At face value, this looks like yet another monumental failure by government, but actually it’s not.  Rather, it is the result of a wise choice to prepare for the worst at a time when the future path of the pandemic was both frightening and uncertain. Fortunately, and notwithstanding the appalling number of deaths, the worst-case scenario did not materialise. 

South Africa’s procurement of Covid vaccines happened in the first few months of 2021, just as we were emerging from the second wave which had killed roughly 100,000 people across the country.

Read: Bradshaw D, Dorrington R, Groenewald P, Moultrie T (2022). Covid-19 and all-cause mortality in South Africa – the hidden deaths in the first four waves. South African Journal of Science. 18(5/6).

At the time, international consensus was that herd immunity would require seropositivity in at least 70% of people which, in our youthful population, meant that everyone aged 18 and older would need to get vaccinated. Wealthier countries had already placed massive orders both for immediate and future delivery of vaccines and supply timelines were already highly unpredictable. 

Faced with these realities, a decision was made to order enough vaccines to reach the coverage levels for herd immunity. These orders required upfront financial guarantees; cash-on-delivery wasn’t an option and neither could the government retract purchase orders if the pandemic fizzled out and the vaccines weren’t needed anymore. 

While the thought of potentially wasting any part of the R6.5-billion allocated by National Treasury for the purchase of vaccines stuck in the craw, the alternative was even more unpalatable. In 2020, the South African economy had shrunk by 6.4% of GDP as a result of the global shock and our own lockdown policies. That loss of about R350-billion could not be repeated in 2021. 

There was emerging evidence both from other countries and our own that older people were more likely to be hospitalised and die from Covid-19, but no one was sure what the virus would do next. After all, the first wave in South Africa had been half as deadly as the second, which suggested that things could get a lot worse. It was conceivable that, having decimated the vulnerable older population, new and even more dangerous variants might select younger people at risk from underlying conditions like HIV and TB. 

Jo Sekepane receives her Covid 19 vaccine at the Covid-19 vaccination site inside GrandWest Casino and Entertainment World on June 15, 2022 in Cape Town, South Africa. (Photo: Gallo Images / Misha Jordaan)

Smooth out the history of epidemics and they tend to follow the same course: initially rampaging through the population and then gradually becoming more benign before burning themselves out. But zoom in a bit and their trajectories look a lot more volatile. If the government had bet on a predictably declining incidence of Covid-19 and the actual course had proved otherwise, it would have been rightly pilloried if vaccine stocks had run out. 

An abundance of caution was validated by the third ‘Delta’ wave, which resulted in even more deaths than the second. Based on the number of excess deaths since May 2020 — mortality above that which is expected from prior years ebbie Bradshaw and other researchers (see their article above) calculate that at least 270,000 people in South Africa died from Covid-19.  According to weekly hospital surveillance by the National Institute of Communicable Diseases (NICD) Over 80% of those who died and three-fifths of those hospitalised were older than fifty years of age.

According to an article in the Lancet, Global impact of the first year of Covid-19 vaccination: a mathematical modelling study, internationally, vaccinations made a massive difference in reducing severe disease, with ten-fold reductions in intensive care and death rates among those vaccinated compared to those who were not. At the same time, the notion of herd immunity was proving elusive, even in countries with very high rates of vaccination coverage. Omicron transmitted itself at double the speed of previous variants, regardless of the vaccination status of its host. 

According to scientific studies (see for example, Collie S, Champion J, Moultrie H, Bekker L-G, Gray G (2021). Effectiveness of BNT162b2 Vaccine against Omicron Variant in South Africa. Letter to Editor in the New England Journal of Medicine, December 29, 2021), the main benefit of vaccination, it turned out, was to reduce the risk of severe disease — not to staunch the flow of infections. 

By January 2022 and in countries where natural immunity was already very high, it made little sense either to argue for compulsory vaccinations or to appeal to people to get vaccinated for the greater good.  

Young people

In South Africa, nearly 7 million 18-34-year-olds have come forward for vaccination. In absolute numbers, this is more than any other age band, but still only constitutes two-fifths of that sub-group because of South Africa’s massive youth bulge. It is quite astounding that 30% of our total population is in that age bracket. Their relatively low uptake has had the effect of diluting the total population coverage, with just on half of all adults having had at least one dose. 

