Vaccine Hesitancy Is a Serious Issue From South Africa to the U.S.

The risks posed by the new COVID-19 omicron variant and even the story of its origins are up for debate, but vaccines and boosters appear to offer some protection against severe disease. When news emerged that omicron was found spreading across southern Africa, U.S. President Joe Biden’s initial response was fast, firm, and ultimately ineffective at actually getting shots into arms globally.

In addition to calling for Americans to get vaccinated or a booster, the president stated: “I call on the nations gathering next week for the World Trade Organization (WTO) ministerial meeting to meet the U.S. challenge to waive intellectual property protections for COVID vaccines, so these vaccines can be manufactured globally. I endorsed this position in April; this news today reiterates the importance of moving on this quickly.”

The WTO is unlikely to move on this quickly. The 12th WTO Ministerial Conference, which would have addressed the Trade-Related Aspects of Intellectual Property Rights waiver on vaccine patents, was itself postponed because of the omicron variant. This postponement is indefinite. Even if IP protections were somehow waived—which is unlikely given opposition from several governments—it would do little to ease the immediate situation in South Africa.

The risks posed by the new COVID-19 omicron variant and even the story of its origins are up for debate, but vaccines and boosters appear to offer some protection against severe disease. When news emerged that omicron was found spreading across southern Africa, U.S. President Joe Biden’s initial response was fast, firm, and ultimately ineffective at actually getting shots into arms globally.

In addition to calling for Americans to get vaccinated or a booster, the president stated: “I call on the nations gathering next week for the World Trade Organization (WTO) ministerial meeting to meet the U.S. challenge to waive intellectual property protections for COVID vaccines, so these vaccines can be manufactured globally. I endorsed this position in April; this news today reiterates the importance of moving on this quickly.”

The WTO is unlikely to move on this quickly. The 12th WTO Ministerial Conference, which would have addressed the Trade-Related Aspects of Intellectual Property Rights waiver on vaccine patents, was itself postponed because of the omicron variant. This postponement is indefinite. Even if IP protections were somehow waived—which is unlikely given opposition from several governments—it would do little to ease the immediate situation in South Africa.

This is because South Africa is currently awash in vaccine supply. South Africa has more than 16 million doses already on hand. Amid the global outbreak of panic about omicron, South African health policymakers asked Johnson & Johnson and Pfizer to defer vaccine deliveries.

However, only about 35 percent of South African adults are fully vaccinated. The reasons for this disconnect between supply and uptake are multifold and hold lessons for the United States. Supply was initially very constrained, and there are ongoing issues with access, such as limited transportation to vaccination sites. The South African vaccine rollout’s design posed further barriers: “Authorities insisted on people registering on an Electronic Vaccine Data System with scheduled time and place where to go for their vaccines, which undermined a swift uptake of vaccines for most of the populace,” wrote Shabir Madhi, dean of the University of the Witwatersrand, Johannesburg’s faculty of health sciences, in an email.

There is an additional issue slowing vaccine uptake in South Africa, which might be even harder to solve: vaccine hesitancy. “Many people simply don’t believe there is an urgent need for vaccinations,” Madhi wrote. “It’s a combination of apathy and hesitancy.”

Although current headlines are focused on vaccine hesitancy in South Africa, this is very much a challenge facing the global north.

In Europe, the binding constraint preventing additional vaccinations is not so much distribution or access—as is true in much of Africa—but rather vaccine “acceptance.” There is huge variability in vaccination rates across Europe and within countries: In Belgium, Flanders is highly vaccinated while Wallonia is somewhat less so and Brussels lower still, with only 56 percent of Brussel residents having received at least one shot. In Portugal, where vaccine hesitancy is negligible, 81 percent of the population has been fully vaccinated, which is comparable to Malta, Iceland, and Ireland. But in formerly communist Southern Europe, vaccination rates are much lower. Only 34 percent of Romania’s population has been fully vaccinated, and in Bulgaria, only around 22 percent has been fully vaccinated.

The European Centre for Disease Prevention and Control addressed these issues in a technical report meant for policymakers. It drew no generalized conclusions, finding, “the underlying reasons for lower uptake vary considerably among and within countries.” For instance, in Belgium, hesitancy resulted from the unfounded belief that vaccines impacted fertility. In the Netherlands, hesitancy was associated with “a more general hesitance against government and governmental institutions.”

Strategies to successfully increase uptake and acceptance were similarly varied across countries. The Netherlands found that “vaccine ambassadors,” campaigns targeting the young, and vaccinations without an appointment were all effective. Finland took measures aimed at immigrants, including talks at “mosques, in social media, radio and TV in specific language groups.” In addition to these communications and outreach strategies, the report noted that “countries have also introduced incentives to be vaccinated.”

