Kate Alexander | Vaccine mandates are not a panacea

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Vaccine sites in areas with bigger populations in Johannesburg are smaller than in more affluent area, writes the author, which could play a role in way people aren't vaccinating.
Vaccine sites in areas with bigger populations in Johannesburg are smaller than in more affluent area, writes the author, which could play a role in way people aren't vaccinating.
Gallo Images/Papi Morake

Kate Alexander writes that mandatory vaccination, while important, is not a solution to the Covid-19 pandemic, and says we need to consider other measures that must be taken.

Echoing the general line of big business, the Sunday Times demanded: "Enforce jabs, not lockdown..

Superficially, this is an attractive proposition that could protect jobs and mental wellbeing, as well as lives. However, closer scrutiny shows while mandatory vaccination can assist in reducing the risk of infection, at least in certain environments, it is not a panacea, and over-simplification could be dangerous.

The principal problem we face is a generally low level of vaccination.

About 43% of the world's population, children as well as adults, is now fully vaccinated. The figure for South Africa is only 24%. The contrast cannot be explained by the country's poverty.

Some countries with a lower GDP/capita have a higher rate of vaccination. These include, for example, Vietnam and India, with, respectively, about 51 and 32% of their populations fully vaccinated. The figure for upper middle-income countries, which includes South Africa, is 65%.

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Vaccination reduces the chance of infection, especially serious infection, decreases transmission and limits the creation of new variants. The level also affects whether mandatory vaccination will be acceptable, not only in a formal sense, but also whether there is sufficient consensus to dismiss workers, exclude students and bar people from food shops.

So why is the level of vaccination so low?

Even among adults, we have only reached 36% fully vaccinated and 42% partially vaccinated. Widespread hesitancy, linked with social media, are easy answers for politicians. They are part of the problem, but not the main part. They do not explain why vaccination rates are so much higher elsewhere. Moreover, the fourth round of the UJ/HSRC Covid Democracy survey showed groups that were least accepting of vaccination, including whites and people with medical aid, were also most likely to be vaccinated. 


The chief problem has been lack of access - things like time and cost required to get vaccinated, and sometimes simply not knowing where to go. Car ownership makes matters much easier.

In an experiment and a pilot project, our University of Johannesburg research (undertaken with activists from Protea South informal settlement in Johannesburg) showed if free transport was provided or a site was conveniently located, people known and trusted in their community had considerable success with mobilising vaccines.

Moreover, the cost was minimal, R10 to R20 per head, compared with the current R100 incentive. 

One example helps to illustrate the problem of class and inequality.

It comes from Johannesburg, the health district with the most significant number of unvaccinated people. As of 28 November, there were 256 sites. Of the city's seven regions, the one that includes Rosebank and Randburg, Region B, has the least poverty and smallest population but the most sites (58); and the ones covering Soweto (D) and Orange Farm (G) have the most poverty and high population (D is highest and G comes fourth), but the fewest sites (respectively 22 and 20). 

If other regions were disaggregated between their wealthy and poor parts (e.g. Sandton and Alexandra), the pattern would likely be replicated because there are more private than public sites (197 versus 59) and the private ones tend to be in better-off areas. Residents of informal settlements usually suffer the most, with sites, private or public, nearby.

To be fair, the Gauteng Department of Health and City of Johannesburg try to address the disparity using pop-up sites, but there are not enough of these, and they are often poorly organised, so inequality remains, and Johannesburg vaccinates far fewer people than it could. 

Multitude of authorities 

One of the underlying problems is the multitude of different authorities responsible for health and the rollout. There is the national Department of Health, which has a minister (who reports to the president and is represented on a plethora of committees).

The department is responsible for purchasing and distributing vaccines, registration of vaccination and general rollout policy. Then, there is the distinction between the private and public sector. The former includes numerous companies and wields considerable influence. The latter consists of the nine provinces, but also health departments located in metros and other districts.

The organogram is complex, but the practice is even more so - overlapping responsibilities, different political interests, corruption, varied quality of management/staff relationships, and local traditions.  

READ | Adriaan Basson: The case for mandatory Covid-19 vaccinations in SA

There are now substantial differences in the rate of vaccination by province.

While the Free State, Limpopo and Western Cape have fully vaccinated more than 42% of their adult populations, KwaZulu-Natal, Mpumalanga and Gauteng all score less than 32%.

The variation is yet to be explained, at least publicly, but suggests differences in commitment and capacity, all of which are complicated and partly explained by the convoluted structure of governance and diverse practice. Moreover, the role and variation of civil society players and their different relationships with health providers also have an impact.

