Vaccine hesitancy in Mali
Twelve months after the first COVID-19 vaccines entered global clinical trials, their rapid international rollout is threatened by hesitancy among populations throughout the world.
Data gathered in southern Mali by Critical Care International suggest very few of the population would accept a vaccine if offered today.
COVID-19 emergence and impact
The spread of COVID-19 and its economic, medical and societal impact has differed significantly between countries, largely a result of inherent demographic differences, contrasting political approaches and varied usage of non-pharmaceutical interventions, such as lockdowns and social distancing.
At the end of April, with almost 150 million cases and over 3 million deaths, the tide of the pandemic rests on supplying vaccine doses and getting them into the arms of willing recipients.
COVID-19 vaccine hesitancy
Supply issues are becoming increasingly complicated by geopolitics and threats of vaccine export bans, at least in Europe. In Africa, COVAX offers the best hope of a reliable, albeit very slow, supply to nations not in a position to negotiate individual contracts with providers.
Although countries such as Mali have now received initial shipments, vaccine hesitancy threatens to derail plans of widespread immunisation, with Critical Care International’s doctors in southern Mali observing a wave of hesitancy far beyond that predicted earlier in the pandemic.
A study published in late 2020 by the Africa CDC suggested that vaccine hesitancy in Africa was unlikely to pose a problem to vaccine uptake. The survey, conducted between August and December, in partnership with the London School of Hygiene & Tropical Medicine, concluded that 78% of respondents in Africa would take a COVID-19 vaccine "if deemed safe and effective".
Despite this seemingly reassuring finding, colleagues working in Mali have found high rates of vaccine scepticism amongst mine employees. Our experience does not dispute the above but suggests that, at present, a large majority do not feel that vaccines have reliably been shown to be both safe and effective.
A small confidential survey of thirty employees, distributed via WhatsApp and email has, at the time of writing, shown that while 25% would consider vaccination, none would definitely accept inoculation today.
The survey shows that worries about side effects and a desire to wait for further information underpin the reluctance to be vaccinated. Unfortunately, efforts to gather further responses were hampered by widespread unwillingness to participate and suspicion about why such questions were being asked.
Critical Care International research
Critical Care International is a healthcare provider specialising in medical staffing, consulting and advisory services for organisations working in remote, austere or high-risk environments.
The author spent three years working in West Africa with CCI and maintains close links with national and expatriate healthcare workers in the country. Throughout the pandemic CCI has worked closely with clients worldwide, to ensure their operations and onsite healthcare services are aligned with international best practice and optimised to prevent, identify and treat COVID-19 cases.
Over the past months, this has increasingly involved planning for upcoming vaccine rollouts and we are finding hesitancy is likely to pose significant difficulties. In Mali, at the time of writing, vaccination is open to anyone.
For organisations such as mining companies with a large rotational workforce, widespread vaccination offers a chance to relax current quarantine and social distancing procedures and usher in a post-pandemic return to normality. Despite this, conversations among workers have revealed a variety of concerns underpinned by some key themes.
First is a feeling that it is premature to conclude the vaccine is safe. Mali’s COVID-19 vaccination campaign started on 31 March with almost 50,000 vaccinated by the end of April, according to social media from the Ministère de la Santé et du Développement Social, the government’s health department.
Alongside updates, the department also provides education and reassurances that the AstraZeneca vaccine is safe and effective. It should be noted that post vaccination follow-up is thorough with patients receiving regular phone calls to enquire about side effects.
Despite this, responses to such social media updates are negative and focus on it being too soon for the government to make comments regarding safety. In the absence of further evidence such an opinion is entirely valid, however these thousands of Malian patients sit upon the millions vaccinated during clinical trials and around the world.
Where does this disconnect come from?
Early in the pandemic, as we began delivering education sessions within our clinics and to wider groups of workers, we were confronted with a strongly held opinion among many Malians that COVID-19 would not affect them. It was seen as a virus affecting Asians and Europeans, but not Africans.
Elsewhere in Africa, this seemed to stem from government-led misinformation. In Tanzania, for example, the late president John Magufuli declared the country COVID-free last June after three days of national prayers.
While such opinions have evolved with the global spread of COVID-19, there is still a lack of exposure to the virus among many. The country has escaped the scenes observed in Europe, most lives have been unchanged and cases have been low.
