**3. Factors in African Vaccine Resistance**

While, as we have seen, the nature of VH and VR in Sub-Saharan Africa is fueled by a legitimate impulse to resist the continuing threat of colonialism, whether that threat is real or merely feared, this impulse is motivated by discreet and important components. First, there lingers a suspicion of all medical protocols, of which a vaccination program is one example. This is a direct consequence of activity on the part of Western, and often white, actors in the post-Colonial era whose own interests continue to govern their decision making. Second, resistance to vaccination programs derives from a suspicion which extends beyond policy making in general to medical facilities and personnel themselves, leading to a distrust of the places and people who would facilitate a vaccine program. Third, and quite understandably, access to medical care, including vaccines, is always more challenging in the developing world than elsewhere. Less exposure to something also leads to less comfort with it. Fourth, there are religious and political misgivings insiders harbor which often manifest as conspiracy theories about Western motivations for intervention. Finally, there are larger questions about worldview: in places in the world which are not so science centric, we should at least ask, is a vaccination program the best way to address a pandemic, or is something else? Because vaccines work, does this mean they ought to be the go-to weapon against the pandemic? It behooves us now to take a look at all of these factors in a little more detail.

## *3.1. Suspicion of Post-Imperial White Activity (Part One)*

It is certainly true that while many motives for VR across Africa are based upon nothing more than unfounded suspicion, there is no shortage of documented episodes of abuse on the part of white, Western actors coming to Africa in the post-Colonial era whose interests do not align with those of African peoples. Such abuses consist both of flagrant violations of the principles of ethical research, and, more specifically, of a failure to respect the African subjects employed for research projects. Conspicuous and well publicized examples of this have occurred from the second half of the twentieth century on. In 1954, the French drug Lomidine, a treatment for sleeping sickness which had not been properly tested by either its manufacturer or the medical establishment, was responsible for the deaths of at least 32 inhabitants from the Gribi district of Cameroon (Lachenal and Tousignant 2017). Washington (2007) cites instances of recent bad, even criminal, practice on the part of white, European medical personnel in different parts of Africa. A white American doctor was convicted of murder after killing three black American patients with lethal injections of potassium, and is suspected of causing the deaths of 60 other people, many of them in Zimbabwe and Zambia during the 1980s and 1990s. In Zimbabwe, in 1995, a Scottish an anesthesiologist working in Zimbabwe was accused of five murders and convicted in the deaths of two infant patients whom he injected with lethal doses of morphine. In South Africa in 2000 a white South African doctor was fired for using excessive, lethal chemotherapy on black patients. These doctors may not have always had murder in mind when they committed their crimes, but they were white, often foreign actors wantonly, if sometimes unwittingly, sacrificing the assurance of the well-being of Africans under their care for an abstraction in the form of the "pursuit of scientific advancement".

#### *3.2. Suspicion of Existing Medical Facilities and Personnel*

In many African countries, medical facilities are skeletal, under-staffed and almost always under-resourced. Clinicians are often viewed with suspicion, figures to be avoided, sometimes treated with barely concealed hostility. In many parts of Africa, "the (local) clinic is the lowest stratum in a hierarchy of health services ... " (Nxumalo et al. 2016). Compounding this impression, unfortunately, is the reality that such clinics are often the last places to receive funding, so that " ... unintegrated and poorly resourced services inadvertently create barriers for poor households ... " and " ... impact on access and quality of care, and hence on the clients' trust that the health system will be able to assist" (ibid.).

A study in Harare found that there was a fair level of knowledge about the causative factors for cervical cancer (in large part because of effective radio broadcasting), but that only a small percentage of women would be able to utilize available services, mainly because of a lack of confidence in local services. As Lily Kumbani and colleagues note: "You walk into a rural health facility and you ask nurses about cervical cancer or cancer in general but they have no clue of what it is ... " (Kumbani et al. 2013). Health workers who, through no fault of their own, are subjected to expressions of dissatisfaction from their clients are likely to become defensive or hostile, thus further worsening the cycle of inability–mistrust between caregivers and clients. The following testimony is typical of many:

We need a team leader who will do home visits with us. The (one) that we have has never done any ... We only see her at the end of the month to check on our books. We have incidents that ... need her attention but she tells us that she is busy ... We do not know whether we are doing things correctly because there is no one to guide us . . . . (ibid.)

