Covid-19 and Vaccine Inequalities in South Africa: The Second Year

Lerato Coulter, Nunu Dlamini, Jonathan Govender, Sarah-Jayne Du Plessis, Ryan Harries, Khanyisile Maphalala, Dineo Mtetwa, Katso Sebina, Hannah Sunpath, Storm Theunissen and Lenore Manderson

University of the Witwatersrand

Twelve months after it all began here, sanitisers, physical distancing and masked guards had become just part of the everyday, and we had lost count of deaths except of those nearest to us. We’d all gained health literacy and become lay epidemiologists: we could talk of risk factors and surges, variants and ventilators. But we’d grown weary of being locked down, locked in and locked out; we craved for the rich social lives that made us human. The longer the pandemic ensued, the more we looked to biomedicine again; we upheld preventive health measures, to be sure, but we held out hopes for a vaccine. We followed the trials, and considered vaccine safety and its efficacy against variants of the virus; we considered whether, if, why, and when we’d have the jab.  By this time, we’d gone from being bystanders to participants, deeply embedded in this global saga. In this context, we began to write.

~ ~ ~

            Soweto. The South Western Township. My home. Each and every day I wake up to the legacy of apartheid.  A family of seven living in a three-room house built in the 1930s, in a network of townships built to separate black people from white.

            Conceptions of the coronavirus vaccine highlight the legacy of apartheid in Soweto, triggering a mistrust of white people and a kind of generational trauma. The pandemic and vaccine have become my favourite topic of conversation in a taxi or the local spaza (convenience) store. People speak of vaccines in South Africa as being different from those available elsewhere, developed in order to “control the African population” or “wipe out” black people; the “correct” vaccines sit securely in western countries.  Race shapes how we think about the vaccine, just as it shapes our risks of infection and death, and our everyday lives.

            I had casually spoken with a stranger in a supermarket queue. We were looking at a magazine headline related to the vaccine; concurrently, we shook our heads. My head shake was at the government’s claim that it might reach its target and vaccinate 67% of the population by the end of 2021. I was right. On 25 March 2021 – a year and a couple of days after the first lockdown was announced — the government confirmed that it would not reach the target: rollout might not even start until November 2021. But the stranger beside me shook his head out of anxiety: his concern was about being “killed by a vaccine that comes from white people.”

            The same point keeps emerging on WhatsApp. Some people, maybe many in my community, still have some mistrust, anxiety or maybe post-traumatic stress about white people. They focus less on the theory and reasoning and scientific evidence behind the rollout of vaccines, or on how they and others might benefit from being vaccinated; instead, they focus on where these vaccines are from. The consequences of such conceptions can be fatal. It takes the decision of one person not to vaccinate, and the whole community suffers.            Meanwhile, like everyone else, I continue hoping that the vaccine will eventually reach us, and we can enter into a new “normal” ( Dineo Mtetwa).

Frontline healthcare workers queuing to get vaccinated at Medforum Hospital, Pretoria. Photo: Leah Maenetja, 13 May 2021.

~ ~ ~

            As the first wave hit in March 2020, there was panic, both heightened and contained by the declaration of a National State of Disaster and the implementation of a national lockdown. The lockdown was a response to an urgent need to mobilize all possible medical resources, and to prioritise those presenting with severe COVID. The corollary was neglect in responding to (other) medical emergencies.          

            During Lockdown Level 5, from 26 March – 30 April 2020, the daughter of a family friend broke four fingers and was unable to receive care for several hours. Brought to the hospital, she was told – due to lack of resources and pain medication – to come back later. There were multiple other reports of delayed presentations to care for non-COVID-19 conditions (Siedner et al. 2020), despite a significant reduction in most emergency department cases attributable to the COVID-19 lockdown regulations (Manyoni and Abader 2021).

