The Delta variant and South Africa’s vaccination problems
- Ozayr Patel with Shabir A. Madhi
Pasha 113: The Covid-19 resurgence in South Africa is likely to take a heavy toll. It is important for vaccination efforts to be ramped up.
The Delta variant of SARS-COV-2 – the virus that causes Covid-19 – is spreading across South Africa, sparking a strong resurgence of infections. The president has placed the country under stricter regulations in an attempt to curb the spread of the virus. Gauteng province, the country’s economic hub, where 25% of the population live, is the epicentre. It’s likely many more people will be hospitalised in the coming weeks and some will die. Severe disease usually lags behind infections in the community by about two to three weeks.
Based on what happened in India, the number of cases is expected to decrease gradually. That is dependent on people adhering to lockdown restrictions. And South Africa’s vaccination strategy needs to be reviewed. In today’s episode of Pasha, Shabir A. Madhi, a professor of vaccinology and director of the SAMRC Vaccines and Infectious Diseases Analytical Research Unit at the University of the Witwatersrand, discusses the flaws in South Africa’s vaccine rollout.
South Africa’s vaccine quagmire, and what needs to be done now
- Alex van den Heever, Imraan Valodia, Martin Veller, Shabir A. Madhi and Francois Venter
South Africa has clearly suffered the consequences of poor strategic decisions to this point. It doesn't need to continue along these lines.
South Africa’s approach to its COVID-19 vaccine programme has been characterised by a large number of missteps. In aggregate it has left the country behind many others on the continent, and essentially left millions unvaccinated as a savage third wave descends on the country.
This has happened despite an established vaccine procurement and distribution network, access to the first large batch of vaccines on the continent, and a large number of pandemic and vaccine experts.
As the country battles a severe third wave crisis, at great cost to health, economy and society, the rollout of a vaccine programme remains the only sustainable means to protect the population against COVID-19 severe disease and death and return to some level of acceptable economic activity.
Strategically, therefore, policy needs to be hyper-focused on the delivery of a responsive vaccine programme to protect especially high risk groups against severe disease and death.
In this article, we outline the history of the vaccine strategy and its pitfalls. We also suggest a way forward.
Some context
As the pandemic first unfolded South Africa had, from a vaccine perspective, a number of things going for it. It has a large childhood vaccine programme although with weaknesses in overall coverage. It also has a private sector able to distribute adult vaccines, and experience of rolling out large programmes, such as antiretrovirals.
While reeling from a devastating first wave and associated lockdown in this period, the country was well poised to rapidly implement a mass vaccine programme.
In September 2020, for instance, a vaccine subgroup (the MAC Vac) of the Ministerial Advisory Committee on COVID-19 (MAC) was set up. It was made up of a small group of virologists, regulators and other public entities. It recommended supporting COVAX, a pooled procurement and distribution initiative aimed at securing large volumes of vaccines for countries that might struggle with bilateral agreements.
But during early December 2020 it became worryingly clear that government had no vaccine strategy at any level of maturity apart from the fragile COVAX arrangement.
To quote the deputy director general of the Department of Health, Dr Anban Pillay:
We have not delayed the procurement at all. We took a decision at the time we will go to (sic) COVAX facility because COVAX was purchasing vaccine (sic) from multiple vaccine producers, rather than taking the risk and going with one vaccine supplier.
Despite also asserting that individual companies had in fact been approached, there was no evidence of this, including within the publicly released MAC Vac advisories.
In late June 2021 the first 1.4 million doses of Pfizer vaccine were finally delivered to South Africa through the COVAX facility. It still remains unclear what will be delivered of the roughly 10.6 million doses still owed to South Africa during 2021.
As no signs of a coherent strategy by the government were surfacing, a group of academics drafted a 10-point vaccine strategy in early December 2020 to prompt a strategic response from government.
But no strategy emerged during that month.
January – February 2021
In frustration a group of South Africa’s health academics and activists published an article in early January 2021 condemning the absence of a vaccine strategy. They raised the concern that South Africa would enter the winter wave of SARS-CoV-2 infections without a significant part of the population vaccinated against infection or severe illness.
The article provoked a response. The health minister called a news conference, announcing that a strategy would be forthcoming and that confidential bilateral negotiations were in fact under way.
He failed to disclose any details.
A day later, on 4 January 2021, the Department of Health for the first time began belated bilateral negotiations of any seriousness with the Serum Institute of India for whatever doses they could make available of the AstraZeneca vaccine.
Within a week a commitment of some 1.5 million doses was made for delivery during February and March, with the potential option to purchase another 1.5 million.
This revealed what was possible if government began to act with purpose.
Also, within a relatively short period, an application for registration was submitted to the South African Health Products Regulatory Authority and emergency approval provided.
However, there was no rollout strategy, with no vaccine sites or registration system to manage the process. The first AstraZeneca vaccine batch then arrived on 1 February 2021 with much fanfare and was immediately transferred to the Free State for quality assurance.
As there was no other commitment to purchase, until this period no other vaccines were being evaluated by the regulatory authority apart from a rolling application by Johnson & Johnson. And as government had indicated it would be the sole purchaser and distributor of COVID-19 vaccines, no other party had applied for registration.
Despite the rolling application, the Aspen facility in Gqeberha was set to fill and finish 300 million doses of Johnson & Johnson vaccine in 2021. But there were no plans to use these in South Africa as the government appeared to show little interest up to that point.
Aspen confirmed it had the capacity to make up to 300 million doses of the vaccine, in a Port Elizabeth plant, and that all those doses would be earmarked for export.
Confusion then ensued when the health minister announced that due to the AstraZeneca vaccine not demonstrating efficacy against mild to moderate COVID-19 against what is now referred to as the Beta variant in the small South African AstraZeneca trial, the rollout of the vaccine was put on ice. The decision was criticised by local scientists, and not supported by the World Health Organisation.
March 2021
Due to the intervention of researchers involved in the Johnson & Johnson vaccine trial in South Africa a workaround was quickly negotiated for 500,000 trial doses to be made available. These would be prioritised for health workers with implementation in March 2021.
However, this was an expanded observational trial (Sisonke trial), not a rollout. It could only rely on trial sites for expansion, severely restricting the scaling up of the programme.
