Integrating civil liberty and the ethical principle of autonomy in building public confidence to reduce COVID-19 vaccination inequity in Africa

ABSTRACT

Concerns regarding the safety of COVID-19 vaccination have caused hesitancy and lowered uptake globally. While vaccine hesitancy is documented globally, some continents, countries, ethnic groups and age groups are disproportionately affected, resulting in significant global inequities. To date, Africa has the lowest COVID-19 coverage globally, with only 22% of its population completely vaccinated. It might be argued that the difficulty with COVID-19 vaccine acceptance in Africa was triggered by the anxiety created by misinformation on social media platforms, particularly with the misinformation regarding depopulating Africa, given the significance of maternity in the continent. In this work, we examine numerous determinants of poor vaccination coverage that have received little attention in primary research and that may need to be considered by various stakeholders engaged in the COVID-19 vaccine strategy at the national and continental levels. Our study also emphasizes the importance of a multidisciplinary team when introducing a new vaccine, for people to trust that the vaccine is truly helpful to them and to be convinced that immunization is, all things considered, worthwhile.

KEYWORDS:

• Pandemic
• global equity
• South Africa
• human rights
• ethics
• immunization
• SARS-CoV-2
• autonomy

Introduction

The spread of the COVID-19 virus has determined what is now represented as the biggest worldwide crisis since World War II.¹ The current situation may be experienced as extremely threatening. The threat is felt at different and interrelated levels: individual concerns – e.g., the fear of losing friends or relatives, of being alone, of not “making it” economically – intertwine themselves with the generalized sense of being projected into a global scenario of uncertainty, where nothing will ever be as before. This situation poses a hard challenge to clinicians, healthcare institutions, and policymakers because it merges different conditions that probably are active together for the first time. On the one hand, millions of people’s psycho-physical health is at risk and therefore interventions aimed at protecting and restoring individual well-being are a strategic priority. On the other hand, people are also unintentional drivers of the pandemic and because of this, they have to be seen as the target of social and economic measures aimed at neutralizing their potential contribution to the spreading of the virus. This has to be done together with policies enabling the whole system to contain the impact of both COVID-19 and interventions to counteract it.¹

Vaccines have long played a crucial role in the prevention, mitigation, and eradication of infectious diseases.² The COVID-19 pandemic has brought the phenomenon of the vaccine race to the forefront of personal, national, and global preoccupations.³ The COVID-19 pandemic has illustrated the need for the swift development of new vaccines targeting emerging pathogens causing outbreaks of infectious diseases.³ Vaccines are the most effective and cost-effective prevention tools we have. Vaccinations have reduced disease, disability, and death from a variety of infectious diseases.³ Vaccines not only provide individual protection for those persons who are vaccinated, but they also provide community protection reducing the spread of disease within a population.² Furthermore, that this chain of human – to–human transmission can be interrupted, even if there is not 100% immunity, because transmitting cases do not have infinite contacts.²

The rationale of the study

In human struggles against major infectious diseases such as smallpox, rabies, typhoid, plague, and many more, vaccines have played critical roles in reducing disease-specific mortality rates.⁴ The same holds true for COVID-19. However, according to the World Health Organization (WHO) despite the fear of contracting COVID-19 among people, there is still a high level of hesitancy toward a COVID-19 vaccine.⁵ Vaccine hesitancy, or the motivational state of being conflicted about (or opposed to) getting vaccinated, poses a threat to achieving the number of vaccinated individuals necessary to achieve community protection or to limit SARS-CoV-2 potential of producing new variants of concern.⁶ It is therefore important to understand the dynamic drivers of vaccine hesitancy to improve vaccine uptake and equity in Africa where COVID-19 vaccine coverage is so far the lowest worldwide⁷ (Figure 1). It is yet unclear how public protests about liberty and autonomy have affected vaccine uptake. Indeed, since the discovery of the first COVID-19 vaccine, several anti-vax movements have used public demonstrations in the name of civil liberty to oppose the safety and effectiveness of vaccines in general and to halt any effort relating to vaccine mandates by governments or employees in particular.⁹ In this commentary, we reviewed the literature and focused on case studies of South Africa, the most affected country by COVID-19 in Africa in terms of reported deaths as well as the country with the highest number of vaccines on the continent, to understand the impact of discussions about civil liberty and the ethical principle of autonomy on shaping vaccine hesitancy, vaccine uptake, and how immunization programs can use tailored communication to build confidence on COVID-19 vaccines.