None of these measures may be enough to overcome vaccine hesitancy. The European Union is contemplating compulsory vaccinations, with Austria taking the lead and Germany about to impose a lockdown for the unvaccinated. The issue is now highly politicized. Far-right parties have organized marches in protest. Libertarians are opposed as well, as is the conspiracy-minded far left. Businessman Piers Corbyn leads an anti-vaccine movement in the United Kingdom.

In the United States, the issue of vaccine hesitancy—and mandates as a solution—is, if anything, more politicized. Anecdotally, there are sub-groups of people against vaccines all over the place, from athletes to adherents of alternative medicine. For much of the right, including the center right, vaccine mandates have become a galvanizing issue that can easily bleed into personal vaccine hesitancy. COVID-19 vaccines, rather than uniting the United States in a shared sense of purpose, threaten to fracture the country.


The 2014 Ebola outbreak in West Africa suggests the importance of finding the right message to address hesitancy. U.S. diplomat Deborah Malac, who was the U.S. ambassador to Liberia during the outbreak, said, “there was a great deal of initial skepticism that Ebola was a real threat.” The initial outbreak took place in remote regions. In Liberia, there was deep-seated distrust of the government among some of the population.

“The first obstacle is: How do you communicate there is a public health threat when you have years of distrust?” Malac said. “The early risk messaging was highly scientific and too Western.” It was in English, not tailored to audiences in rural Liberia with low literacy rates, and it didn’t take into account how some of the prohibitions—such as not attending funerals—would be received culturally. The risks Ebola posed soon became obvious when the disease exploded in the densely populated capital city of Monrovia, Liberia.

The U.S. reaction to Ebola was completely different from the way the country responded to COVID-19 in Africa years later. Former U.S. President Barack Obama announced a major U.S. response on the ground, involving 3,000 personnel from the Defense Department, the Centers for Disease Control and Prevention, the U.S. Agency for International Development, and the National Institutes of Health. The U.S. Embassy was charged with, among other things, negotiating with the Liberian government to conduct a phase two clinical trial (designed to test efficacy and safety) of a vaccine. The trial was done with full-informed consent.

“Starting a trial in the midst of an outbreak was a huge gamble,” Malac said. The United States needed to persuade the government and recipients that the vaccine was safe, allowing the trial to launch. “Messaging work was done with local community leaders to get uptake of the vaccine for ring vaccination purposes to stop local pop-up outbreaks,” she added. (Ring vaccination means vaccinating anyone who has come into contact with someone with the disease as well as their contacts.)

“I could speak as the U.S. ambassador, and many people would believe something just because I said it,” Malac said, referring to the United States’ long and close history with Liberia. But others would be skeptical and believe Americans were trying to infect people through the vaccine.

“We worked closely with the government, local health authorities, community leaders, and religious leaders to adapt the message—and also to find the right messenger,” Malac said. The vaccine was never meant to be something that would be given to broad swaths of the population. It was meant only for communities where Ebola was present to keep it from spreading. Liberia was declared Ebola free in May 2015.

It is hard to generalize how African countries are responding to COVID-19 because each country has handled the pandemic differently. Tanzania’s former president was a COVID-19 denier, but the new president takes the disease very seriously. Some countries have tried lockdowns. There are huge differences in resources, culture, history, trust in authorities, and robustness of health systems.

When it comes to addressing vaccine hesitancy in Africa, “we can provide sample messaging and share what worked elsewhere,” Malac said. “But ultimately, local governments and communities understand their own people best and are best-placed to determine who the messenger(s) should be.”


If policymakers are serious about vaccinating the world, either to prevent future mutations or provide boosters targeting the current ones, they will have to broaden their current supply-centric approach to include bolstered vaccine distribution and administration as well as global bio-surveillance. Vaccine hesitancy needs to be taken seriously rather than treated as an afterthought.

“Much of [our] challenges are internal to [South Africa],” Madhi wrote. “However, they are likely to be experienced by many other African countries as well—who have very likely underestimated community acceptance of vaccination, and the logistics required to deploy vaccines at scale, particularly to adults among whom there is not any culture of being vaccinated.”

South Africa shows a way forward. In a nationally televised address on Nov. 28, South African President Cyril Ramaphosa said, “I would like to call on every person who has not been vaccinated to go to their nearest vaccination station without delay.” In addition to demands for lifting international travel bans, he said the “government has set up a task team that will undertake broad consultations on making vaccination mandatory for specific activities and locations.”

Whether it is the messenger, the content—Ramaphosa’s speech contained calls for everyone “to take responsibility for our own health and the health of those around us”—or simply the heightened media attention surrounding omicron’s risks, the message is getting through. South Africans seem less hesitant to get jabbed. Compared to the week before the speech, adult vaccinations have increased by nearly 25 percent.

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