Nevertheless, the Sisonke workaround was a local initiative that spared the lives of many frontline health workers.
April 2021
The minister of health then controversially chose to discard the initial one million AstraZeneca doses rather than use them. It is our understanding that this was based on the MAC VaC advice.
He also took a decision to forgo the additional doses that would have been made available from the Serum Institute of India in terms of both bilateral agreements and the first round of COVAX. This was despite the World Health Organisation position that while not effective against infection by the Beta variant, it would be effective against the original wild-type variant still prevalent in South Africa and would probably offer protection against severe illness due to the Beta variant, which was subsequently corroborated in animal model studies. The protection against Beta-variant severe COVID-19 in the animal model study was evident despite the low levels of neutralising antibody induced by the AstraZeneca vaccines against the Beta variant, indicating such protection is likely mediated by CD4+ and CD8+ cellular immune responses that are largely unaffected even due to mutations in the Beta variant.
A number of experts were critical of this decision. They argued that South Africa should urgently use all available vaccines.
The minister also indicated that South Africa would not make use of NOVAVAX either, despite it being the only vaccine shown to protect against mild to moderate COVID-19 from the Beta variant and considered in the same league as the mRNA vaccines for efficacy against severe COVID-19. No evidence was offered for the decision.
The AstraZeneca decision effectively knocked South Africa out of the running for the first round of COVAX doses, which were made up of AstraZeneca (237 million doses) and some Pfizer (1.2 million doses).
The decision not to pursue the NOVAVAX vaccine potentially explains why they did not seek authorisation through the South African Health Products Regulatory Authority.
While the South African government did begin to take bilateral contracts seriously, our understanding is that substantial negotiations with Johnson & Johnson and Pfizer only began from February 2021.
This guaranteed that South Africa would face a winter wave of the epidemic with most of the 17 million or so high risk population unvaccinated.
The bilateral negotiations bore fruit with both Johnson & Johnson and Pfizer making significant commitments. But delivery was to be spread out intermittently through the remainder of the year – largely missing the predicted winter wave.
May – July 2021
South Africa officially started its rollout in May 2021 with Pfizer. But it did so with limited sites.
Expansion to scale is now restricted by the availability of doses rather than the ability to expand the number of sites.
The achievement of scale during June was then scuppered by the Federal Drug Administration’s (FDA) determination that the very 2.2 million initial Johnson & Johnson doses earmarked for South Africa by Aspen were contaminated and needed to be destroyed.
Despite the very long lead time to this decision, no apparent contingency arrangements were negotiated in the meantime. This resulted in a scramble to compensate for the failure of Johnson & Johnson to deliver on time.
Although replacement doses were subsequently made available, South Africa’s already belated vaccination drive was substantially diminished.
By the end of June 2021 South Africa had administered only 3 million doses, 480,000 of which were from Johnson & Johnson through the Sisonke trial and the remaining 2.2 million from Pfizer.
The end of June target for vaccinations was however 5 million outside of the Sisonke trial. Going into July 2021 South Africa should therefore have stock of around 4.3 million doses available if the 6.5 million doses promised by the end of June have arrived.
However, this stock is largely due to the slow pace of vaccinations. We should have had only around 1.7 million doses available at the end of June if everything had gone according to plan.
The bungling continues. Vaccines have moved up to around 100,000 doses administered per day. But, inexplicably, virtually no vaccinations occur over weekends at the majority of sites. And government has not made arrangements for non medical scheme members to make use of private sector vaccination sites.
What has been learned?
Without a proactive strategy government will perpetually respond to events. Any reasonable strategy must account for contingencies.
What could go wrong? What is not yet known for certain but may be true?
This requires combining evidence with hedging decisions for unknowns where no evidence is yet available.
In this pandemic, as in many other aspects of government policy, decisions have to be made even when perfect information is unavailable.
With this in mind four strategic errors were made.
First, vaccine nationalism was plainly the greatest risk to securing doses in late 2020. Without timely and assertive bilateral contracting beyond COVAX it was guaranteed that South Africa would be at the back of the international queue when it began to realise its mistake.
Second, low vaccine efficacy, especially when confronted with variants, is a contingent risk you have to mitigate through careful vaccine candidate selection (for procurement) together with diversification – booking multiple candidates. This includes the advance contracting of booster doses updated for variants of concern.
Third, the ground-game – or rollout process – requires advance preparation to rapidly achieve scale. However, scaling up requires that you start early and learn from mistakes. South Africa has started. Finally. But it is nowhere near the levels required before the winter wave of infections.
Fourth, a substantial winter third wave was predictable and every effort was required to vaccinate the high risk population, particularly for those over the age of 60 and with co-morbidities, by May 2021 with at least one dose of a vaccine that could prevent severe illness. South Africa unfortunately gave this option away despite a contingent probability that AstraZeneca vaccinations would protect against severe COVID-19.
A look at the strategy for 2022?
South Africa has clearly suffered the consequences of poor strategic decisions to this point. It doesn’t need to continue along these lines.
But strategy going forward needs to account for three key factors.
First, from the end of July 2021 many of the advanced countries will have surplus doses and are likely to shift their focus to updated vaccines that address variants of concern. It is therefore probable that the COVID-19 vaccine world will be characterised by a simultaneous glut of original vaccines and constrained supplies of updated booster shots.
Second, global herd immunity, even though an aspirational goal, is unlikely to materialise with the current generation of COVID-19 vaccines and the ongoing evolution of the virus. Instead the objective should be centred on protecting against severe illness and death despite ongoing transmission. One possible contingency is that a single complete mass vaccination programme permanently reduces COVID-19 to a mild illness – with ongoing infections acting as a booster to immune responses. The alternative, less likely contingency is that new variants emerge that evade even natural infection and vaccine induced immunity against severe illness. Both contingencies need to be prepared for.
Third, the pace of vaccinations remains constrained by access to doses rather than the capability of the public and private health systems to administer vaccines. Addressing these supply constraints is therefore a priority.
Taking account of these factors, the following four considerations should form part of the strategy for 2021 and into 2022:
First, bilateral negotiations need to be assertively pursued despite the doses already booked. These should focus on the more effective vaccines that are likely to move into surplus during the latter part of 2021 and into 2022. Therefore negotiations need to be ongoing with proactive procurement for both 2021 and the whole of 2022.
