INVESTIGATIONS

Claims of vaccine hesitancy in African countries are at odds with the reality on the ground

KAMPALA, UGANDA – SEPTEMBER 29: Patients queue prior to being vaccinated on September 29, 2021 in Kampala, Uganda. The Ugandan Ministry of Health recently started its rollout of the Pfizer Coronavirus vaccine after receiving 1.67 million doses of the drug from US Government. Uganda is using the doses as part of an ‘accelerated vaccination campaign against COVID-19’ that started on Monday. They plan to vaccinate 4.8 million people by the end of December (using a mixture of Aztrazeneca, Moderna, and Pfizer) before the planned re-opening of schools in January 2022. Around 1% of the Ugandan population has been fully vaccinated against COVID-19, and the country has seen 3,148 deaths from the disease. (Photo by Luke Dray/Getty Images)

MBARARA, UGANDA — When word gets out that Covid-19 vaccines are locally available, crowds rush to Mbarara Regional Referral Hospital in western Uganda. Hundreds of people will wait for hours in the sweltering heat outside the hospital’s always full vaccination tent; many are turned away when vaccine doses run out.

As public health workers supporting vaccination efforts in Uganda — two of us (A.H. and S.A.) on the ground in Uganda — we are constantly confronted with the challenges of getting people vaccinated in places like Mbarara. The local vaccination team, responsible for an area with about one million people, sometimes gets shipments as small as 200 doses as a result of Uganda having only enough vaccines for 15% of its total population. People in rural areas often have no transportation to get to cities like Mbarara where vaccination sites are clustered. Even those living within walking distance frequently cannot afford to step away from their jobs to wait in line for hours, especially when uncertainty over local supply looms large.

Our work serves as a continuous reminder that local demand for vaccines is high and access is the biggest barrier to increasing full vaccination rates — less than 3% for Uganda and 9% for the entire continent of Africa.

So we have watched with dismay as an alternative narrative has crept into the mainstream of American dialogue: that low vaccination coverage in Africa stems from people not wanting to be vaccinated.

In recent days, The New York Times and other outlets have painted a different picture from what we are seeing in Mbarara, warning of increasing “skepticism or outright hostility toward the Covid vaccines” in African countries after several nations declined shipments of doses. White House Press Secretary Jen Psaki cited global “hesitancy issues” in a press briefing hours after President Biden described a “reluctance” by people in South Africa to get vaccinated. A few weeks earlier, Pfizer CEO Albert Bourla stated that levels of vaccine hesitancy in poor countries on the continent are “way, way higher” than in Europe or the U.S.

None of these claims reference the high percentages of African people who say they wanted to be vaccinated, which are similar to or even higher than rates of vaccine acceptance reported in the U.S. This distortion of the narrative of global vaccine equity is detrimental to progress.

Earlier this year, the Africa Centers for Disease Control and Prevention (Africa CDC) released results of a large survey across 15 African countries in which 79% of respondents said they would get vaccinated against Covid-19, with even greater rates of acceptance among people living in villages. In August, another 12-country study found acceptance rates ranging from 67% to 89% in Burkina Faso, Mozambique, Nigeria, Rwanda, Sierra Leone, and Uganda.

For comparison, the same 12-country study found that only 65% of Americans planned to get vaccinated, a number consistent with current vaccination coverage levels.

To be sure, these polls found pockets of vaccine hesitancy in all surveyed countries, an unsurprising finding anywhere, especially in communities still affected by colonialism, unethical clinical trials, and extractive global health practices. In Mbarara, community members regularly ask about vaccine safety and side effects, and people expect us to fully answer these before they request their shot.

Effective vaccination campaigns anticipate, plan for, and respond to the concerns that people have, understanding that trust in vaccines is dynamic and achievable through sustained community engagement. Low- and middle-income nations have consistently shown the rest of the world how to achieve excellence in vaccine delivery, from Nigeria eliminating polio after partnering with religious leaders to promote immunizations, to Rwanda vaccinating 93% of girls against human papilloma virus (HPV) after enlisting local leaders in outreach.

Instead of acknowledging this remarkable vaccination track record, outsiders have taken reports of declined vaccine shipments in some African countries — likely the result of numerous factors, including poorly coordinated donations and the difficulty of moving doses to rural areas — as evidence of widespread distrust across the continent, overlooking the heterogeneity of 54 countries, more one billion people, and distinct local health, cultural, and political contexts that strongly influence vaccine uptake.

Hesitancy is a red herring when it comes to immunization in Africa. Multiple challenges abound to reach World Health Organization’s goal of vaccinating 70% of the world’s population by mid-2022.

In addition to poorly coordinated donations, these include receipt of expiring doses, receipt of large numbers of different types of vaccines with unique storage and transport requirements, over-centralized vaccine production, profiteering in the pandemic, and more.

In Mbarara, we worry about our friends dying, local economies suffering, and new variants emerging not because of Covid-19 vaccine hesitancy — something local health leaders know how to work on — but because, despite outstanding Ugandan responses to containing Covid-19 in 2020 and 2021, vaccines are still barely available.

Instead of exaggerating, distorting, and oversimplifying claims of Covid-19 vaccine hesitancy in African countries, commentators would better serve the urgent need for global Covid-19 control by amplifying the actual urgent asks from health experts to the rest of the world: donate stockpiled doses, support waivers of intellectual property, share manufacturing know-how, support regional vaccine production, and strengthen local health systems.

At best, claims of widespread vaccine hesitancy across African nations are uninformed speculations, not supported by data. At worst, they are deliberate attempts to distract audiences from the injustice of unequal access to lifesaving Covid-19 vaccines by blaming Africans. To support vaccination efforts in Mbarara and around the world, please help us call those sharing this narrative on their bluff.

Azfar Hossain is a program coordinator of the Vaccine Advocacy Accelerator — Uganda program and a medical student at Harvard, currently based in Mbarara, Uganda. Stephen Asiimwe is an epidemiologist and program director of Massachusetts General Hospital’s Global Health Collaborative at Mbarara University of Science and Technology, as well as principal investigator at the Kabwohe Clinical Research Center, both in Uganda.

Louise Ivers is the interim chief of infectious diseases at Massachusetts General Hospitalchair of global health equity at the Massachusetts General Hospital’s Center for Global Health, and professor of medicine at Harvard Medical School.

Azfar Hossain

Louise Ivers

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