Many commentators have clucked at the seeming indifference of young people, but compared to their actual risk of hospitalisation or death, they have in fact been more amenable than older people. By the end of the 4th wave, 7% of adults younger than 35 years of age with confirmed Covid-19 had been hospitalised, compared to a quarter of those aged sixty years or older. Again, according to the NICD’s hospital surveillance studies, their case fatality rate — the number who died compared to confirmed Covid cases — was 1 in 300 compared to 1 in 8 people older than sixty. 

With higher morbidity experienced from HIV and TB, it is unsurprising that many younger people chose to stay home.  Why spend R30 of your Covid-19 grant on a taxi ride to and from a vaccination site when, for the most part, the vaccine’s own side effects will probably be just as unpleasant (or just as benign) as the symptoms of the disease itself? Still, adjusted for the risk of hospitalisation, twice as many young people got vaccinated than people older than fifty, and compared to their real risk of death, ten times as many came forward.

Not only were young people at low risk of severe disease, but most already had some level of naturally acquired immunity as a result of exposure in the Beta and Delta waves. By the end of the second wave, in an article in the Lancet, Heather Zar and colleagues had found Covid-19 IgG antibodies in 90% of mothers in a community in the Western Cape.

It is time that we accept that deferring vaccination until there is renewed threat to life or well-being is not an unreasonable decision. 

Having said that, my own view is that we must continue vaccinating young adults for three reasons, namely:

• the debilitating effects of long Covid;
• the small, but still real chance of the emergence of a nasty variant in immunocompromised populations; and
• the fact that hybrid immunity still seems to offer greatest protection.

Further, we have vaccines to spare. No young person needs to die of Covid-19, but with the benefit of hindsight, and in the face of so many other demands on health services, procuring vaccines for young people no longer seems like a fiscal priority. The case for vaccination in younger children is even less compelling, where the fractional benefit might even be outweighed by the small risk of adverse events. 

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Age-based sequencing: risk targeting

In terms of risk-targeting, South Africa’s vaccination programme has ended up in a fairly good place, with nearly two-thirds of people over fifty now having had at least two doses.  

We might have been a lot worse off if the original prioritisation plan for the general public had been implemented. Priority categories then included a mish-mash of those over sixty, essential workers, people with co-morbidities and those in congregate settings like institutions of care and prisons. Special interest groups spent an unsavoury couple of weeks jostling over who would be at the front of the queue. 

Fortunately, sanity prevailed and age-based sequencing was implemented during the period in which vaccine supply was still constrained. After health workers, older people were positioned first in line.

As each age band opened up, wealthier people rushed in their cars to vaccination sites, giving the impression of ubiquitously high demand. However, just one month into the vaccination programme, it was already clear that the opportunity costs of vaccination were much higher for poorer people. 

By the end of 2021, according to a study on vaccine inequality and hesitancy by the HSRC and University of Johannesburg, twice as many people earning R20,000 a month and more had been vaccinated (relative to their share of the population) than those earning less than R1,000 a month, even though most people with low-incomes indicated that they wanted to get vaccinated. Whether they acted on that intent was being shaped by their perception of Covid risk relative to all the other risks and pressing issues in their lives. 

It was also determined by political sentiment and flailing levels of trust. Faced with the aggressive language of war, corruption scandals associated with procurement of personal protective equipment and the Digital Vibes controversy, the general public had reason not to trust government. 

Political legitimacy of the programme seemed to take a further knock in the local government elections, with first dose vaccinations 20% lower in the following fortnight than in the prior two weeks. Apart from the adrenalin surge associated with the discovery of Omicron, daily vaccination numbers never recovered.

Public health communication 

Against this backdrop, public health communication had limited success. The Vooma Weekends led by the President attracted half a million more people than usual. Vooma Vouchers of R200 for people fifty years and older resulted in 10% more first-dose vaccinations in that age group in the three months it was implemented. Within two weeks of launch, the KeReady campaign for young people had already attracted a quarter of a million more vaccinees than prior trends had predicted, and joint mobilisation by business and labour achieved over 80% coverage in some companies and on many mines.