Second, South Africa should be advance purchasing the updated vaccines which could have higher effectiveness against the variants of concern. These should include agreements well into 2022.
Third, rather than advance purchasing too few doses, or just enough, consideration should be given to purchasing more than is required. This would cater for the contingent risk of ongoing transmission resulting in severe illness in the vaccinated population.
It would be a mistake for South Africa to again take its foot off the pedal when the opportunities for bilateral contracting are increasing. But the window for astute early action is closing.
Fourth, and more generally, greater transparency in strategy, implementation, and the strategic rationale for decisions is required, given the importance these decisions hold for the well-being of the country.
False story about decuplets was a low point for journalism: how to fix the damage
- Franz Krüger
Tighter controls are not the answer; the opportunity should be used to think differently about trust and journalism.
It is difficult to imagine a bigger journalistic disaster than the recent decuplets story by Pretoria News, based in South Africa’s capital city. But it may present an opportunity to think anew about what could be done to address journalism’s crisis of trust.
For a moment, the tale of a woman in Tembisa, northeast of Johannesburg, and her record-breaking “10 babies” seemed like a welcome distraction from the depressing grind of COVID-19, political intrigue and state failures.
But it was a very brief moment. The red flags began fluttering almost before the metaphorical ink was dry on the story. Health officials who would have known about such a rare and complex medical event could find no trace of the birth. Then the man’s family distanced themselves from the claim and the woman was taken into psychiatric care.
There seems little doubt that the inquiry will find an overwhelming lack of babies.
Journalistic failure and fallout
It is clear that the reporting failed to pass the most elementary test of journalism, as no attempt was made to verify the claim, and it has caused further damage to journalism. Critics like Helen Zille, chair of the opposition Democratic Alliance, gleefully used the story to rubbish the media as a whole. Though it is easy to dismiss her opportunism, stories like this undoubtedly further undermine trust in journalism. Without trust, journalism can’t do its work of holding the powerful to account and enabling civic discussion.
For some, the answer to journalistic missteps lies in tighter control.
But, it would be a mistake to go down this road. There is no possible system of control that can completely prevent misreporting, whether deliberate, manipulated or by mistake, just as even the most draconian laws are unable to prevent crime completely. And the damage that tighter controls would cause to free speech and, therefore, to democracy is simply too great.
Instead, the opportunity should be used to think differently about trust and journalism in the changed and overwhelmingly cluttered information system we now inhabit.
Changed media landscape
Changes to the ways in which people get their information have shaken old certainties. The advertising-based business model that sustained journalism for around a century is dying as media income goes to the giants of the internet. Jobs are disappearing and newsrooms are being hollowed out.
At the same time, journalists’ position of authority over the kinds of information called news is waning. Everyone is now able to publish easily. That is often a good thing, but it has also meant a dramatic rise in misinformation. The not-for-profit organisation First Drafttalks of an information environment that has been polluted by disinformation, and where
it has never been harder to know what to trust, and never easier to be misled.
As a result, trust in journalism has been declining for some years, though the new Digital News Report by the Reuters Institute for the Study of Journalism has found that the COVID-19 pandemic has brought some global recovery of trust.
Separating wheat from chaff
Solutions to the problem of trust will have to be multi-faceted, starting with close attention to quality. Business models and improved media literacy need attention, and it is critical to enable audiences to distinguish reliable, verified information from everything else.
There are “markers” of credibility that have traditionally offered some guarantee of reliability, such as the signature tune of the main evening newscast, the masthead of a serious newspaper, the tone, language and design of news reports that are different to those in the adverts next to it. These external features have marked journalism as different from other kinds of communication, signifying reliability and helping build trust.
Information online has far fewer markers of this kind, and the merchants of misinformation have proved adept at mimicking the look of journalism. There is a need for new ways of identifying journalism that are appropriate to the new platforms.
Strong brands carry their reputation onto new platforms: a post from the BBC’s newsroom carries the authority of the parent organisation. The name of an individual, trusted journalist on a social media account signifies credibility in the same way.
An important challenge for journalism is to find additional ways of improving the visibility and distinctiveness of trustworthy reporting.
Rebuilding trust
The Journalism Trust Initiative, initiated by the NGO Reporters without Borders, has created indicators for trustworthiness and offers media outlets the opportunity to assess themselves and then publish a “Transparency Report” which can be audited.
benchmarks of quality and independence must be transparent and verifiable to reinstate trust. To that end, JTI provides indicators for media outlets to self-assess and comply with – and for citizens, advertisers and regulators to reward it.
Such a “badge” of journalism is reminiscent of the trusted South African Bureau of Standards mark, which, for example, tells consumers that a particular can of beans has met quality benchmarks. Or the system of stars that grades hotels: if a consumer insists on staying in a sub-par establishment, they can’t complain if there is mould in the bathroom.
A similar system for journalistic media could be developed, to be administered by the South African Press Council. It would be a better alternative to calls for the registration of journalists that were made to the recent Satchwell inquiry into ethics in the media, and would give the council a powerful new tool to raise standards.
Publishers would need to earn their rating against an agreed, transparent set of indicators. It should be voluntary, leaving consumers to decide whether to listen to ungraded information providers. And it should be open to a range of different kinds of information producers, small and large and regardless of platform.
After a disaster like the Tembisa 10 story, a graded newspaper might be downgraded or lose its grading entirely.
Jacarandas in parts of South Africa are flowering earlier: why it’s a warning sign
- Jennifer Fitchett
Climate change is causing jacarandas to flower earlier.
In September each year, South Africa’s Gauteng province turns purple. The cities of Johannesburg and Pretoria are well covered with trees – and jacarandas (Jacaranda mimosifolia), with their purple blooms in late spring, are a prominent part of this urban forest.
About 16% of the land in the Gauteng City Region is planted with trees, forming one of the world’s largest and most densely vegetated man-made urban forests. Johannesburg alone is recorded to have over 10 million trees. Jacarandas were introduced to Pretoria and later Johannesburg in the early 1800s, specifically as ornamentals to line the streets of the suburbs and central business districts.
Octogenarian residents who have lived in Gauteng their whole life might remember that jacarandas did not always flower in September. In the 1920s and 1930s, the trees only started to bloom in mid-November. Gradually over the decades, the date of bloom has advanced through October to the early weeks of September. This is referred to as a phenological shift, and is being observed across a range of species globally as a result of climate change.
