*3.3. Difficulty of Access*

Africa is vast, and all sub-Saharan African countries have poor road and rail infrastructure, making it difficult for people in isolated rural settlements, and in the outskirts of large informal townships, to access medical facilities. Intra-urban bus and train fares may be too expensive for the poorest people to reach central hospitals and clinics (Kumbani op.cit.). Paradoxically, improvements in major roads, such as metaling of larger trunk routes, can lead to increased isolation of the rural poor, as vehicle owners tend to keep their vehicles exclusively for the best roads, leaving far-flung rural settlements with even less transport than before (Porter 2012; Francis and Edmeston 2022). Efforts to get vaccines from medical bases in larger towns and cities out to rural towns and villages may be undone by failures in the cold-chain preservation system (Pabst and Taylor 1988). These factors and others combine to make basic access of goods and services, particularly within the area of health care, a challenge. This, in turn, feeds into a general impression that even if one is receptive to vaccination, one will have to rely on other methods for protecting oneself against the hardships of a pandemic.

#### *3.4. Religious and Politcal Factors*

"Mass vaccination campaigns (may) provoke resistance based less on secular concern than on religious belief: some will always assume that God offers better terms than the Ministry of Health, a credo that turns acquiescence in vaccination into heresy" (Greenough op.cit.). There are, as we have seen, functional reasons for the low rate of vaccination in many African countries, but the principal cognitive reason is deep suspicion of the motives of the vaccinators, a suspicion fed by religious leaders who, in the developed world, are overwhelmingly behind vaccination programs, but in sub-Saharan Africa are generally against them. The result is that most African countries have not one particular reason for VH/R, but rather harbor a combination of factors both functional and cognitive, a mix readily exploited by religious leaders who are hostile to vaccination in principle.

Nigeria, the most populous country in Africa, boycotted the polio vaccination campaign of 2003. According to Jegede (2007), Nigeria had the highest incidence of polio in the world, accounting for 45% of cases worldwide and 80% of African cases in 2003 (ibid.). Local uptake of the polio vaccine had always been poor, so Nigeria would have appeared to be a ripe candidate for the campaign. However, the leaders of the Muslim states of Northern Nigeria were convinced that the Western powers supplying the vaccines were united in a conspiracy against Islam, and had adulterated the vaccines with HIV, anti-fertility drugs and other pathogens. (A similar set of beliefs occurred in Pakistan after it became well known that the United States used the pretext of a vaccination campaign to find and kill Osama bin Laden) (Etokidem et al. 2021; Rezaei 2021). This tied in with a belief that a previous birth-control campaign was being continued covertly, using the polio vaccine as a method of delivery. Suspicion of this was not restricted to the Muslim areas. In a country with skeletal medical provision at best, the sudden appearance of an aggressive polio campaign was viewed with profound suspicion in circumstances where any measures suggestive of birth control went against dominant socio-cultural mores (Sullivan et al. 2019; Orisaremi and Alubo 2012; Kunnuji et al. 2017; OlaOlorun et al. 2014; Oyediran 2006). It has been assumed that the cultural and religious differences between the Muslim north and Christian south account for the poor uptake of vaccine programs in Nigeria (ibid), but this is not necessarily always the case. In 2012 another anti-polio campaign was attempted. This one foundered not upon political-religious divisions, but on the ancient beliefs that either polio did not matter, or that it was sent as a scourge from God (Michael et al. 2014). In the meantime, a strain of Wild Polio Virus (WPV) spread from Nigeria to other sub-Saharan countries, including Sudan and Botswana, which previously were polio-free (Jegede 2007).

Independent laboratory tests appeared to show that tetanus vaccines sent to Kenya in 2014 by the WHO were adulterated with Human Chorionic Gonadotropin (hCG), a contraceptive agent, leading Catholic Bishops to claim that this was part of a covert campaign on the part of the WHO to reduce Kenya's population (Oller et al. 2017). Similar accusations were made against a contemporaneous anti-polio campaign (Njeru et al. 2016). As a result of this belief, albeit one not fully substantiated, vaccine refusal in Kenya rose from 6% in November 2014 to 12% in August 2015 (ibid.; Ghinai et al. 2013).