Certainly, it was a failing of government that R9-billion was spent on the procurement and management of the vaccination programme, while almost nothing was committed to public communication. To a large extent, this gap was eventually filled by philanthropic foundations and the Solidarity Fund through the distribution of millions of pamphlets and posters in 14 languages, high-frequency radio advertising and engagement of young people through social media and community mobilisation. This massive effort only kicked in three months after the start of the public vaccination programme in May 2021, which would have likely benefited from earlier communications clarity and cover. 

Truth be told though, all of these efforts had limited effect on a wary and disillusioned nation. It kept a steady stream of people coming through the clinic doors, but couldn’t substantially ramp up national demand.

It is not clear to me that additional public spending on health communication would have stimulated substantially higher uptake. There is a 15 percentage point gap between the province with the highest overall coverage (Free State) and the lowest (KwaZulu-Natal), and differences in management capacity do not fully account for inter-provincial variation. In some provinces, the gap between vaccination rates of older and younger people is far wider than others, suggesting that access was not the binding constraint and demand rather than supply was the main problem. Yet all had received the same intensity of centrally-procured public communication. The reality is that the choice of whether or not to be vaccinated was largely determined by factors outside of the Health Department’s control.

Mistakes

This is not to suggest that the Department of Health did not make mistakes:

• The question must be asked as to why procurement of vaccines was only initiated in January 2021, four months after the US Food and Drug Administration had approved the first Covid-19 vaccine and at about the same time as the first vaccines were being delivered to developing countries like Brazil.  If our public vaccination programme had started three months earlier, some of the devastating impact of the Delta wave may have been averted and thousands of lives saved.
• Early on, there was an impression that the vaccination programme was really just a matter of logistics and that people would line up en masse at taxi ranks and in stadiums. However, the rapid declines in uptake beyond the initial surges quickly put paid to that idea.
• The preparatory phase of the public vaccination campaign coincided with the revelations of the Digital Vibes scandal and it wasn’t initially clear whether the Ministry, the National Department of Health or GCIS was to lead the public communication. This led to a gap in public understanding which was seized upon by conspiracy theorists and anti-vaxxers, who made hay until a more cohesive strategy was designed.

Another major constraint was the hypersensitivity to the Protection of Personal Information Act, which had come into effect during the first lockdown. In the wake of the corruption linked to PPE procurement and under intense scrutiny from the Auditor-General and the Information Regulator, the small but highly committed vaccination team in the National Department of Health were dogged in their determination not to put another foot wrong. 

Information from the Electronic Vaccination Data System (EVDS) was so closely guarded that, for the first six months, even district health officials did not have access to their own facilities’ data. This meant that they couldn’t move personnel around or change their opening hours to respond to area-specific patterns of demand. 

Similarly, the National Contact Centre was only allowed to be used for inbound calls, even though the EVDS required registrants to accept that they might be contacted for purposes of follow-up. This restriction missed the opportunity to phone those people who had failed to come in for a second dose and are therefore still not fully vaccinated. Very soon, we must clearly define a Popia-compliant information regimen that should be instituted in the next public health disaster, so that officials feel able to act without fear of overstepping legal boundaries, perceived or real. 

Next time around too, let us avoid the language of war that alienated the public and undermined trust. The Disaster Management Act speaks of intergovernmental committees and management centres, not of ‘command and control councils’. 

We also need to make clear distinctions between political and technical decision-making, so that leaders with the right competence make appropriate decisions. Let the Health Minister ensure that there is one head of the Disaster Management Centre, so that officials don’t trip over each other’s feet.  And let us not be so paralysed, neither by narrow interpretations of law nor by the unpredictability of the looming crisis, that we fail to make the right decisions.

In many ways, we are fortunate that we haven’t had to make use of the 18 million vaccines stockpiled for the worst-case scenario, but that doesn’t mean that government was wrong in procuring them. 

When there is so much wastage, inefficiency and corruption, it is easy to write off every government intervention as a failure. If we do that, we undermine the paths to the rehabilitation of the State, because every green shoot will get treated like a weed. We will also undermine the effective management of future disasters if we don’t distinguish between bad decisions and bold decisions that must be made in times of extreme uncertainty.  DM/MC

David Harrison is CEO of the DG Murray Trust. He led coordinated donor support to the Covid-19 vaccination programme from February 2021 to June 2022.