The most notable example is the Japanese cherry blossoms. Not only are the cherry blossoms a key tourist attraction, and the cherry festivals important cultural events, but this also represents the world’s longest phenological record. Phenological analyses show that current cherry blossoming is occurring earlier than any time in the last 1,200 years.
We explored this change in the timing of jacaranda blossom in our paper published in the Journal of Urban Forestry and Urban Greening. Phenological shifts are species and location specific – in some areas, and for some species, events are even being delayed as a result of specific climate drivers. There is very little phenological data for South Africa, and so very little phenological research has been conducted compared to the work in countries across Europe, Asia and North America.
Because jacaranda blossoms result in such a dramatic change in the urban landscape each year, they are often reported on in the news and, more recently, in social media posts.
We mined these sources to compile a list of flowering dates of jacaranda trees spanning 1927-2019. This record allowed us the chance to contribute to the global attempts at recording phenological shifts.
The records confirmed the advance in flowering dates, and from these we quantified a mean rate of advance of 2.1 days per decade.
We then explored the climatic drivers of this advance, by comparing the flowering dates to meteorological data from across Gauteng. The advance in flowering took place against a backdrop of warming temperatures, ranging from 0.1-0.2°C per decade for daily maximum temperatures and a more rapid 0.2-0.4°C per decade for daily minimum temperatures. Rainfall changes during this time were less uniform.
If plants flower too early in the year, they are at risk of frost damage during the late winter months, and often do not complete their dormancy. Therefore, although phenological shifts represent an adaptation in plants and animals, these advances in flowering dates cannot continue indefinitely. At a critical threshold, the flowering season will become unsuccessful.
Understanding the role of climate
While phenological shifts are highly species and location specific, the broad climate drivers are well understood. Spring blossoms are triggered, in most cases, by temperatures warming above a certain threshold, following the completion of a dormant period. That dormant period often requires a certain number of days below a threshold temperature, or an accumulation of chilling units.
For some plants, the onset of rainfall is also important in triggering blossoms. While factors such as soil moisture, temperature and composition, sunshine hours, and the health of the tree can affect the mean flowering date, the shifts in flowering are driven by climate. The biometeorological science of phenology has developed over the past five decades, with methodologies to determine the climate drivers responsible for phenological shifts.
The strongest climatic driver of the phenological advance of jacaranda blossoms in the Gauteng city region was found to be daily maximum temperatures during the month of June – falling within the dormant period of the tree. This is not uncommon, as the dormant period is critical for resource management in the tree. It does mean that by the time the spring months of September and October come around, day to day temperature and rainfall will have less impact on when the trees flower. Over the period 1918-2019, June mean maximum daily temperatures have increased by 0.2°C a decade, while mean minimum daily temperatures have increased by 0.2-0.5°C a decade.
Jacarandas occupy a peculiar position in South Africa: they are well loved and noticeable trees but they are invasive aliens. Due to their status as invasive species, replanting of jacarandas is currently prohibited, although the species has certain urban areas in which restrictions are less strict. This means the population of trees is ageing. The trees can live for over 100 years, but for some of the original trees, their centenary has already passed.
Phenological shifts represent an adaptation strategy for the plant – they cannot move on their own to a cooler climate that more closely matches what they are traditionally accustomed to, and so they alter their annually recurrent biological events. This cannot happen indefinitely, and as temperatures continue to increase, a more general risk of heat stress to the tree is heightened. This could mean that the years of purple spring seasons in Gauteng are limited.
The rate, direction, and climatic drivers of phenological shifts are specific to individual species. Therefore, we cannot extrapolate these results to all flowering trees in Gauteng, or even to all invasive species in the city-region. However, the results of this study do provide a warning for the urban forest, and an urgent call for future research. Collating data from a range of sources, including traditional and social media, can contribute to better understanding and modelling these changes.
Angola needs a mixed electoral system. This would promote accountability through the direct election of representatives from constituencies.
Angola has a unique electoral system. Its main peculiarity is that it involves voters electing the president, deputy president and members of parliament simultaneously with a single mark on a single ballot paper.
This has a negative impact on the quality of the country’s representative democracy. It prevents voters from voting differently for the president and members of parliament. And it reduces the ability of voters to hold elected representatives to account besides keeping them in office, or voting them out every five years.
Hence, the need for reform.
An alternative electoral system would have the following components. It should provide for the direct election of the president. And it should allow for the representation of Angolan communities abroad. In addition, seats in the legislature should be allocated through direct election of representatives from constituencies combined with compensatory seats for political parties in proportion to their overall outcome.
How does the system work?
Angola uses a closed-list proportional representation electoral system. Voters cast ballots for lists of candidates drawn up by political parties. Parties are then allocated seats in the legislature in proportion to the share of votes that they receive at the polls.
This electoral system is used widely elsewhere. Examples include South Africa and Portugal.
The specific variant used in Angola is outlined in the country’s current constitution. It was approved in 2010 to replace the interim constitution, which had been in effect since 1992.
The constitution states that the individual occupying the top position on the list of the political party or coalition of parties that receives the majority vote is appointed president. The individual next on the same list becomes the deputy president.
The 220-member National Assembly is elected on a two-level constituency: 130 candidates from a single national constituency and 90 candidates from 18 provincial constituencies (five per province). The national assembly is unicameral.
Advantages and weaknesses
There are several advantages to the closed-list proportional representation system.
One is its simplicity. The design of ballot papers allows even illiterate voters to make effective choices. It is also fair in that political parties get seats according to the proportion of votes that they receive at the polls.
It also promotes inclusiveness. It ensures that political, gender, ethnic and other minorities are not excluded from the legislature.
But, as a political scientist and a student of Angolan politics, I am of the view that the current system undermines voters’ ability to elect political representatives effectively.
Firstly, fusing executive and legislative elections prevents voters from splitting their votes for the presidency and parliament. This forces them to choose a president and a deputy president from the party with the majority in the national assembly.
Secondly, the electoral system prevents voters from electing the president directly. Yet Angola has a presidential system of government with an all-powerful presidency that exercises executive powers without effective checks and balances.