Figure 1. Global COVID-19 vaccine uptake as of 15 January 2023. Variable time span December 13, 2020 – January 15, 2023⁸.

Methodology

This study was based on a review of previously published papers and of case-studies¹⁰ collected through searching national and international databases such as PubMed, Google Scholar, and Jstor, from inception to October 2022. We focused on case studies from South Africa where most of the COVID-19 cases and deaths in Africa have been reported. We used Boolean operators to enhance research terms using the following concepts: pandemic, global equity, South Africa, human rights/Bill of Rights, ethics, immunization, vaccine, hesitancy/uptake, COVID-19, SARS-CoV-2, autonomy, Behavioral and Social Drivers (BeSD). This study presents the summary of the reading together with a critical analysis of the phenomenon under study.

Findings and discussion

Vaccine hesitancy and vaccine uptake in South Africa

In a recent population-based study (n = 1193), conducted in June -July 2021, using the WHO Behavioral and Social Drivers (BeSD) framework adapted for COVID-19 vaccination,¹¹ we reported that 32% of participants were hesitant to receive COVID-19 vaccines. During the study period, participants belonged to minority groups (Colored: 49%), unemployed (58%), and between the ages of 18–34 (56%).¹¹ Further, participants who showed distrust in the government and those who believed in conspiracy theories were all three times more likely of being vaccine hesitant. One of the contributing factors to a lack of trust stems from the findings of South African investigators who flagged COVID-19 contracts for possible corruption and fraud.¹² Similar findings from a study conducted by our group in February 2020 - March 2021 indicated that a growing number of persons have become hesitant about vaccines, fearing side effects and not appreciative of the enormous health and economic benefits that vaccines provide.¹³ Unfortunately, the fast-tracking of the clinical development of vaccine candidates for COVID-19 has added another reason for vaccine hesitancy, even among those who might otherwise be very confident in vaccine safety and efficacy such as healthcare workers as shown by another study conducted by our group in March – May 2021.¹⁴ Even whilst vaccines were still in developmental stages, the fear of potential side effects was noted as the fundamental reason for the lack of intent to get vaccinated, purporting that risk perception is a key barrier to COVID-19 vaccine uptake.¹²

Civil liberties and vaccine uptake

Vaccine hesitancy has existed ever since the physician Edward Jenner invented the first vaccine in the year 1796. During 1902 an outbreak of smallpox occurred in the United States.¹⁵ In the case of (Jacobson v. Massachusetts, 1905), the US court ruled “If a person should deem it important that vaccination should not be performed, and the authorities should think otherwise, it is not in their power to vaccinate by force, and the worst that could happen under the statute would be the payment of $5 .¹⁶ ” In South Africa, Chapter 2 of the Bill of Rights, section 12 refers to the freedom and security of a person, specifically section 12(2) states everyone has the right to bodily and psychological integrity which includes the right to section (12) (2) (b) security in and control over their body.¹⁷ These rights imply that every person has the right to decide on medical interventions, including the rejection or acceptance of the COVID-19 vaccine. Section 36 refers to the limitation of rights, purporting that rights in the BOR may be limited to the extent that the limitation is reasonable and justifiable in an open and democratic society based on human dignity, equality, and freedom, taking into account all relevant factors, including – The nature of the right, the importance of the purpose of the limitation, the nature and extent of the limitation, the relation between the limitation and its purpose, and less restrictive means to achieve the purpose.¹⁷ During the COVID-19 era is the case of (Khosa and Others v Minister of Defense and Military Defense and Military Veterans and Others, 2020) ¹⁸ the South African High Court ruled that in instances where such rights do infringe, “least restrictive measures must be sought .¹⁸ ” Implying that the least restrictive and intrusive means must be implemented before a right is limited.¹⁹ Consequently, some retail outlets are offering incentives for vaccination as a means of a less restrictive strategy than mandatory vaccination.¹⁹ Prior studies have indeed illustrated the effectiveness of incentives in increasing vaccine uptake.²⁰