            So where does the vaccine come in? The COVID-19 vaccine has as its goal herd immunity, but this can be realised only if a large percentage of the country’s population is vaccinated. This will decrease the likelihood of exposure to those unable to be protected by vaccines and susceptible to exposure. No vaccine provides 100% protection, but herd immunity allows these people to have substantial protection. Ultimately, this will mean that fewer people will suffer severe illness, which will free-up medical resources, reduce overcrowding, and allow primary medical care to be reprioritised. Trauma and emergency patients will have access to urgent and rapid medical attention.  And this may, again,  save the lives of many others (Katso Sebina).

Leah Maenetja, frontline
essential healthcare worker,
celebrates her COVID-19 shot in
Pretoria. Photo: Relebohile
Monare, 13 May 2021.

~ ~ ~

            In the context of the lockdown, other health problems were also neglected. COVID-19 was somehow “more important,” more urgent. “Non-essential” medical treatments and surgical procedures were deferred; non-urgent clinic visits were cancelled.  The care system for HIV changed from retaining patients into care to limiting clinical visits. On ‘World AIDS Day’ on 1 December 2020, Gauteng Premier David Makhura addressed the progress of HIV control efforts in South Africa during the COVID-19 pandemic, and noted that HIV infections have risen in Ekurhuleni and Johannesburg. He called on citizens to “work harder”.  He continued: HIV testing in Gauteng province had increased from 728 532 from April-June 20020 to 1.78m in the July-September quarter, the result, he suggested, of “catch up plans” as COVID-19 was increasingly incorporated into primary care services (Javan 2020). On the other hands, 225 000 people with HIV had ceased to access treatment, in particular reflecting stockouts of ARVs and unable to take time of work to collect medications. Meanwhile, the South African National Tuberculosis Association stopped all operations, unable to continue to the supervised care of people with TB. Everywhere, lockdowns created barriers for patients who needed treatment and access to medication (Javan 2020). Programs for HIV, malaria and TB all reported about 80% disruption in their services.            

             HIV was a predominant public health concern for four decades; TB caused growing concern as a syndemic of HIV (Montales et al. 2015, Singer et al. 2017). Other non-communicable and chronic conditions gained attention in the past twenty years as they came to dominate the burden of disease. But while they were clearly ‘risk factors’ for severe morbidity and mortality from COVID-19, they slipped out of sight in terms of services, from research agendas and policy debates. As vaccines roll-out for COVID-19, perhaps there will be space to turn back to these conditions. For our obligation is also to continue shedding light on other illnesses, and ensuring that those who experience them can be assured of quality and affordable care, and continuing support (Storm Theunissen).

Sister Zoliswa Gidi-Dyosi, a
registered nurse and midwife, was
the first recipient of the Covid-19
vaccine at the Khayelitsha Hospital
in Cape Town, South Africa. Photo:
Jeffrey Abrahams/GroundUp, 17
February 2021.

~ ~ ~

            One million doses of the Oxford University-AstraZeneca vaccine reached South Africa on 1 February 2021; they were quickly reassigned when it was identified that the viral strain (501Y, V2/B.1.351) of the second wave had circumvented the vaccine’s efficacy. The health department moved quickly to ensure that phase one of the vaccine roll-out, directed at healthcare workers, stayed on track, by administering the Johnson and Johnson (J&J), under the auspices of a ‘Phase 3b study’ (clinical trial).

            “Heard that some people had severe symptoms and even died after taking it (COVID-19 vaccine)…thought that taking it wasn’t going to benefit me in any way…because I already had Covid, and my body has antibodies against the virus” (Registered Nurse Naidoo, 2021).

            Upon consulting with doctors at his hospital, Naidoo became aware that naturally produced antibodies to fight COVID-19 remain in the body for 3 to 4 months, but this is followed by increasing rates of susceptibility, as new strains emerge. Naidoo was vaccinated on 26 February 2021. But his comments reveals the breadth of vaccine ambivalence, even among healthcare workers.