Here Angola deviates from the norm. In countries that adopt presidential systems of government, the executive does not get its legitimacy from the legislature. That is why it is elected directly by the voters.
Thirdly, voters cast ballots for party lists rather than individual candidates. This arrangement privileges political parties rather than individuals in the political process. This means that, once elected, representatives are not personally accountable to the electorate because they aren’t directly linked to any territorial constituency. Rather they are beholden to party leaders who hold the power to compile the party list.
This results in a massive accountability deficit in the political system.
In addition, the use of party lists bars independent candidates from standing for political office unless they are included in a party list that has been cleared to run in the elections. But giving effect to this is extremely difficult. Realpolitik prevents parties from choosing independent candidates at the expense of party members in good standing.
There is also the practical use of the two-level constituency – provincial and national – instead of a single national constituency.
The adoption of the 18 provincial constituencies, which goes back to 1992, is premised on the idea that all provinces need to be represented at the national assembly. But this does not make sense, as Angola is a unitary state, with a unicameral parliament.
Among Lusophone countries, which inherited this system from Portugal, Angola is the only country that introduced the national and provincial level constituency system.
There are no provincial legislatures and no functional or formal distinction between parliamentarians elected at the provincial level and those elected at the national level. They all represent the whole nation, and should all be be elected from a single national constituency.
There are several types of electoral systems and each has advantages as well as disadvantages.
A system that best serves democracy in one country might not work in another country. Hence, the best electoral system for a country must be informed by its particular history, social cleavages and political realities.
In the case of Angola, this means breaking with the past to end the persistence of adverse practices. These include the unchecked executive power, concentration of state resources in the hands of a small politically connected elite, widespread corruption, a culture of impunity in which those in authority get away without being punished, and a government that is not responsive to the needs of the population.
In my view, the best way to address these issues is reforming the current system. This would require a return to the direct election of the president by voters and the reinstatement of a constituency for the representation of Angolan communities abroad. This was stipulated in the Constitutional Law of the Republic of Angola, an interim document revoked in 2010.
In addition, the 18 provincial-level constituencies should be scrapped. There is no practical reason for their existence. A constituency element should be added to ensure the direct election of deputies and compensatory seats introduced for the representation of political parties in proportion to their share of the votes.
The resulting mixed electoral system would promote accountability through the direct election of representatives from constituencies. It would also ensure the proportional representation of political parties.
Healthcare in South Africa: how inequity is contributing to inefficiency
- Russell Rensburg
Patients shouldn't be treated better simply because they can afford to pay more.
South Africa has a two-tiered, and highly unequal, healthcare system. The public sector is state-funded and caters to the majority – 71% – of the population. The private sector is largely funded through individual contributions to medical aid schemes or health insurance, and serves around 27% of the population. The public sector is underfunded while most South Africans can’t afford the exorbitant cost of private care. To balance the scales, the government tabled the National Health Insurance Scheme. The proposal was to provide universal healthcare by buying services from health professionals through a National Health Insurance Fund. These services would then be delivered at private and public facilities. But there are many unanswered questions about how exactly this scheme will work and many doubts about it. Russell Rensburg is the director of the Rural Health Advocacy Project, which champions equitable access to quality healthcare for the country’s rural communities. He shares with The Conversation Africa how the gaps may be plugged.
What has the pandemic exposed about South Africa’s healthcare system?
Firstly, South Africa’s biggest problem is that the health needs of its people exceeds capacity.
Secondly, the vast majority of people actually don’t know their health status which delays access to care.
Thirdly, the way the system is funded perpetuates inequality.
What are the solutions?
There’s a massive opportunity to reform the system. The biggest lesson that’s been learned from COVID-19 is that if there is poor health utilisation at the lower levels, people are at increased risk of severe illness and death due to COVID-19. Comorbidities are a risk factor for COVID-19. If the health sector did a better job of diagnosing and treating people living with diabetes at the community level, for example, the outcomes would be better.
If the country had a strong primary health care network with competent well trained community health workers, it would have had a better chance of containing the spread of COVID-19 as well as linking people to care sooner so that deaths could be reduced.
We also need to look at the efficiencies of hospitals. Some fundamental questions need to be asked, such as are we doing the work that should be done in a hospital? Yes, it’s hard to turn people away. But so much is being done poorly in public sector hospitals. Many are falling apart.
Another area that needs close attention is explicit prioritisation. Given the levels of poverty and inequality in the country, there should be explicit priority setting in determining who accesses key services such as surgery and when. Who benefits from that at the moment? Is access based on how close someone is to the system? For example, people who live in Cape Town or Johannesburg have a better chance of getting an elective surgery like a hernia repair.
The World Health Organisation says those people with the least coverage need to be prioritised before expanding access to others with more access to care. While everyone has the right to health, there is not equal enjoyment of that right. For example in the current response to COVID-19 how quickly people can access testing, care or even vaccination is determined by their ability to pay. This is neither just nor fair.
As the country considers the development of a comprehensive primary health care package, it should look at prioritising services where lower income groups enjoy the least access.
South Africa should also consider a universal pricing and admission criteria.
Access to medical schemes shouldn’t lead to over-enjoyment of capacity. The Competition Commission conducted a five-year investigation into the country’s private health sector. One of its findings was that South Africa admitted more people to ICU that other countries with comparable data.
Patients shouldn’t be treated better simply because they can afford to pay more. The high cost of private care has detrimental effects on public health care. If most doctors work in the private sector, there will be a limited number of doctors working in the public sector. These two markets affect each other. If the cost of private healthcare isn’t reduced, the costs will increase for everyone. Which means that the public health sector will suffer over the long term as it struggles to keep up with the cost of care.
How should South Africa manage the unequal nature of healthcare provision?
The country has to find a way to make sure the availability of care is spread more evenly throughout the system. We can’t look at the private and public sectors separately. One has an impact on the other.
South Africa’s healthcare system is inefficient – both public and private. The cost of healthcare is too high. In the long term, improving the quality of care in the public sector would balance out people’s need to have expensive medical insurance.
South Africa’s institutional frameworks perpetuate inequality, rather than address it. Publicly-funded healthcare is not allocated based on need, but determined by each province’s relative share of the population. In this scenario, funding for the Western Cape and Eastern Cape provinces would be roughly same – despite vastly different implementation context. When you consider the vast area covered by the Eastern Cape, it is clear the current arrangements do not address inequality of access.
