Covid shots in the dark
Dose of discrimination: Why the government failed to reach its vaccination targets
South Africa’s problems with low vaccination rates are connected to race, class, disdain for community organising, and underfunding of the vaccine roll-out. Our New Year’s message to the President is: reflect on the real reasons for your failure and fix them fast.
At the end of September, President Cyril Ramaphosa told a family meeting: “We have set ourselves the target of vaccinating 70% of the adult population in South Africa by the end of the year.”
As of 26 December only 39% of adults had been fully vaccinated, with a further 6% partially vaccinated. The additional numbers before 31 December will be tiny because there are now fewer jabs per week than at any point since mass vaccinations began in May.
There has been no shortage of supply.
Dr Nicholas Crisp, at that time the acting director-general in the National Department of Health, said 61 million doses would be delivered by year end, which is double the number of shots actually administered. Vaccines have been turned back. We cannot blame “global vaccine apartheid”.
South Africa’s rate of vaccination is pitiful by world standards. Only 26% of the total population is fully vaccinated. The average for all upper-middle-income countries, including South Africa, is 72%, and even those defined as lower-middle-income have reached more than 33%.
What is the government’s explanation for failing to come close to its target? Rather than reflect on its own weaknesses, Minister of Health Joe Phaahla blamed people’s choices not to vaccinate and the role of social media and fake news.
Professor Francois Venter, University of the Witwatersrand expert, responded tersely: “It’s not because people are stubborn. It’s because the health system is not patient-friendly.”
To the extent that people’s “hesitancy” is part of the explanation, it has been a problem since before September and could have been reduced by effective government campaigns.
Data from Round 5 of the UJ/HSRC Covid-19 Democracy Survey, to be published in the new year, shows that in November only a quarter of adults could be regarded as hesitant (that is, will definitely or probably not get vaccinated or “don’t knows”).
The remainder were either vaccinated or definitely or probably intended to get vaccinated. Had the government persuaded these people to take the vaccine, the 70% target would have been met.
The Covid-19 Vaccine Survey (CVACS), conducted by a team from the University of Cape Town, produced similar findings. It asked unvaccinated adults: “Do you plan to get vaccinated, and if so, when?” There were four possible responses. A quarter opted for “definitely not”, which is approximately 15% of all adults, very close to the UJ/HSRC figure of 13%.
Thirty-four percent – about 20% of all adults at the time – went for “as soon as possible”. If all these were vaccinated, we should have reached 62% vaccinated by the end of the year. Adding those in the “wait and see” camp would push the figure over the 70% marker.
The government’s public education campaigns have been lamentable. Detailed knowledge of fake news and misinformation has been received from the Health Department’s Social Listening Committee every week. The committee includes a range of experts, all familiar with different sources and techniques, but it appears to have had little impact on the department or the Government Communication and Information System.
For the most part, the government transmits messages through social media, where information remains unseen in a cacophony of visual noise. Yet, as the UJ/HSRC surveys show, the most influential medium by far is television. On this terrain propaganda has been minimal, mostly unimaginative and sometimes inappropriate.
“Poster” now implies an image on a smartphone, probably in English, rather than an unmissable, memorable slogan on a billboard, lamp-post, wall or shack, where it could be in a language far better known locally.
Why has the government been so lacking?
The most commonly cited explanation is the Digital Vibes scandal, which sucked about R150-million from the Health Department’s communication budget. While this certainly had an impact, if the government had been seriously committed to public health campaigning it would have found additional resources from elsewhere.
There is a danger of “social media” and “fake news:” becoming an excuse for bigger problems.
In the CVACS survey, the main reasons people in the “as soon as possible” category had not been vaccinated were to do with access, with respondents saying things like “no time” and “vaccination site hassles”. With the UJ/HSRC survey, people regarded as “favourable” to getting vaccinated mentioned not knowing where to go, the cost of getting to a site, no time, and problems getting to the site.
These problems could be addressed relatively easily.
At the beginning of June we released a short report on problems faced by older people in Protea South informal settlement when they wanted to be vaccinated. We made a few simple suggestions, one of which was picked up by Acting Minister Mmamoloko Kubayi-Ngubane, who turned it into a neat slogan: “Get vaccines to the people.”
Sadly, this became a mantra rather than an organising principle. The practicalities could have been straightforward:
- Vaccination sites must be open in the evenings and over weekends so that workers can get vaccinated;
- There must be far more sites, so people can get to them easily and cheaply. Cost has been a barrier for too many people;
- The location of sites and their opening hours must be widely publicised; not just on social media, but on local radio, traditional posters and flyers;
- Assistance should be given to people with disabilities;
- Undocumented people should be encouraged to get vaccinated; and
- There should be support for mobilising campaigns run by community leaders and activists.
The government has not provided a detailed response to such proposals, but on the first it has pleaded there is a shortage of resources.
