On the 1st of March, the Nelson Mandela Foundation, housed at the Nelson Mandela Centre of Memory, instituted its mandatory vaccine policy that stipulates that any person over the age of 12 must be fully vaccinated against COVID-19 before entering the premises, subject to a few exemptions. This policy, of course, required staff to be vaccinated. I support the policy, and others like it, as much as I am uncomfortable with the notion of it all. It seemed in a way that we are saying ‘Anti-vaxxers not welcome’. It wasn’t a particular policy clause that I needed a conversation on, but the very notion of a vaccine mandate.
The apparent sentiment against so-called anti-vaxxers is of those that would not do God’s work if the devil bade them, as the saying goes - entitled, precious, wilfully ignorant, the less said about them the better. And I’m sure many of them have earned that sentiment. Their response, as compelling as it can get, seems to go something like - in a modern democracy, nobody should ever forcefully do anything to my body without my consent. Progressive liberals and queer activists have used this kind of argument themselves in different contexts, “my body, my choice.”
I don’t want to talk about the people described above. I want to talk about people who are hesitant to take the vaccine because they don’t trust the state, because the state has given them genuine reasons not to trust it, because they feel fundamentally betrayed by the state. Central to this conversation is the argument that, inasmuch as vaccines are free and relatively easy to access, vaccine mandates so easily present the threat of entrenching existing ghettos and exclusion points. Vaccine mandates that are pursued in the place of effective, community-based advocacy and information campaigns should not be implemented without regard for the world they participate in creating, for better or worse. This applies especially to private mandates that control spaces that exist as public resources for the public good such as the Nelson Mandela Centre of Memory, which houses and makes publicly available memory resources related to the life and times of Nelson Mandela.
To be sure, the risk analysis the Foundation undertook, based on their obligation as an employer to generally secure the safety and wellbeing of their employees and visitors, noted that, based on the work we do, COVID-19 is a significant threat to the health and safety of people in the Centre’s physical space. As such, the vaccine mandate was issued to fulfil that obligation with particular mind for the kind of work we do. This also helped to ensure that we do not further endanger the communities we serve. To be sure, everybody should get vaccinated, it shouldn’t bear repeating here.
Somewhere in all of the reasonableness informing our own discourse, there is a kind of vilification of the unvaccinated that is happening. The unvaccinated without exemption are holding us back, are uneducated and a reckless, unnecessary threat to society - it seems we are saying. They are immediately classed, racialized, anti-anybody existing outside of society’s protection. The careful considerations that went into the decision to publish a vaccine mandate seem to exclude discursive and political dimensions related to vaccinations.
“The social nature of vaccination views is really not unique to COVID-19. We have found that public views about a diverse range of vaccines and vaccination drives in South Africa, and elsewhere for that matter, are deeply embedded in the wider social worlds in which people live. So, through their vaccination choices, people are often communicating not just what they think about vaccines but also who they are, what they value, and with whom they identify.”[1]
Each instance of vaccine hesitancy plays out differently in each region, each with its own political, structural and cultural contexts and motivations. However, in many instances of vaccine hesitancy in Africa, public trust in the state and public health science is particularly important. This is because convincing healthy people to undergo, in some ways, novel medical treatment requires overwhelming trust in the agent doing the convincing, in this case, the government. A government that is seen as capable of being dishonest or working against the interests of its people is not an ideal agent to convince healthy people to undergo medical treatment like the COVID-19 vaccine.
The causes of the 2003 Polio Vaccine Boycott in northern Nigeria also had many contextual reasons, many of them largely centred around public trust in the state.[2] After Nelson Mandela launched the “Kick Polio Out of Africa” campaign, with the aim of immunising 50 million children from the disease in 1996 alone, the campaign faced its most daunting challenge in 2003 when it undertook to eradicate polio in West and Central Africa. At the time Nigeria made up 43% of the world’s polio cases and 80% of the continent’s cases.[3] That’s when the boycott struck, based on fears that the vaccine had antifertility agents, HIV, as well as carcinogens.