When health services were officially desegregated in 1988, South Africa’s spending in the former mainly white provinces was R172 average per capita. Public sector healthcare expenditure was R55 in areas designated under apartheid for black people. Known as the “homelands”, it’s where most black South Africans were forced to live.
Many of these inequities have persisted with a disproportionate spend on health infrastucture in large metropolitan areas. This has lead to an under investment in primary health care where the 80% access services.
The system needs to be more responsive at the levels where the majority are likely to access it. This means moving services out of facilities and being proactive in engaging with people through lower level workers such as community health workers.
Doing this would easing the burden on facilities and health diagnose people at early stages of disease and infection – before they get sick.
South Africa has followed this approach with community testing of HIV. It saw also saw the effectiveness with the community screening and testing at the being of the COVID-19 pandemic in March 2020.
There are no simple solutions to South Africa’s health crisis but we have a once a generation opportunity to begin addressing the crisis . The improved electronic vaccine registration system can contribute to a better understanding of where people are, the investment in diagnostics can lay the platform for expanded screening and diagnostics and the introduction of reforms like the NHI can facilitate better cooperation between the public and private sector. Failure to act on these opportunities will show our disregard for the lives and living of the 80% of the population trapped in a poverty and under development.
Water, power cuts and neglect are taking their toll on South Africa’s top hospitals
- Professor Daynia Ballot
South Africa is quite capable of delivering world-class healthcare to all its citizens. But this is constantly being hampered.
A fire at one of the biggest public hospitals in Johannesburg, the Charlotte Maxeke Johannesburg Academic Hospital, and the delay in reopening the facility has brought infrastructural issues into sharp focus. The fire broke out in mid-April. Only now is a phased re-opening of the hospital being undertaken.
Reopening was delayed due to fire safety issues. A host of compliance measures weren’t in place. These included fire hydrants without a water supply, fire hydrants without correct couplings, non-functional fire doors and a lack of emergency lighting in the stairwells. These deficiencies had been longstanding.
I am extremely familiar with conditions on the ground in hospitals in the area. I interact daily with doctors and students in the different academic hospitals on the circuit of the University of the Witwatersrand. These include the Charlotte Maxeke Johannesburg Academic Hospital, Chris Hani Baragwanath Academic Hospital, Helen Joseph Hospital and Rahima Moosa Mother and Child Hospital. I also visit different institutions in the region.
I completed both my undergraduate and postgraduate training at these hospitals and worked for more than 30 years in the neonatal-paediatric intensive care unit and neonatal unit at Charlotte Maxeke Johannesburg Academic Hospital.
During this time I’ve observed many changes in the healthcare sector in general, and in these hospitals in particular.
South Africa’s healthcare system compares favourably on a global level. Both the medical schools of the University of the Witwatersrand and the University of Cape Town are ranked in the top 100 in the world. Over the years, the region has produced many eminent healthcare workers. And the country is quite capable of delivering world-class healthcare to all its citizens.
But this is constantly being hampered by an increasingly unconducive environment.
These large public sector hospitals provide tertiary and quaternary services to more than 250,000 inpatients and almost 1 million outpatients every year.
Most were built more than 50 years ago and have been poorly maintained. The crumbling infrastructure results in flooding, sewage leaks, lack of water, problems with the supply of medical air and oxygen, and electricity blackouts. Leaky plumbing creates a damp environment that favours pests such as cockroaches and rodents. Inadequate air conditioning results in working conditions that are unbearably hot or freezing cold. Both are harmful to patients.
Doctors and nurses are having to deal with a shortage of hospital beds on a daily basis.
Gauteng provides healthcare to many patients from other provinces, as well as surrounding countries, particularly Zimbabwe. The provinces of North West and Mpumalanaga do not have medical schools and therefore send patients for specialised tertiary and quaternary care, such as cardio-thoracic surgery and renal dialysis, to the Gauteng academic hospitals.
In addition, under-resourced regional and district hospitals result in primary and secondary patients receiving treatment in the tertiary or quaternary institutions because there is nowhere else for them to go.
Overcrowding and infrastructural issues negatively affect patient care. Hospital acquired infections with “super bugs” resistant to almost all known antibiotics are a major health challenge. Sewage leaks and inadequate plumbing increase the risk of infections.
Ongoing power cuts and water shortages compound the internal infrastructural issues at each hospital. There have been rolling electricity blackouts in the country as the government struggles to keep the power utility, Eskom, operational.
Each hospital has a diesel generator. But this emergency back-up does not always kick in during blackouts and load shedding. Patients in intensive care and the operating theatre are particularly at risk.
Water infrastructure, which has not been maintained by local authorities, is in a state of disrepair resulting in a growing number of water outages. In recent weeks, three of the largest hospitals in the province– the Helen Joseph Hospital, Rahima Moosa Mother and Child Hospital and Chris Hani Baragwanath Academic Hospital – all experienced a water outage that lasted several days.
Surgeons were scrubbing for theatre using buckets, people could not flush toilets, and patients were issued with bottled water and could not wash.
On top of all this, the COVID-19 pandemic is now raging in the province. This is proving to be the last straw for a buckling health system. Shortages of hospital beds, lack of oxygen supplies, inadequate ICU facilities are a few of the problems being faced.
There are multiple reasons for the current debacle. These include a lack of preventative maintenance, poor administration, corruption, poor forward planning, lack of financial resources, and a lack of strong governance at both municipal and provincial level.
The governance of the hospitals is complex and falls between different government departments. The Department of Infrastructure and Development, or Public Works has been tasked by the Department of Health to take care of the hospital infrastructure. This means that a hospital CEO isn’t directly responsible for maintenance of the building.
In turn this means that the system for responding to maintenance issues is not agile.
Bureaucratic processes designed to minimise corruption result in long delays. Management at all levels tends to put out fires rather than implement a long term strategy to improve the situation.
Facilities have also been affected by strikes about wage disputes. In some cases hospital facilities have been damaged during the industrial action.
Criminality is also a problem. Theft is common with wall mirrors, bathroom tiles, soft furnishings, even large potted plants disappearing. Most recently copper plumbing pipes were stolen from Charlotte Maxeke Johannesburg Academic Hospital while it stood empty.