This “shortage”, and the government’s whole approach to the roll-out, has clear implications for racial and class discrimination, for social justice, and for the overall rate of vaccination.
Round 5 of the UJ/HSRC survey shows that whites are far more likely to be vaccinated than black Africans (44% versus 35%) and people living in suburban houses are far more likely to be vaccinated than those living in informal settlements (46% versus 30%, with township residents at 38%).
It is not that black Africans and people in informal settlements are more resistant. On the contrary, while 26% of whites and 29% of suburbanites were favourable to vaccination (but unvaccinated), the figures for black Africans and informal settlement residents were 41% and 46% respectively.
Comparing people living in rural areas with suburbanites and people with and without medical aid, we found similar disparities.
The explanation for these inequalities can be found partly in the principal language and the main platform used in government communications.
It should be recalled that English is a minority mother tongue. According to the 2018 General Household Survey, the approximate figures are Zulu (25%), Xhosa (15%), Afrikaans (12%), Sepedi (10%) and English (8%).
In the Community Organising Working Group (COWG) and the National Vaccine Monitoring Group (NVMG) we found there was always demand for flyers in at least one Nguni language (usually Zulu), or other Sotho-Tswana languages and Afrikaans, as well as English.
Moreover, according to the 2019 General Household Survey, only about 67% of households used a mobile device (smartphone) to access the internet.
But the capacity to use these gadgets is reduced by the cost of data and power outages. COWG/NVMG always had to find some funding in order to function in a reasonably democratic way using Zoom. We have never found access to Zoom or similar platforms to be an obstacle in university or government settings.
Getting to sites
The problem of getting to vaccination sites is partly about ease and cost of transport, notably car ownership, an issue we raised back in June, but also distance.
Our colleague, Londiwe Sithole, has found considerable inequality across Johannesburg. The city is divided into seven regions. Region B (covering Randburg, Rosebank, etc) has the smallest population and the least poverty, but by far the highest number of vaccination sites (58). In contrast, the two poorest regions, D (covering most of Soweto) and G (covering the deep south, including Orange Farm) had the largest population (D) and a large one (G), but the lowest number of sites (22 in D and 20 in G). See here and here.
An important issue is that because private sites – for example, pharmacies – tend to be located in malls, and there is a higher proportion of malls in the suburbs, it is easier for suburbanites to find sites. This would apply to the more socially mixed regions in Johannesburg, which has more unvaccinated people than any other metro, and presumably to cities and towns elsewhere. Drive-in sites also privilege people with cars.
Some provincial health departments have tried to overcome such inequality by deploying pop-up outreach units. However, in our experience, there are too few of these, their appearance is inadequately publicised, mobilisation of potential vaccinees is amateurish, they “pop-down” very quickly, and the commitment of staff is often (though not always) rather poor.
It does not have to be this way.
The COWG has worked around pop-up units with the Gauteng health department and recently with the University of Pretoria/Médecins Sans Frontières team vaccinating undocumented people. These collaborations have produced higher vaccination rates. In future we hope to work with Clicks on pop-ups.
The COWG activists are generally known and trusted in their communities; they mobilise by going door-to-door with flyers, as well as using megaphones; they make lists of people who want to be vaccinated; and they provide transport for the disabled and frail. Where resources allow they make vaccinees comfortable by providing water and oranges. Volunteers receive just R50 per day, enough for lunch. Even so, funds are often inadequate, and some mobilisations are more successful than others.
A key factor in the success of the COWG approach is that it combines argument against hesitancy with practical activity to reduce problems of access. See here for a description.
There is substantial provincial variation in rates of vaccination. While Gauteng, our richest province, has only vaccinated 42% of its population (35% fully), and the figures for KwaZulu-Natal and Mpumalanga are even worse, the Western Cape has vaccinated 53% (46% fully), with the Free State slightly higher.
Back on 21 September, the national Health Department showed that in the Western Cape the vaccination rate among the insured population (which approximates to those with medical aid) was 68%. Regrettably, there has been a decline in transparency and we do not know the latest figure.
However, comparing the province’s vaccination rate at that earlier date with the present one, there has been a rise of 29 percentage points. While this increase will not have been equal for the insured and uninsured, it is inconceivable that the rate of vaccination for the Western Cape’s insured population is less than 70%.
In other words, if everywhere had been as effective in vaccinating their populations as the Western Cape has been in vaccinating its insured residents, the President’s target of 31 December 2021 would have been met. We would have been happier and safer.
South Africa’s problems are ones of race, class, disdain for community organising and underfunding of the vaccine roll-out. Our New Year’s message to the President is: reflect on your failure. DM/MC
Kate Alexander and Bongani Xezwi are at the University of Johannesburg, where Kate holds the South African Research Chair in Social Change and Bongani is a researcher. Both are active in the Community Organising Working Group and the National Vaccine Monitoring Group. They are grateful to their comrades and colleagues, and to the National Research Foundation and National Institute for Humanities and Social Sciences for supporting their research.
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