            The COVID-19 virus has been perceived by many as a ‘bio-weapon’, and this narrative filtered into South Africa and is reflected in varying degrees in the perceptions of citizens about the vaccine(s). The speed at which the vaccine was developed, bypassing strict trial protocols in the name of ‘emergency use’, raised questions of efficacy and readiness for distribution. It led to concerns about harmful side-effects, validated as countries halted the delivery AstraZeneca and Pfizer-BioNtech.

            Responding to perceived impending mortality either from COVID-19 or the vaccine, coupled with distrust in state capabilities, people seek alternative treatments. Social media found its voice in the context of lockdown and social distancing, fuelling concerns of trust  already well documented, elsewhere, as contributing to vaccine hesitancy and refusal (Yaqud 2014). The government and the healthcare sector need to unpack and respond to such public perceptions, to build rapport and forge buy-in into vaccine rollout endeavours (Jonathan Govender).

Vaccinations at the
Khayelitsha Hospital in Cape Town,
South Africa. The Johnson &
Johnson vaccine only requires one
shot and it can be stored in a
normal fridge. Photo: Jeffrey
Abrahams/GroundUp, 17 February

~ ~ ~

Members of the public are advised to practice basic hygiene which includes regular washing of hands with water and soap, cough or sneeze into a tissue or sleeve, coughing into one’s elbow instead of hands and staying at home when developing mild symptoms unless one is in the high-risk category.

            This might have been a recent reminder in the current pandemic. But it’s not. It’s from the South African Government News Agency, dated Sunday, 16 August 2009 (SAnews 2009).

            Pandemics have a way of shaking up societies globally and bringing about great anxiety as people work to  adapt to a new ‘normal’. The emergence of pandemic-potential infectious diseases has occurred regularly in history, and the reactions towards these are more or less similar depending on the severity of the pandemic. The COVID-19 pandemic response mirrors the government response to the H1N1 virus in South Africa, but with particular anxiety because of its lack of containment. It disrupted social interactions and cultural traditions, with constraints that were hard to accept.

            The HIV/AIDS pandemic did not bring about such harsh disruptions. Not everyone was at risk of contracting the virus because it was always seen to predominate in certain populations. And although the HIV/AIDS pandemic is ongoing – approaching 40 years – there are now means of protection, like the cabotegravir antiretroviral drug given every two months, that reduces chances of infection. We can now speak of the H1N1 virus in past tense because of vaccines. Parents and guardians spend hours at clinics, routinely queuing and waiting for their infants and young children to receive vaccine shots  for measles, tetanus, pertussis, polio. What makes COVID-19 different? Why was there a frenzy among those willing to participate in the trial for the vaccine?

             In accepting a vaccine, people are influenced by risk perceptions: risk of infection, severe illness, death, or severe vaccine side-effects (Seale et al. 2010).  It does not help that we are now living in a society of social media access, which at times plays a role in perpetuating ‘fake news’, spreading false information on vaccines and their effects. The acceptance of and adherence to stipulated public health measures is highly dependent on how people perceive a threat, and those who do not see the COVID-19 pandemic as a threat are less likely to comply (Seale et al. 2010). ‘Conspiracy theories’ around the pandemic have made it more difficult for people to understand the pandemic for what it is, and what harm it could cause if no vaccine is rolled out and widely accepted (Nunu Dlamini).

~ ~ ~

I lock out every demon of COVID-19, I lock out any vaccine that is not of You [God]. If there be any vaccine that is of the devil, meant to infuse triple-six in the lives of people, meant to corrupt their DNA … Any such vaccine, may it be destroyed by fire in the name of Jesus – Chief Justice of South Africa, Mogoeng Mogoeng, 10 December 2020 ( 2020).

            Chief Justice Mogoeng Mogoeng prays at Tembisa Hospital  for a vaccine that is free from the number of the beast. Some mocked the statement; others were angered that it might discourage vaccine uptake. But still, for some, the image of the mark of the beast entering your bloodstream was hard to shake.