The ethical principle of autonomy and infection prevention control

Vaccination raises ethical dilemmas between the autonomy of an individual who has the right to make decisions about their own body which includes the refusal or the acceptance of medical interventions, and the crucial need to protect public health.²¹ An individual’s freedom is limited and not absolute in instances of crisis such as a pandemic because the individual’s choice to not vaccinate results in that person being a potential vector in spreading the COVID-19 virus which has potential life-threatening harm to the broader population, especially for those at increased risk of presenting severe outcomes.²¹ As stated by WHO ethical considerations policy document, limitations on individual freedoms must be justified by the public health goal of the population for which the limitation is intended.²² This tension has certainly been accentuated by the COVID-19 pandemic and the public measures to contain it.²¹ In the case of (Minister of Health of the Province of the Western Cape v Goliath and Others, 2008) .²³ The South African High Court ruled that people with highly infectious resistant tuberculosis would be kept in isolation. This implies that in the interest to protect public health, the right to bodily autonomy is outweighed by public interests.²⁴

Building public trust and confidence

When compared to the pre-pandemic era, vaccination mis-opportunity has significantly increased globally, particularly in the WHO region of Africa.²⁵ The COVID-19 pandemic has hampered planned vaccination campaigns. Since January 2020, nearly 16 million African children have missed measles vaccine doses in 15 African countries.⁵ Vaccine hesitancy to non-COVID-19 vaccines may increase because of COVID-19 vaccine national or global politics – whether real or perceived. People who are otherwise minimally vaccine-hesitant may experience a drop in confidence in the COVID-19 vaccine due to concerns that, in expediting the testing and production of the vaccine to stem the pandemic, scientists’ pharmaceutical companies, and regulatory bodies may be cutting corners in a dangerous way.²⁶ Public health authorities must direct energy and funding to build public trust and confidence that will minimize the fear of vaccine associated hesitancy. One natural way to combat mistrust in motives is transparency.²⁶ Meaningful transparency entails not only making clear how clinical trials were conducted, but also how data sharing aided in speeding up the process, what adverse effects following immunization might be expected (solicited), how people experiencing adverse events following immunization (AEFI) can report them on time, and how post-marketing data are processed.²⁶ Furthermore, while government officials are at the forefront, global and national surveys suggest that healthcare workers and community leaders, for example, are more trusted by the people than public officials.²⁶ As a result, while executing the pillar relevant to an effective communication strategy,²⁷ immunization programmes may consider including the former in the process of creating public trust.²⁸ This pillar should be people-centered,²⁷ with a focus on improving public health literacy through multidisciplinary teams addressing vaccination safety and effectiveness, which are important drivers of vaccine reluctance in relation to civil liberty and the principle of autonomy at the community level.²⁷

Conclusion

Even though people can bear witness through their life and media experiences, the devastating effects of COVID-19, vaccine hesitancy remains high among the general population. Consequently, there is a pervasive opinion that COVID-19 is no longer a plight in South Africa and there are low levels of vaccination currently making the hesitancy theory relevant. To successfully immunize against SARS-CoV-2, a comprehensive national development plan for public education about vaccine safety and efficacy will be required. As a result, human rights activists, ethicists, politicians, and healthcare workers must collaborate to ensure a high level of coverage among populations for whom vaccines are recommended, as well as to build resilient immunization programmes in the face of emerging public health emergencies of international concern, such as the Mpox (monkeypox) virus.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.