Such complaints are both well reflected and documented in reports emerging out of Malawi, Kenya and Tanzania and South Africa, where women opt for traditional birth attendants, rather than the conventional maternal and child health services, due to concerns of competence deficiency in health staff, and to feelings of having been disrespected and undermined in health facilities. Consider the following accounts:

"I think always of a sentence of this woman who lost her baby. She said that she lost her baby because of the midwife. The woman described the way she was treated, I was not proud of my profession . . . ."

"One day, we listened on a tape to a husband's interview. I can always remember his words, 'we came with a baby alive in the womb of my wife and we left with our dead baby in a carton box.' There was a big silence in the room . . . ."

"(The midwife said) yes if a person is troublesome, we beat her up. We are very annoyed with some who exaggerate and cry when giving birth." (Kumbane op.cit.: Essendi et al. 2011)

Regardless of the extent to which the clinicians and support staff charged with seeing through the successful delivery of these babies are actually at fault, there is at the very least a profound loss of trust with regard to care rendered on behalf of women's health, particularly in the area of childbirth, which is one of the most intimate areas of clinical care. Naturally, a collective memory of these experiences is likely to inform developing attitudes towards trusting externally introduced vaccination programs in these regions of Africa.

Logistical challenges and shortages of personnel do not help matters. In her article on Western and folk medicine in Kenya, Howland (2020) notes that there is one traditional healer for every 500 people in Kenya, and a single medical doctor for every 400,000. Such a troubling ratio of carers to cared-for leads to a simple truism: medicine will work best when it is administered by known and trusted practitioners. Examples abound in the literature of how important it is to trust those administering to health care needs. In Kenya, according to Howland, many do not trust doctors. The one they see in a hospital is, as likely as not, unfamiliar with the health issues of the patient's district and unlikely to form a bond of trust because that doctor is not bound, in the large urban hospitals in which they are working, to see that patient again after an initial consultation. In many settings, the doctor and patient may not even speak the same language. A local healer in the developing world, by contrast, will be known to native patients and will see them time and again, developing a bond likely to last a lifetime. (Research from the developed world has shown that communities respond in exactly the same way when there is a choice between being seen by a known and trusted practitioner or by a visiting, mobile clinic, so this appears to be a universal human dynamic (Wardle et al. 2012).) Thus, trust in a local, non-medical healer, whose traditional methods and materials may not cohere with those of the medical establishment, is more likely to be sought out by local people than any given modern medical facility.

Suspicion of visiting vaccination teams is also apparent across the developing world as well as elsewhere, and it behooves us to keep in mind that, wherever they surface, government-organized vaccination campaigns are, among other things, political projects which express state power and involve taxing, policing, and conscription, all of which arouse anxiety ... " (Greenough 1995). In the developing world, however, the immediate spur of resistance is different. It is the question not only "What is in this vaccine?" which raises eyebrows, but also the question, "why are vaccination campaigns so well-funded and available while other health facilities, such as clinics for basic health care, are not?" (Closser 2010; Savulescu et al. 2021) The success of the Global Polio Eradication Initiative (GPEI) since 1988 is one of the great achievements of modern medicine (Gonzalez-Silva and Rabinovich 2021; Aylward and Tangermann 2011). Yet, no-one asks the local populations of developing countries what they want in terms of health care. There are arguments that coercion can and should be used to enforce the acceptance of vaccine programs (Savulescu et al., op.cit.), as well as some arguments against this idea (Pennings and Symons 2012). But there are special obstacles in rural locations in the developing world. The systematic neglect of local folk belief systems, alongside a militant local cleric telling you that vaccinations "stop you from having children", or "interfere with God's will", combine in a cocktail of ingredients for vehement vaccination refusal. Closser and colleagues report:

in Kumbotso (in Kano state, Nigeria) and SITE Town (in Karachi, Pakistan), whose crumbling health systems' almost only functional activity was to implement polio vaccination campaigns on a near-monthly basis, refusals were common and vehement. One major contributing factor in both places is the relative *lack of availability of international aid funds for basic health services compared to disease-specific interventions* (author's italics) like polio eradication ... 'Not even a month has gone by since the last campaign, and now it has started again. Why?'. (Closser et al. op.cit.)

Clearly, there is a disconnect between foreign wisdom and local custom, manifesting as a distrust which impedes effective care at the most concrete and crucial ground level of medical intervention.
