Vaccine Anxieties, Vaccine Preparedness: Perspectives from Africa in a Covid-19 Era

"How are Covid vaccines understood and experienced in particular African social contexts? In what ways have vaccine supply and distribution affected demand or hesitancy? How are people's perspectives and experiences shaped by political dynamics across scales, from local to global?"

Vaccination came to the forefront of global discussion and policy in the second year of the COVID-19 pandemic. Supply-focused debates focused on vaccine inequities as a reflection of longstanding, broader inequities in global health, while parallel discussion emphasised the problem of vaccine hesitancy. The latter has been seen to reflect the public's lack of knowledge of vaccine benefits and (mis)perceptions of their risks, with communication needed to address a deficit in understanding. However, people are not blank slates who blindly accept the messages they read on social media, for example; particular "conspiracies" are shaped by people's own interpretations of vaccine policies and politics. This paper addresses the anxieties of local publics in African settings about COVID-19 vaccines through a lens that attends to wider bodily, social, and political dimensions. An aim is to bring to light the over-simplifications in dominant discourses, thereby fostering "a more nuanced understanding that interlinks supply, delivery and demand, considers how these interlinkages could be anticipated, and attends to longer-term, contextually-embedded social and political relations."

The vaccine anxieties framework as outlined in the paper builds on and connecting strands of anthropological and social science work on vaccination, health, and science: Bodily dimensions - exploring how the body and aetiology of health and disease are understood and experienced and the place of vaccination in this; social dimensions - exploring the social worlds that vaccination becomes part of, involving relations within families, communities, clinics, and health systems; and political experiences - exploring people's encounters and imaginings about health and related institutions nationally and internationally, and the broader political and economic histories and governance regimes in which they are embedded.

This study forms part of a broader collaborative anthropological research programme on pandemic preparedness in Africa that involves global research, as well as investigation in the regional hub of Senegal and in national and local sites in Uganda and Sierra Leone. Methods included: documentary, social media, and policy analysis; participant observation in regional meetings and in Uganda and Sierra Leone; ethnography involving informal, open-ended interviews in two rural villages and/or a peri-urban context in each country; and observations in the two countries' provincial/regional urban centres. Focused data collection on vaccine anxieties took place from January-September 2021.

To set the stage, the paper discusses the global and regional situation regarding COVID-19 vaccine supply in Africa as it unfolded during the first eight months of 2021. For instance, multiple procurement routes had consequences for vaccine supplies at country level; these supplies were unpredictable in their quantities and timing, and they involved different vaccines with different technologies, origins, and financial and political implications. Many countries delayed joining COVAX, a worldwide initiative working toward equitable access to COVID-19 vaccines, until at least December 2020, for reasons such as doubt about of the relevance of vaccines for their own populations, having experienced low COVID-19 prevalence and mortality in 2020.

Furthermore, the World Health Organization (WHO)'s Vaccine Readiness Assessment Tool used in all 47 countries in the WHO African Region showed that just 12% had plans to communicate with communities; WHO thus feared that populations would not be sufficiently informed to accept vaccines. A review by Bardosh et al. (2021) of several surveys amongst Africa populations cited in the present paper indicates that, in tune with that WHO assessment, attitudes towards vaccination were affected by popular understandings of the virus: its origins, perceived risk profile, ideas of natural immunity, and the impact of variants on vaccine effectiveness. Concerns were also raised about safety, side effects, rushed vaccine trials, and new technologies. Speculation was evident about a lack of accessibility on the continent due to limited funds or corruption. Fears about possible forced vaccination also featured.

During the first eight months of 2021, the vaccine anxiety study's regional fieldwork and observations in meetings raised further issues that illustrate the dynamics at the interface of supply and demand. To name only one: In March 2021, blood clots associated with the astrazeneca (AZ) vaccine became a dominant topic in international news. The narrative that the AZ vaccine was suitable for low-income settings due to easy refrigeration and its related promotion for COVAX, combined with the safety issues flagged in the United States (US) and in Europe, reinforced the idea of it as an inferior vaccine. This notion led to speculation that it was being "dumped" on African populations, as was evident from the researchers' fieldwork in Uganda.

The country case studies of vaccine anxieties in Uganda and Sierra Leone show how the supply and procurement dynamics, as they played out nationally and locally, were interpreted by different people such as to become part of their vaccine anxieties, while also affecting their experiences of accessing vaccination. In keeping with the vaccine anxieties framework, the findings are organised according to bodily, social, and political dimensions. In Uganda, for example:

• The researchers explore why certain publics did or did not want COVID-19 vaccination, amidst their understandings of the disease - e.g., participants questioned the idea of vaccination for a disease that at least until the second wave, was of questionable existence - a "disease of the radio" as some put it. Other bodily concerns were related to the worry expressed by villagers in Kasese district, Uganda, that their bodies might be overburdened by multiple vaccines. For example, COVID-19 followed closely on a hepatitis vaccination campaign in the village - suggesting, in the local language Lukonzo, that bama hekya emibiri ye bindu binene (we are making our bodies carry too many things).
• With regard to social and community dynamics, for instance, in contrast to the widely accepted children's vaccination programme in Uganda, the distribution of COVID-19 vaccines was associated with a heavy-handed and already-resented state pandemic response. The fact that soldiers were the first prioritised group and allegedly took the vaccine with 100% compliance only increased its association with a distrusted militarised state.
• In the political realm, protracted periods of lockdown, arbitrary arrests, and enforced hospitalisation of asymptomatic cases fuelled discussion about whether or not the government's underlying intention was to poison particular ethnic groups or anti-government individuals, whether the COVID-19 vaccines would impair fertility, and whether they would enable the government to take the land of affected groups. There were additional concerns about the vaccines on offer: Chinese products are often perceived to be low quality in Uganda.