            Many apocalyptical claims in Christianity are founded in Revelations, and these symbolically laden images and events have attracted many different groups of Christians. Their convictions are not usually made so public. I browsed through videos and read through messages forwarded through groups, as warnings of the end times were seen to be played out in daily events.

            I thought that the countless images of people gasping for breath or on ventilators would drive people into the safe arms of any vaccine, but once I emerged from my year of Staying Home to Save Lives, I was surprised that almost as many people were against the vaccine as for it. The “anti-vaxxers,” we say.

            People worldwide have reasons for and against taking a vaccine of any kind, but the anti-vaxx movement stemming from Christian Nationalism is one of the largest groups in America opposing the COVID-19 vaccine (Whitehead and Perry 2020). The allegiance to conservative political leaders that often rejects scientific evidence has created concern in America regarding the possibility of achieving herd immunity. The population of Christian anti-vaxxers may not be as concentrated in South Africa to hinder large-scale immunity (health systems weaknesses may do this), but the global Christian response has created definite discomfort even within the borders of South Africa. Whether this will promote the vaccine or hinder its acceptance is yet to be established. In the short term, without the vaccine, we hardly have a choice (Hannah Sunpath).

Frontline essential health
worker Relebohile Monare receives
her Johnson & Johnson 1 shot
vaccine at Medforum Hospital,
Pretoria. Photo: Leah Maenetja, 13
May 2021.

~ ~ ~

            Public resistance to vaccines has long existed, with the anti-vaccination movement formed in opposition to forced vaccination campaigns of the smallpox vaccine in England in the nineteenth century (Fitzpatrick 2005). Resistance had various reasons – religious, or  iatrogenic side effects, as reflected in the discredited claim that the measles, mumps, and rubella (MMR) vaccine was linked to the development of autism spectrum disorders (Gross 2009, Hussain et al. 2018). The issue of public resistance to vaccination is more complex than simply proving vaccine safety, as Sharon Kaufman (2010) illustrates: how individuals manage risk, and the trust they place in experts who are supposed to keep them safe, are complex issues.

            ‘Resistance to vaccination’ and ‘vaccine resistance’ appear to be synonyms, but they are not. ‘Resistance to vaccination’ is what people do. Vaccine resistance refers to the mutation or development of a pathogen such that the vaccine loses its efficacy. This is a very real problem of given the multiple variants of the SARS-Co-V2 virus. Entire national COVID-19 vaccination campaigns could be rendered useless if the selected vaccine has low efficacy for a new or different variant. This suggests that the global pandemic may not be close to its end, that there could be a resurgence of even worse waves.

            Public hesitancy and resistance towards vaccination could potentially prolong the pandemic. Emphasis needs to be placed on building trust between the public and fields of medical sciences. Misinformation around vaccine resistance needs to be managed as a priority. Vaccine resistance incites fear and  anxiety over the failure to contain the virus, and this is often fanned by news items: “Pfizer vaccine blow as Israeli tests find reduced efficacy against SA variant.” “New variant COVID findings fuel more worries about vaccine resistance.” “South African variant more resistant to vaccine, BGU finds.” Ultimately, the soteriological nature of modern-day science and medicine is in question. Will science and medicine be able to end this global nightmare? Or will the COVID-19 virus (often anthropomorphized) be too ‘smart’ to be defeated? (Ryan Harries)

~ ~ ~

            Increasing socio-economic gaps and systemic inequalities were already heavy topics in South Africa before the pandemic; COVID-19 highlighted these issues further and opened up opportunities for previously marginalised, disadvantaged and discriminated voices. The introduction of vaccinations has heightened the importance of these issues as social divides widen further.

            Many South Africans are struggling to gain access to the vaccine. Individual and collective catastrophes are consuming people’s rights to breathe by emphasising immediate and inherited traumas, death and disability, dispossession, exploitation, historical injustices and inequality. To live through and endure the COVID-19 pandemic, combined with individual catastrophes, people are asked to live without breathing (figuratively) at least for a short while (Mokgopa 2020). Navigating these factors with limited resources is a struggle in its own way. The roll out of vaccinations for many South Africans means finding one’s right to breathe, or fighting for one’s right to survive.