It is worth noting that Tanzania's policy of COVID-19 vaccine refusal, instituted under the previous president, John Magufuli, has been reversed since the accession in March 2021 of the current incumbent, Salia Suluhu, and that semi-autonomous Zanzibar has also now agreed to accept it (Mwai 2021). Results, though, have been patchy. Skepticism in Tanzania remains high. In September 2021, several months after Suluhu's accession to power, only an estimated 0.5% of the population of 58 million (i.e., about 300,000) had come forward for the vaccine (Makoni 2021). Much VH is due to the "traditional" resistance urged by religious leaders who deny the existence of the virus and urge trust in God to protect against infection (ibid.; Makoye 2021). Tanzania also has low compliance with HPV screening as part of the battle against cervical cancer, mainly because of a lack of confidence in provision for diagnosis and treatment (Urasa and Darj 2011). As Heyerdahl and Pugliese-Garcia note:

Despite universal provision, evidence suggests relatively low vaccination coverage in Zambia' (Babaniyi et al. 2013; Heyerdahl et al. 2019), with the result that, despite there being provision for universal coverage of vaccinations in Zambia since the 1970s, during 2013–2014 there was only a 60% vaccination take-up rate. A systematic study showed that the principal obstacles to full vaccine coverage in Zambia were a belief in traditional remedies, general aversion to injections and distance from medical centres. (ibid.: Heyerdahl et al. 2019)

In Zimbabwe, research has shown that the rise of the Apostolic church movement has had a deleterious effect on vaccination and other modern health practices, due to the emphasis from its religious leaders on relying on Prophet-driven cures obtained via prayer, and the conviction that to seek medical help is to disrespect God and the Bible. Ha and Salama observe that "[a]postolic sect members in Zimbabwe have been associated with higher maternal mortality ... , [as] apostolicism promotes high fertility, early marriage, non-use of contraceptives and low or non-use of hospital care. It causes delays in recognizing danger signs, deciding to seek care, reaching and receiving appropriate health care" (Ha et al. 2014; Dodzo et al. 2016).

A study in South Africa unearthed similar responses to those in Zambia, Tanzania and Zimbabwe, including poor communications, parental resistance, anti-immunization policies and staffing problems, as well as the disinformation propagated by various religious factions (Machingaidze and Wiysonge 2021). DRC has one of the lowest rates of vaccine acceptance of any kind, sharing with Madagascar the world's lowest level of immunization rates for measles in 2019, partly because of the general dislocation caused by a simmering civil war, but mainly because of a distrust of medicines generally, and of vaccines in particular (Alfonso et al. 2019; Global Conflict Tracker 2021). In 2018 DRC declared its tenth outbreak of Ebola virus, but despite the virulence of this disease, and the offer of vaccinations, uptake was very low, due largely to disbelief in either the existence of the virus or of the effectiveness of the vaccine, or of both (Vinck et al. 2019).

In Benin, as Foun and Haddard note:

Despite the efforts of health authorities, vaccination coverage of targeted child populations is still poor in many regions ... The faithful perceive vaccinating children against their parents' will to be a violation of the rights of both children and parents . . . According to them, prayer is the only means of obtaining God's protection against illness ... Church members who disobey instructions and have their children vaccinated provoke their pastor's anger and discontent. One pastor, in explaining this situation, said, 'as soon as I find out this has happened, I punish these followers before the divine wrath comes down on them, because they are disobeying God'. (Fourn et al. 2009)

Resistance to all vaccines in these and other African countries has transferred to a similar disposition towards COVID-19 vaccines. In each of these examples, authority and credibility reside with local leaders. The combination of distrust of global, and often Western efforts, and the failure on the part of global leaders to convey their messages in vocabulary likely to be understood and embraced in local settings, has led to the unnecessary and devastating spread of infectious diseases across the African continent.