This is compounded by the ever present risk from diseases such as malaria which kills over 400,000 people each year, most of whom live in sub-Saharan Africa. A Malian healthcare worker explained his reasoning when we spoke about his decision not to get vaccinated:
“I do not know anyone who has died from COVID here....the symptoms are only (those) of the common cold, feeling tired or sore throat.”
Furthermore, according to some we have spoken to, the perceived lack of interest from global actors in combatting malaria over past decades, combined with enthusiasm from Western governments to now supply vaccines designed and made outside of Africa has stoked suspicion.
When considering vaccine education campaigns in sub-Saharan African governments, regional health authorities and private organisations are, therefore, not going to be able to replicate strategies employed by their European and American counterparts.
Public engagement must focus on the particular concerns of the population explored within the specific cultural circumstances in which they exist. Distribution of correct, up to date and culturally sensitive information, however, poses its own challenges.
Untruths and conspiracies
The past decades have seen Sub-Saharan Africa bypass investment in certain infrastructure and instead adopt more modern technologies; mobile phones over landlines, solar panels over national electricity grids, and social media over traditional print journalism.
The latter of these mean many individuals now rely heavily on social media for their news and information, without parallel consumption of other forms of press.
Untruths and conspiracies can therefore run rampant and unchecked, as they do elsewhere in the world. Focus groups onsite confirm this; most individuals, including some healthcare workers, report they are getting most of their information from peers and not from reputable national or international medical sources.
A corollary to this, among some of the population, is the consumption of French media and its associated widespread negative coverage of recent concerns regarding blood clots.
Considering the significant vaccine scepticism in France – a December survey, conducted in partnership with the World Economic Forum, found it to have the lowest rates of vaccine acceptance, at 40%, among the 15 countries included – this importation of French media is likely to have had a knock-on effect in Mali.
Deep scepticism and negative coverage
Focus group discussions have highlighted the extent of scepticism, at present the depth of hesitancy is far worse than predicted or otherwise expected. Although this is concerning, our survey responses and conversations do suggest that in time a large proportion of Malians would accept vaccines when they feel their safety has been proven.
Concerns appear to stem not from the idea of vaccination but from the timeline currently perceived in Mali. In the UK the population feel intimately involved with the development of the Oxford-AstraZeneca vaccine, a year ago we heard it was entering trials and since then we’ve enjoyed regular updates.
By the time many of us were offered it we’d heard and debated nine months' worth of news, both positive and negative, and understood each step in its development. However in Mali commencement of the national vaccination programme coincided with the initial announcement of cases of unusual and fatal thromboses.
Negative coverage surrounding the AstraZeneca vaccine and an association with fatal blood clots seeded much of the original hesitancy in the country, with recent decisions in Europe to suspend jabs for younger adults fuelling the current wave.
Appreciation and concern regarding this newly discovered risk is entirely logical and West Africans feel currently that if Europe deems the risk too great then why should they be expected to bear it.
Although the numbers of lives lost from thrombotic events are exceedingly small, when considered in a country where the risk from COVID-19 is perceived to be very low, the knock-on effect is significant.
A long path to walk
Our findings suggest there is a long path to walk before widespread vaccination is possible. Although insights from mine workers may not be generalisable, they do provide a stark warning regarding the depth of vaccine hesitancy in parts of sub-Saharan Africa.
The presence of concerns and questions is understandable and expected in any population, however it would seem there remains an unmet educational need so individuals can make decisions with up-to-date information from reliable sources.
CCI education campaigns have focused on addressing the risk and benefits of vaccination from two perspectives. First, on a personal level by putting the risk into perspective – COVID-19 itself causes far higher rates of thrombotic disease, for example, than vaccination – and, secondly, on a societal level by appreciating that the benefits of vaccination extend beyond the individual, to our grandparents, colleagues and to individuals we will never meet, through the collective effects of herd immunity.
Tackling vaccine hesitancy in the long term requires us to think beyond our current COVID tunnel vision; considering structural, cultural and societal causes and exploring novel solutions. Greater investment in vaccines for other communicable diseases is crucial and although there was good news recently, regarding the R21 malaria vaccine, far more resources will needed to scale up subsequent trials and potential production.
Beyond this, future sustainability depends upon the expansion of scientific and pharmaceutical infrastructure across the continent to allow the development, testing, production and distribution of vaccines designed and made in Africa by African scientists.
Implementing these, and other strategies doesn’t offer a quick and easy solution. While the challenge may be great, the resulting success offers not only individual countries but whole continents the chance to move towards a post-pandemic future.