            This fight to the idea of ‘being infected before one is infected’ (KaCanham 2020). This perfectly describes how South African society was already infected, by systemic inequalities, racism, economic and social inequality, broad injustices and corruption (Le Roux 2020). The roll out currently underway needs to attend to this ‘previous infection’ in order for vaccination cover in South Africa to successfully reach herd immunity. People I know personally who have received the vaccine have needed to take five days off from work to manage post-vaccine symptoms. However, the majority of South Africans cannot afford unpaid work or sick leave due to part-time positions, uncontracted work, and income generated on a day-to-day basis. Simply put, society’s ‘new normal’ during the pandemic and vaccine roll out phase ignores and occludes the lived experiences of  trauma and catastrophe that shapes many lives.

            Further, the idea of ‘delegated death’ – that some humans live because others die – is crucial in finding one’s right to breathe during roll out (Mbembe 2020).  Covid-19 is a wake-up call showing that everyone is vulnerable to death and that death cannot be delegated. The vaccine roll out in South Africa suggests the opposite: it categorises citizens as essential and non-essential, while identifying illegal residents who cannot receive vaccinations because they entered the country without papers. Their humanity is erased, and social impacts of the virus are normalized. Mbembe highlights this loss of humanity within Covid-19: the majority of people do not have the ‘right to breathe’ (Sarah-Jayne Du Plessis).

~ ~ ~

            South Africa obtained its first dispatch of COVID-19 vaccines in early February 2021. In a public briefing, President Cyril Ramaphosa declared that the government aimed “to make the vaccine available to all adults living in South Africa, regardless of their citizenship or residence status.” This contrasted with the prior statement made by Health Minister Dr Zweli Mkhize:  that only South African citizens would receive the vaccine during the roll-out and that the government did not have the capacity to assist undocumented foreign nationals.  Such misleading and ambiguous statements made by a government official risked stirring up xenophobia in a country where xenophobic violence is endemic. Episodic eruptions of violence occurred from 1995, with near annual outbreaks leading up to extended violence in 2008. In 2015, xenophobia was triggered by the late Zulu King Goodwill Zwelithini, who reportedly asked foreigners to pack their bags and go back to their countries because they were utilizing South African resources at the expense of locals (Tella 2016); there were extensive violent riots again in September 2019. 

            The South African Human Rights Commission (no date) notes that “The Constitution and the National Health Act 61 of 2003 envisage a single health system for South Africa … The right to health care can however be limited in certain instances, depending on the availability of resources. However, the right cannot be denied completely.”   The government has an obligation and a responsibility to adhere to the human rights of refugees, asylum seekers, and people without legal documentation within its borders, including their right to health. Excluding or limiting any groups of people access to vaccination would compromise public health’s objectives of eradicating the virus according to the principles of equal respect and national equity prescribed under the World Health Organizations’ SAGE Values Framework for the Allocation and Prioritization of COVID-19 Vaccination.

            For South Africa to successfully tackle the Covid-19 pandemic, therefore, the government needs to ensure that all people have equitable access to vaccines and are included in the national COVID-19 vaccination program, regardless of nationality or residency status. Undocumented migrants may not voluntarily come forward because of language barriers, poor access to information,  and concern about their legal status, suggesting the urgent need to address inequalities in accessing the vaccine. The foremost principle of a successful herd-immunity strategy is that everyone is included (Lerato Coulter).

~ ~ ~

            South Africans aren’t angry enough about the state of corruption in this country.

            We are, but what can we do? We don’t want to get shot by cops – so we laugh!

            O tlo nka Vaccine? (“Will you be taking the vaccine”) is now also woven into our lexicon. Another string of words added to our reality, as common as a greeting. An introduction to a conversation that began in March 2020 for South Africa.

