want to know what the public health and other experts on the Ministerial Advisory Committee have advised the government on this matter. Have our local and global experts stood up for the rights of all people living here, or only some? The public needs to see all the committee’s advisories now.
Vaccine nationalism is leaving many countries behind, including South Africa. As a country, we have called out the international community for failing to ensure equitable access to vaccines globally. South Africa is leading the fight in Geneva for global vaccine equity (TRIPS Waiver), while here at home we now run the risk of driving our own form of vaccine nationalism: the most marginalised are being left behind. How we respond today will be remembered for years to come.
We must avoid making the mistakes of the past. The years of Aids denialism should remind us that we mustn’t forget how the impact of poor decisions is felt decades later; lives lost due to poor and ill-informed and xenophobic decisions, which go against all public health advice, cannot be recovered later. We must draw on the lessons learnt from the global response to HIV.
For many years there have been calls to develop migration-aware health systems, in which population movement is central to the design of health interventions, policy and research. Research clearly indicates this means establishing a national migration and Covid-19 task team and developing a basic “scorecard” to guide responses; this should include implementing systems to ensure that undocumented persons can access Covid-19 services, including vaccination programmes, and face no penalties when doing so.
We must ensure everyone has access to life-saving technologies, including vaccines: in a pandemic, effective health interventions belong to everyone. Denying access not only undermines the Constitution and international health law, it also means the national response to Covid-19 will fail.
South Africa ratified the International Covenant on Economic, Social and Cultural Rights, an international United Nations treaty that recognises the right of everyone to enjoy the benefits of scientific progress and its applications.
As such, we echo the statement by United Nations human rights experts on the universal access to vaccines, and we remind the state that it has “an obligation to ensure that any Covid-19 vaccines and treatments are safe, available, accessible and affordable to all who need them.
“This is particularly relevant to people in vulnerable situations who are often excluded from health services, goods and facilities, including those living in poverty, women, indigenous people, people with disabilities, older persons, minority communities, internally displaced people, persons in overcrowded settings and in residential institutions, people in detention, homeless persons, migrants and refugees, people who use drugs, LGBT and gender-diverse persons.
“Many of them may have lived experience of poverty and find themselves in situations where they are most likely to be exposed to the risk of contagion, yet the least likely to be protected from Covid-19 or supported by adequate and timely tests and health services.”
It is imperative that access to Covid-19 vaccines and treatment are provided to all without discrimination and prioritised for those who are most exposed and vulnerable to Covid-19.
We call on Kubayi to do the right thing and follow international guidelines to ensure the Covid-19 vaccination programme is inclusive. Without doing so, we will fail to achieve population immunity, variants will continue to emerge and we will all suffer. Civil society and the research community are here to help, but we need a seat at the table to do so.
Public Health 101: A cheat sheet for Acting Minister Kubayi
Jo Vearey, Director, African Centre for Migration & Society (ACMS), Wits University; Sally Gandar, Scalabrini Centre of Cape Town; Rebecca Walker, independent researcher and African Centre for Migration & Society (ACMS), Wits University; Thea de Gruchy, African Centre for Migration & Society (ACMS), Wits University; Fatima Hassan, Director, Health Justice Initiative; Dr Tlaleng Mofokeng, United Nations Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health (The views expressed herein are personal and do not necessarily reflect the views of the United Nations); Pinky Mahlangu, Medical Research Council; Nicholas Maple, African Centre for Migration and Society (ACMS), Wits University; Francois Venter, Director, Ezintsha; and Sharon Ekambaram, Lawyers for Human Rights.
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