The fallacy that South Africa has two healthcare systems
There is a perception of an “us and them” among many South Africans. People with medical aid feel relieved that they have access to private healthcare, which does not have all these problems.
This is a fallacy. The country has one healthcare system – the public academic institutions train the healthcare workers who work in both the private and public sector. If the public healthcare sector collapses, the private sector will follow. The solution is proper management and accountability at all levels. South Africa spends enough money on healthcare (just over 10% of GDP), but there is terrible waste at many levels. The government is pursuing a National Health Insurance scheme, with the aim of pooling resources to provide “quality affordable personal health services for all South Africans, based on health needs, not socio-economic status”.
If implemented and governed properly, the new scheme is most likely the best solution to all the many problems facing country’s healthcare system. And it will allow South Africa to reach its full potential of providing excellent healthcare to all.
Women suffered a large and disproportionate effect in the labour market as a result of the hard lockdown, but they’ve also been slower to recover.
With the release of the final wave of the Nids-Cram survey, we can take stock of how the Covid crisis has affected gender inequality one year on. The results are not encouraging.
Women suffered a large and disproportionate effect in the labour market as a result of the hard lockdown, but they’ve also been slower to recover. In March 2021, when the country was in its least restrictive lockdown, men’s employment and working hours were back to pre-Covid levels. Women’s employment was still down 8% against February 2020, and their working hours were down an average 6% (two hours a week).
So while there was a recovery in employment, it has been slower (and remains incomplete) for women. Covid has increased gender inequality in the labour market.
An important factor to consider is the gender split in job types. Women are more likely to be in the sectors hardest hit by the crisis. They are also in more precarious employment relationships, so it is easier for employers to reduce their employment or working hours when lockdown restrictions bite. This highlights the inequality that stems from job segregation and shows that policy to open opportunities for women in "male" sectors, and in more stable employment, needs to take centre stage.
Another likely reason for the uneven effect in the labour market is the uneven impact in the home. The Nids-Cram data shows that the burden of school closures has fallen disproportionately on women: twice as many women as men said child-care responsibilities during the lockdown affected their work prospects. Any serious attempts to close gender gaps in the labour market will need to address this inequality in the home.
An important finding is that even though women account for most of the unemployed and Covid-related job losses, they received the least state income support targeting unemployed and furloughed workers. Our data shows that only about a third of the recipients of the Unemployment Insurance Fund (UIF) temporary employer/employee relief scheme (Ters) and the special relief of distress (SRD) grant were women.
That fewer women received Ters benefits is because they are less likely to be (formally) employed and registered for UIF. However, fewer women received the SRD grant because it could not be paid concurrently with another grant, such as for child support. So unemployed women were penalised if they were also the main caregiver to a child.
If the SRD grant is reintroduced in future, this issue will need to be urgently revisited.
SA is well into its third, brutal wave of Covid, with tighter restrictions progressively reimposed since late May. But all state income support measures have been discontinued, with seemingly no intention to reintroduce them — despite the effect the new restrictions will undoubtedly have on employment. And, if past evidence is anything to go by, especially on the jobs of women.
The lack of additional income support when the pandemic is still raging is deeply worrying. Measures need to be reintroduced with urgency to help stave off the most devastating effects of this crisis.
Daniela Casale is with the Wits University School of Economics & Finance; Debra Shepherd is a member of Stellenbosch University’s Department of Economics. This article was first published in Financial Mail.
Steve Kekana: an 80s South African pop star, and much more
- Yonela Mnana
We should remember him as just another ordinary human being who did extraordinary things.
Steve Kekana was one of South Africa’s most popular singers in the 1980s era of soul and disco. But he was many other things besides – he was a law teacher, talk radio host and a man who overcame apartheid and disability to thrive. Yonela Mnana is a singer, pianist and music teacher who is currently working on his PhD on South African piano. The Conversation Africa asked him for his impressions of the artist whose songs he teaches and whose paths crossed his several times.
Who was Steve Kekana and what does he represent?
Steve Kekana was a popular and award-winning singer and songwriter, who became blind at the age of five. He was born in the Zebediela district of Limpopo province in the north of South Africa, in 1958, not far from Polokwane, the capital of the province. He went to Siloe School for the Blind at Chuenespoort, Polokwane, the same school that I went to. Belgian missionaries were part of the teaching faculty.
He never finished school because he was expelled for championing student rights. So that’s one of the things he represents, human rights, in more ways than one. And we know his passion for labour law and that he ended up being a university lecturer.
And his singing. This came later – around 1979, when his first album came out. Also, he became much better known after he’d moved to Johannesburg.
His life intersected with mine because we attended the same school. I first met him when the school had its 50th anniversary. I was in the final years of my schooling and I had already started playing keyboards. I did music in extramural class. We used to do his songs in his absence. And one day he came through. He struck me as quite an independent person.
I think he didn’t like hero worship, it made him feel awkward and slightly antisocial. Later I would see that he didn’t really feel chuffed about people telling him how much they thought of his music. He was known as a very honest person.
Tell us why he was so special musically
In the popular music environment, his music represented everything. At first, as a singer and songwriter, he was just doing songs with commentary on social norms and issues. One of his songs speaks about this guy who always wears great outfits, tailor-made suits, but he doesn’t even have blankets to sleep on.
He was as flexible as he could be in the music ethos of the time. As early as 1981, 1982 he began scooping up awards for huge hits like Iphupho (in isiZulu), Mandla (isiZulu) and Abuti Thabiso (Sesotho).
Iphupho.
Most of the guys at the time were able to harmonise by themselves, but when it comes to his singing, we must appreciate fellow blind singer and musician Babsy Mlangeni’s mentorship as well. In 1979 Babsy was already 11 years into the industry when he started working with Kekana.
I find that Kekana’s singing always mutated, as much as his songs did.
Abuti Thabiso.
He also moved quite a lot in terms of record labels. By 1983 he already had a label, Steve Records, which I assume was his own, that released his music. He reminds me of Frank Sinatra in this way. I think the idea of constantly reinventing himself was appealing to him. He was stealing and borrowing from all genres. The Americans do it nowadays, but Steve was doing it years ago.