As of 21 September, the most recent date for which I have a full set of figures, 50% of the insured population had received a vaccination compared with only 25% of the uninsured.

In the Western Cape, 68% of the insured were vaccinated, and if a similar number had been reached in every province, and for the uninsured as well as the insured, we would be approaching a situation where four in five people have now been vaccinated. 

No impact on fourth wave 

Vaccine mandates may increase the level of vaccination a bit, but not enough to have a significant impact on the Omicron-driven fourth wave. 

Workers need to be consulted and given notice about mandatory vaccination in their workplace, which can take several months.

Larger employers and universities with gated campuses can link evidence of vaccination to their own HR and access systems, but substantial problems will arise elsewhere. Certificates, whether on paper or on smartphones can be copied, borrowed or stolen. This means they will have to be used alongside a photo ID. In certain settings, this might work well, giving added protection to staff and customers (in some restaurants for example). However, it is naïve to believe it will work for busy taxis fearful of losing customers.

READ | Mandy Wiener: No time to waste in introducing vaccine mandates unless we want to repeat cycle again

Furthermore, there are constraints on the numbers of who can be vaccinated under the present regime. In the most recent full week (which ended on 28 November 2021), 550 525 vaccines were administered, a decline from the best west week, 24 October, when 975 042 vaccines were administered.

The latter figure was associated with a Vooma Vaccination weekend when additional sites were open for the weekend, extra volunteers were deployed, and politicians attracted publicity. The national health department would be doing well to get a million people vaccinated a week.

So far, we have had 14.4 million adults fully vaccinated. To take us from this figure, 36%, the target figure of 80% would require about another 44% to be vaccinated.

Assuming the current balance between Pfizer and J&J and one million vaccinations a week, a hard ask, this would involve about 66 million vaccines and take about 10 weeks.

In reality, this is over-optimistic because 12 to 17 year olds are being vaccinated, everybody vaccinated so far and in the near future will require a booster shot, and the Christmas slowdown is fast approaching. Perhaps a figure of 10 months or a year for 80% adult vaccination is plausible. Even this figure requires extra expenditure for nurses' overtime, more mobile units, etc.

The point is that while vaccine mandates can make some difference in addressing the overall problem, it will fall far short of solving it, a task that will not be accomplished until after the fourth wave has ended.

Mild symptoms 

In all likelihood, the people who do get themselves fully vaccinated will be better off, as in the past, rather than the poor and those without IDs.

Given the present level of gatvol among working-class people - related to services, prices, unemployment, welfare payments, and failure of the government reflected in only 30% of the adult population voting - some mandates as well as some features of a lockdown will create greater anger and unrest.

On top of these problems, mandates do not halt the problem of Omicron infecting people who are already fully vaccinated. So far, in these cases, the symptoms appear to have been mild, but those who are infected can pass the disease to those who are not (74% of adults and most of the 20 million minors), so widespread serious infection will likely affect us soon. Mandates will not halt this.

READ | Howard Feldman: Omicron is so last season. Why not 'Bliksem' or 'Gatvol' as new variant's name?

What's the conclusion?

We must go back to enforcing mask-wearing, social distancing and sanitising in all public places. There needs to be strict limits on the size of indoor meetings - more like 20. Good ventilation is essential and larger outdoor gatherings are acceptable. While purchase of alcohol is permissible, curfews should have earlier hours. Bans on transport are worthless, but taxis should be required to run at half capacity and with ventilation. All of this needs to be policed, and masks can be given free to those who need them. 

However, vaccination remains important. It will lower the risk of transmission and reduce the severity of infection. Incentives might assist, but they are relatively expensive. The critical shift we require is towards community mobilisation, where activists can tackle hesitancy arguments and persuade people to be vaccinated at an accessible site. This will require local officials to be respectful of experienced community activists.

More funding needed 

Expanding vaccination, including improved salaries and vaccination drives, requires more funds from the government, and to some extent big business. These are resources that will save lives, reduce unemployment and allow South Africa to restart normal economic activity in the shortest time. 

Mandatory vaccination should not be rejected but it is not a solution to the pandemic, and we all need to consider other measures that must be taken.

- Kate Alexander is professor of sociology and South African research chair in social change at the University of Johannesburg. She is engaged in qualitative and quantitative research around Covid-19 and is active in vaccine rollout campaigns. She acknowledges research assistance from Londiwe Sithole and Bongani Kezei. 

Disclaimer: News24 encourages freedom of speech and the expression of diverse views. The views of columnists published on News24 are therefore their own and do not necessarily represent the views of New24.

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