Epidemics in South Africa: Key lessons on mass vaccination drives learnt from history

First published in the Daily Maverick 168 weekly newspaper.

Medical historian Professor Howard Phillips, the author of Plague, Pox and Pandemics: A Jacana Pocket History of Epidemics in South Africa, has no hesitation when he is asked which mass health project in SA history comes closest to the current Covid-19 vaccination drive.

“Polio vaccination administered by injection or oral means, which immunised nearly 1 million children between 1955 and circa 1961,” Phillips says. “Until Covid-19, this was the largest concentrated mass vaccination in South Africa.”

One major difference, however: it was almost all white children who received the polio jab. This was not solely due to institutional racism; Phillips explains that black children “were not as vulnerable to polio”, and thus not targeted.

In the 19th century, the first vaccination drives against smallpox took place, especially in the Cape, but these were not extensive projects and ultimately not very successful at eradicating the disease.

The latest available surveys show vaccine hesitancy is still likely to be a stumbling block for the Covid-19 vaccination drive. This is no surprise to Phillips, who told DM168 that vaccine scepticism has “deep roots” in SA.

“It should be remembered that vaccination by injection was devised only at the very end of the 18th century, which meant that for many decades it was quite novel and so open to popular doubt,” the historian said.

“From the start of vaccination in South Africa, Muslims avoided it on both political and religious grounds, while many Africans saw it as part of a government plan to kill them. It was only in the 20th century that it gained wider acceptance...”

For SA’s veteran Aids activists, the current Covid-19 vaccination drive evokes memories of the first roll-out of antiretroviral treatment (ART) in the mid-2000s.

“Our biggest challenge was that many people had received confusing messages about the safety of ART,” says Dr Vuyiseka Dubula-Majola, who served as the general secretary of the Treatment Action Campaign (TAC) for six years. She says that the public confusion was fuelled by the government’s own health authorities at the time – and the stance of denialism that characterised the administration of President Thabo Mbeki.

Dubula-Majola believes that the South African HIV programme has many lessons for the Covid-19 vaccination drive.

“It taught us that we need to be innovative and take the vaccines to people, and not rely on centralised ... sites. Why are we not using churches, community halls, old-age homes and schools as vaccination sites?” she asks.

Dubula-Majola maintains that a health drive of this size should not rely solely on nurses to administer the injections. She suggests another lesson from the antiretroviral roll-outs: that lay persons can be taught to perform the tasks of health workers.

Dubula-Majola says a critical aspect of the HIV treatment programme was the mass education campaign run by groups like the TAC, which created the demand for treatment from the affected communities. She proposes that something similar is necessary when it comes to Covid-19 vaccination.

The veteran activist also believes that the registration process is “cumbersome” and out of touch with grassroots realities.

“Not everyone has access to the internet or a smartphone to register,” she says, advocating instead for a system where anyone can walk into a site and get vaccinated.

“I know the argument will be about availability of doses if we allow walk-ins,” Dubula-Majola says. But in her view, a shortage of doses – rather than “sitting with doses and no people for the jabs” – sounds like a good problem to have.

For Phillips, the key lesson from history is about trust.

“The bottom line is that underlying trust in doctors, the pharmaceutical sector and government – in particular – is essential if vaccination is to be rolled out widely. Doubts about their bona fides on any grounds ... will invariably give rise to anti-vaccination sentiments if vaccination is pushed,” the historian says. DM168

This story first appeared in our weekly Daily Maverick 168 newspaper which is available for free to Pick n Pay Smart Shoppers at these Pick n Pay stores.