Notably, by August 2021, views in the project fieldsites began to change. More and more people made their own empirical observations about the impact of COVID-19 on health and well-being. Anti-vaccine rhetoric decreased, and many anti-vaccine campaigners started to lose ground. A pastor in the Kasese study site who spent eight days in hospital described how he almost died of COVID-19 and would now devote his energies to educating villagers about the benefits of vaccination. Thus, anxieties about the dangers of the disease appeared to be starting to co-exist with and in some cases to override negative anxieties about vaccination.

In Sierra Leone,

• Very few villagers claimed to have ever seen a case of COVID-19. If the disease did exist, some villagers reflected, it was common and mild, and probably something they had lived with all their lives. In contrast, they felt Ebola (which also mimicked other more common diseases in its early stages) had been devastating in their country. One village woman said, "most people saw what [Ebola] did and there was no way to deny". Given such understandings, it is not surprising that many people at first were influenced by messages circulating in social media and amongst relatives around the dangerous side effects from a novel vaccine. Yet over time, villagers found no evidence of severe adverse consequences among those they knew who had been vaccinated. Gradually, although limited by the slow roll-out and poor vaccine access in rural areas, negative anxieties about side effects began to diminish.
• With regard to community/health service dimensions, in some places, there was evidence of mass absenteeism when the vaccination team arrives; tellingly, it was in such settings that stories about harsh treatment under Ebola tended to surface. In others, there was an enthusiastic turnout, especially when vaccine teams included staff of the village medical centres; several nurses reported positively on this familiarity factor as a reason for their success in persuading large numbers of potentially hesitant villagers to take the vaccine. The variations seemed to relate mainly to the existing state of trust in government medical services.
• Villagers often expressed concern that COVID-19 was a "political" disease. Concerns that COVID-19 had been bioengineered by the Americans (or the Chinese) to weaken Africa, and especially to control population levels by reducing fertility, readily translated into hostility towards COVID-19 vaccines. However, some people began expressing openness to accept the new vaccines, provided they had been approved by WHO and the African Centers for Disease Control and Prevention (CDC), reflecting confidence in global or pan-African institutions rather than in western countries.

To expand on the latter point, the study also reveals that, where COVID-19 vaccine anxieties shifted from negative to positive, this evolution "seems to reflect both growing experience with the vaccines, and growing experience and fear of the disease in the second wave...Vaccine confidence also grew when the vaccines were delivered by trusted local providers....Yet [the] cases also highlight that as technologies enter everyday experience, they do not become 'just' technical; they remain subject to social and political meanings, and thus vulnerable to shifting social and political dynamics which may re-activate negative anxieties once more....Respectful dialogue that appreciates such perspectives is likely to be more effective in building vaccine confidence than top-down communication of 'correct' information."

The researchers stress that vaccine accessibility as locally experienced depends on people's assessment of vaccine origins and the identities and trustworthiness of providers. Inclusion or exclusion of geographical areas or populations, or interrupted availability, or mandatory vaccination mandates, are interpreted politically. These observations underline "the importance of embedding vaccine accessibility in approaches that build trustworthy health systems for the long-term. This in turn means addressing global supply issues..."

In short: "Whilst it is easy to dismiss comments about vaccines as ill-founded, misguided misinformation and conspiracy - part of an infodemic - it is also the case that they often reiterate longstanding concerns about vaccination in Africa and globally; and they have been given new life by the specific supply issues around Covid-19. The cases of Uganda and Sierra Leone reveal that people's anxieties about Covid-19 vaccines - both negative worries, but also positive desires for the vaccines - are embedded in often sophisticated understandings and reflections that make sense amidst their social and historical contexts and experiences."

For the researchers, these findings imply that, going forward, we must address the longer-term structural, social, and political relations in which vaccine delivery and distribution are embedded and move "beyond narrow assumptions about vaccine demand or hesitancy to address the real anxieties both positive and negative felt by populations, embedded in bodily, social and wider political experience." This movement "must encompass capacities for understanding and communication by health authorities that are less top-down and based on quantitative survey and data snapshots, and more socially-nuanced and interactive, based on respectful dialogue with community members, and attuned to the ongoing interplay of supply, distribution and anxieties, and the social and political meanings they carry, in rapidly-changing local, national and global contexts." And we will need to establish "vaccine policy and governance arrangements in country settings that are more inclusive and localised, able to foster trust and respond sensitively to anxieties, both longstanding and emerging."