            Social networking sites such as Twitter, Facebook, TikTok and Instagram have been a hub for support and engagement throughout the changing lockdown periods. Communities and kinship were maintained, sometimes founded, in these virtual spaces as a temporary reserve.

            South African Black Twitter gave me access to more than just how people experienced the virus and what they thought about vaccination. It brought me back to the familiar and expected South African brand of humour.

            Whether on Black Twitter, in taxi ranks and bus stops, or, in the long 2-metre spaced lines in our grocery stores, laughter tugs at the eyes of our fellow citizens as we force conversation through masks. And the prevalent question remains: O tlo nka vaccine?

            South Africa’s comedy of errors in acquiring the Covid-19 vaccine provided a  plethora of jokes. It began when President Ramaphosa proudly announced the procurement of the AstraZeneca Vaccine, quickly shown to be ineffective against the dominant variant in South Africa.  We used humour as a first defence against disappointment; a tool that rerouted frustration perpetuated by the state into something to laugh about over lunch.

            Laughter and the use of comic relief is not misunderstanding or indifference.  A sense of humour is an important contributor to psychological well-being (Kuiper and Martin 1993); it allows the ego to triumph in the face of adversity. In South Africa, we have years of corruption, mistrust of the state and its officials, misuse of state funds, including the COVID-19 Relief Grant. The irregularities associated with the vaccination roll-out are frustrations that can only be safely expressed as a chuckle, giggle, or a hearty laugh.

            We have a very intimate and intentional relationship with humour: it’s a way to manage fraught relations between citizens and the state. Our diverse cultures, languages and experiences capacitate us with the tools we need to curate material from a grim reality, one that continually reminds us of the growing socio-economic gap and inaccessibility of resources.  Humour allows us to create a healthy distance between ourselves and these problems.

            On the day I write this, Newzroom Afrika releases a breaking news headline:  “SA Government confirms it will miss target to vaccinate 67% of population by end of 2021.” Someone tweeted: “To be fair, they’ve never met any target. Nje?” and everyone laughs.

So I ask, my friends: o tlo nka vaccine? (Khanyisile Maphalala).


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LERATO COULTER is a MA candidate in the History Department at University of the Witwatersrand. Her research interests are interdisciplinary with a focus on medical anthropology and legal history. 

NUNU DLAMINI’s research interests lie in the everyday experiences of female taxi drivers during the COVID-19 Pandemic, focused on the general inequalities between men and women in the taxi industry.

JONATHAN GOVENDER works in the field of acquired brain injury (ABI). His research focuses on how South African families respond to and experience ABI.

SARAH-JAYNE DU PLESSIS is currently pursuing a Masters in Health Sociology, where she is specifically interested in individual trauma, collective trauma and collective catastrophes. 

RYAN HARRIES is interested in various aspects of health, illness and society. He is pursuing a Masters in Health Sociology and researching illness narratives & COVID-19. 

KHANYISILE MAPHALALA’s current research interest focuses on the social experiences of black scholars in former white schools. 

DINEO MTETWA is a Master’s student at the University of the Witwatersrand and is also a documentary photographer. Her work is currently centred around the minibus taxi industry in Soweto.

KATSO SEBINA is currently pursuing a Masters in Anthropology and her research is centred around gender and sexuality in Johannesburg.

HANNAH SUNPATH is currently pursuing a Master’s in Anthropology and writing on aspects of health and nutrition among primary healthcare workers in South Africa.

STORM THEUNISSEN is researching the experiences and narratives of loss and grief within Afrikaans families during Covid-19, and how the pandemic has affected the grieving rituals of these families.

The above authors are Masters of Arts candidates currently studying medical anthropology with LENORE MANDERSON. Lenore is Distinguished Professor of Public Health and Medical Anthropology in the School of Public Health at the University of Witwatersrand, Johannesburg, South Africa.

Photographer permission has been given to share all images

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