**5. Conclusions**

In the ancient Polish folk tale of the Glass Mountain, a beautiful young princess is trapped by a sorcerer in a glass mountain. A young man tries to scale the mountain in order to release the princess and win her love. But the glass is slippery, and for every step up he takes, he slides back down two. So, cleverly, he turns about and climbs it backwards, gaining double elevation with each upward-downward step, until he reaches the princess and releases her (Duggan and Haase 2016).

In an article on polio campaigns in the developing world, Closser (2010) makes the important but counter-intuitive observation that vaccination campaigns were more likely to be successful if they were done less, because such campaigns were regarded as aggressive interventions by a state and funded by companies (and foreign governments) which might not have the best interests of their people at heart. They were also a reminder of how the state, and the wealthy providers of such campaigns, would rather spend money on such alien intrusions than on health centers and clinics that could address all the other issues faced every day by poor people with scarce to no access to medical assistance. As we have seen, one of the most commonly mentioned complaints about vaccination programs is "if they can be financed, why can't health centers which are designed to address basic, day to day needs also be financed"? Populations in the developing world deal with typhus, measles and polio, and no end of other infectious diseases that are not part of the medical scourges that routinely afflict the developed world. Without a fundamental reallocation of

finances and resources, any future vaccination projects, however well intentioned, may be doomed to failure because they may be seen to be in bad (budgetary) faith.

In any case, no progress will be made on the matter until those most obdurate in their resistance are brought around to the view that, maybe, vaccinations are beneficial after all. Maybe the money spent on specialist vaccination programs would be better spent on building local clinics. Such a reallocation of resources could obviate the necessity for specialized "campaigns" against measles, polio, Ebola and COVID-19 because all those things—approved by elders, religious leaders and other respected members of the community, and thereby approved by the community—could be dealt with, routinely, by the local clinic and its doctors and nurses, all of whom would be known and trusted as part of the local community. This noted, some practical recommendations might be proffered for the sake of implementing better messaging:


In case it might be thought that such recommendations are unachievable, Rwanda proves that they are not. In 2015, it had a 98% vaccination rate for its children (Bao et al. 2018). Rwanda is no richer than many African countries (in 2020, its GDP was 10.33 bn USD, against Malawi's 11.96 and Mozambique's 14.02) (World Bank 2020), but it shows that functioning health care systems are possible. There are several reasons for this. First, as Bao and colleagues points out, at the local level, health workers sensitize communities "on the importance of vaccinations and . . . health surveillance duties". Second,

an integrated health management information system guides vaccination procurement and distribution to support vaccine delivery at the local level. Third, at the governmental level, the vaccination programme is driven by strong political will to prioritise health. Fourth implementation is sufficiently decentralized to the district and village level to tailor appropriate approaches for the local population ... Finally, the Rwandan health system benefits from strong relationships with development partners and cross-over effects from global health initiatives, particularly in developing capacity for supply chain and cold chain management. The success of this approach is a result of utilizing the ancient Rwandan philosophy of Imihigo, which is very closely-related to Ubuntu in its outlook and practice. (Bao et al. op.cit.)

If Rwanda can do it, surely other African countries can follow suit.

We have seen that, in many instances, the religious establishments of any given country may be supportive of government initiatives to control the spread of diseases such as COVID-19. However, this is usually in societies where the interests of government and

religious establishment cohere in their intentions towards their citizenry, and where the citizenry are generally well disposed towards both government and religious establishments. In other words, it most easily takes place in countries where there is a broad consensus (usually based upon high levels of education and embedded prosperity across the broad elements of society) between rulers and the ruled. Thus, in Britain, the Scandinavian countries and much of Europe, the role of the church echoes the aims and beliefs of the governments concerned. However, such consensus-based activity is largely passive. In such societies, religious leaders often do not so much express an opinion, much less get in the government's way. In other countries, where there is no such consensus, such as many of the countries of Africa and parts of highly federated polities such as India, and even the United States, religion can act as a negative force, disrupting efforts to control and cure diseases and ignoring or debunking scientific reason and verified fact.

In such cases, authorities intent on vaccinating the population must do one of two things to gain any measure of success. They must either suppress religious organizations and activists, or they must win them over. Given the realities of power-structures and the nature of societies in countries where religion acts as an intransigent barrier to vaccinations, suppression is neither practicable nor desirable. Highly conformist societies, with rigid power structures and social hierarchies, such as China and Japan, have also had to deal with a history of vaccine refusal, and they have not yet managed, for all their power, to suppress dissent. This leaves persuasion. The example of Rwanda shows that a properly organized, community-based structure can overcome refractory religious opposition to vaccines by incorporating them into a society where people find themselves involved in community decisions about such matters, where their voices and views are heard, and where the good sense of creating and financially supporting vaccine programs can finally be made acceptable. Until recognition is given to the observed fact that negative religious sentiments are reinforced by the perceived history of interference on the part of the developed world in the welfare of Africans, nothing is going to change.

Currently, many vaccination outreach initiatives to Africa find themselves similar to the questing lover on the Glass Mountain. Perhaps the order of things should be changed. The man in the legend reversed his approach and doubled his rate of progress. Maybe the medical establishment of the West, and the governments through which they craft their message and make their pitch in Africa, should do the same.

**Author Contributions:** Methodology, J.E.H.; Formal analysis, K.M.; Data curation, T.D. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Conflicts of Interest:** The authors declare no conflict of interest.