The fears had structural causes too. Generally, the use of Western orthodox healthcare services was low in northern Nigeria and so the use of the vaccine was unsurprisingly low. There had also been a population control policy from the 1980s which made it unlawful for a child-bearer to have more than four children. There were fears and concerns that the government may have been trying to enforce this policy through the vaccine programme. However, perhaps the most compelling reason researchers have found for the boycott was “general distrust of aggressive, mass immunization in a country where access to basic healthcare is not easily available”.[4]
“The aggressive door-to-door mass immunizations that have slashed polio infections around the world also raise suspicions. From a Nigerian's perspective, to be offered free medicine is about as unusual as a stranger going door to door in America and handing over $100 bills. It does not make any sense in a country where people struggle to obtain the most basic medicines and treatment at local clinics”[5]
A government that is not trusted, a government that is perceived as corrupt, whose office-bearers are seen as self-serving, a government that flaunts its wealth in front of impoverished people, has little chance of carrying out a successful vaccine campaign, least of all in adults.
The South African government, we would argue, currently holds little public trust too. Many people feel betrayed by the ruling party, by the so-called revolution, even by Nelson Mandela. And they have good reasons for feeling this way. Even recent reports describe the relationship between the government and the people as challenged by many circumstances. It has been challenged by a Minister of Health who was publically humiliated as having benefited from pandemic-related corruption. It has been challenged by a President who doesn’t prioritise dealing with the unfinished business of the Marikana Massacre. It is challenged by being a democratic country that has become the most unequal on earth. In these ways, the South African government is not the ideal agent to convince to undergo what is, in some ways, novel medical treatment.
These structural relations between the people and the state are deep-running and historically rooted. This antipathy, apathy and dissidence towards the state could arguably be driving vaccine hesitancy, or the rhetoric of vaccine hesitancy. In some instances, people refuse to be vaccinated against COVID-19 as a conscientious, dissident, political statement. Which is itself why organisations such as the Foundation have been forced to issue vaccine mandates to fulfil their employer obligations to protect employees and visitors. However, this has the potential of turning the Nelson Mandela Centre of Memory, and others like it, into an exclusion point - a checkpoint that scans for state privilege and protection. So that only those that have particular sensibilities, a particular relationship to healthcare and health sciences, those with particular values and beliefs, may enter.
While it is true that other kinds of vaccine mandates have worked in the past, especially those targeted at children, the World Health Organisation (WHO) released a short policy note in April last year, stating that WHO “does not presently support the direction of mandates for COVID-19 vaccination, having argued that it is better to work on information campaigns and making vaccines accessible.”
It remains unclear whether the government will introduce national or provincial mandates and how quickly and consistently private vaccine mandates like the Foundation’s will spread. It is also unclear whether or not COVID-19 vaccine mandates will be successful. However, the Polio Vaccine Boycott in Nigeria is a clear case study that argues for deep community involvement in vaccination campaigns. Researchers studying the Polio Vaccine Boycott stress the importance of messaging and information campaigns that involve community leaders, religious as well as cultural points of engagement.[6] A vaccine that is championed by members of the community is more likely to be accepted by the community.
Vaccine mandates enacted by the state at a national level are hardly comparable to a private mandate, such as the Foundation’s, and it’s doubtful that the Foundation will become the apocalyptic exclusion zone described here but it is certainly participating in what is a very dangerous and prescient discourse. And doing so to participate meaningfully in creating safe public spaces and not endangering communities we serve.
Our responses to the COVID-19 pandemic, from how we messaged safety to how we give meaning to the vaccine, are spectacles of the shifting boundaries between the human and non-human. The new “wrethed of the Earth”, as Achille Mbembe notes in On the Postcolony, will be those that do not have the right to have rights, the untouchables, ‘undocumented’ and stateless refugees who are seen as threats to our values, our civility, our jobs, our futures and our health. The ‘work’, then, remains a matter of moving from othering to belonging, of constructing human relations that enhance social bonding and broaden the horizons of humanity. Until then, we must work between the fire and its flames.
[1] Sara Cooper in Ina Skosana, “Pasha” podcast, (2021) The Conversation (available at https://theconversation.com/understanding-vaccine-hesitancy-in-south-africa-173703)
[2] Ayodele S Jeged, “What Led to the Nigerian Boycott of the Polio Vaccination Campaign”, 2007 PLOS Medicine 73 (available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1831725/)
[3] Renne E, 2006 Soc Sci Med 63(7):1857-69.
[4] Murphy J. “Distrust of US foils effort to stop crippling disease”, 2004 Baltimore Sun January 4 (available at: http://www.baltimoresun.com/news/nationworld/bal-polio0104,1,6396183.story?ctrack=1&cset=true.
[5] See note 4
[6] See note 2.