Take Your Love was ahead of its time, as were his collaborations with a white artist during apartheid, PJ Powers.
Hip hop musicians trying to fill up a venue are always acting like they’re the first ones to do it in South Africa. He did it in Lesotho in an age when there was no Twitter and no marketing. Of course, then people actually went to see music more. Nowadays we see it more as a product than an experience.
Steve worked with a couple of bands – Hotstix Mabuse was one of the producers. Steve, with his blind trio – Babsy Mlangeni, himself and Koloi Lebona – had garnered a lot of popularity in schools. And not only did they represent themselves, they also advocated for disability and especially blindness in a very real way. And they did it with such panache.
I was lucky enough to be invited to his house to help him with piano, you know, show him some scales. I think he made quite a comfortable living, really, and again I admired his independence.
In 2010 I was invited to a workshop with other blind musicians and Steve, Babsy and Koloi were there and I think they kind of believed that if music worked for them as blind people, who were disenfranchised, it probably should be able to work for everybody else. But it’s sad to look at people from just one dimension. He was many things.
How should we remember him?
I think maybe that’s how we could remember him: he was just another ordinary human being who did extraordinary things. In the way that all other great people do in this world.
Spike in COVID-19 cases points to gaps in South Africa’s response
- Laetitia Rispel
Preventing new infections and containing the pandemic protects health systems from getting close to collapse.
The numbers of COVID-19 cases and deaths in South Africa have increased exponentially over the past 12 months. At the beginning of July 2020 the country had 168,000 cases of COVID-19 and 2,844 deaths. A year later, at the start of July 2021, there were over two million confirmed cases and more than 61,000 deaths. These numbers are only a snapshot of the kind of pressure South Africa’s healthcare system is under. On the one hand, the country needs to drastically increase the number of frontline health workers. And on the other hand, there’s not enough money, according to acting health minister Mmamoloko Kubayi, to employ medical interns, or even extra medical staff. Laetitia Rispel chaired the ministerial task team responsible for the development of the 2030 National Human Resources for Health Strategy. She spoke to The Conversation Africa’s Ina Skosana about the country’s COVID-19 response.
How is South Africa coping with the current wave?
The country is not coping. I think the third wave could have been avoided. There’s been a lot of focus on the vaccination programme. Although vaccination is important, you can’t look at the vaccination programme in isolation from the overall response to the pandemic.
Things could have been done differently.
First of all, the government declared COVID-19 a national disaster in March 2020. That was an opportunity for the National Department of Health to provide strong leadership for the entire health system. But the national department has either remained quiet, or played a supportive role to the pandemic response in the nine provinces. Consequently, the COVID-19 response has varied across the country. In a crisis like the pandemic, you need strong central leadership and management.
Second, there’s been a lot of attention on the ability of hospitals to cope. The first step of any public health response must be prevention. Preventing new infections and community transmission, and containing the pandemic protects health systems from being overwhelmed or getting close to collapse.
By the time hospitals are overwhelmed by people who need admission, it is almost too late. Gauteng is the epicentre of the current surge. The province’s early warning system showed increasing numbers weeks ahead of the surge. Yet very little was done to contain those infections, or prevent a rapid increase.
There has been insufficient involvement of civil society and ordinary community members.
There’s a certain degree of COVID-19 fatigue. But many people still don’t understand why non-pharmaceutical interventions – social distancing, hand washing, wearing masks – are important.
What are your biggest concerns?
There’s a chronic under-investment in the health workforce – the pandemic has exposed and amplified this. This is apparent in the reported shortages especially to deal with the people who are seriously ill and need to be admitted.
You can have as many hospital beds as you want. But if you don’t have the skilled staff to look after patients, then people won’t receive quality care or care at all.
There’s also been a failure to deal with the concerns and fears of frontline health workers. I don’t think there’s been sufficient attention to the psychosocial and emotional impact of the pandemic on these workers. The potential consequences are physical and mental exhaustion, stress, anxiety, and burnout. This could lead to medical errors, lower productivity, increased absenteeism and higher turnover, thus creating a vicious cycle.
What’s been working?
There are areas of innovation that we should recognise. For example government and South Africans were able to put together, at relatively short notice, significant financial resources. Digital innovation included the COVID-19 Alert App, the early warning system of hotspots or clusters of infections and the ability to get daily updates on COVID-19 infections and deaths.
One of the positive aspects was the “whole-of-government” approach and inter-governmental structures that were set up. These enabled different government departments and entities to work together, rather than in silos.
The other thing we have to acknowledge is the visible political leadership. There was very decisive leadership from the president at the early stages of the pandemic.
Hospital and district managers, as well as frontline staff, rescued the day. They went way beyond the call of duty. For instance, frontline nurses and doctors had creative ways of keeping communication going with family members who were not allowed to visit patients. There was a newfound public appreciation for frontline nurses and doctors.
I think the institutionalisation of public health measures is an amazing achievement. Wearing masks, handwashing and sanitising were adopted quite quickly. Compliance and enforcement, however, are still key issues.
What should be done?
The first thing is to strengthen and stabilise leadership and management. If people are in acting positions they are less likely to take risks and make tough decisions. Given the speed with which the pandemic is growing, it’s important to have rapid decision-making.
The second thing is to engage with and involve ordinary people. This can be done through existing community structures. South Africa can build on the experience of managing the HIV epidemic to get public buy-in. People must understand that it’s only through working together that we’ll be able to prevent new infections, contain the spread of infections, and save lives and protect our future.
The third point is the importance of investment in the health workforce. Without health workers it’s not possible to fight a pandemic, or have a functional health system.
Finally, it’s important to act on the data generated by information systems. What is the point of investing in health information systems when you don’t respond to the message? The government needs to take swift action at the first signs of hotspots and not wait for infections to spread.
South Africa in flames: spontaneous outbreak or insurrection?
- David Everatt
Corruption thrives in a destabilised state with weak institutions. South Africa cannot be allowed back to that space because there will be no turning back.
South Africans spent most of mid-July glued to their news outlets, from established media outlets to TikTok, from streaming news to old-fashioned printed words, to see just one thing: would Jacob Zuma blink? Would the country finally get some taste of revenge for the state capture, looting, destruction of institutions and threats to the country’s democracy their former president had enabled and championed? Would the rule of law win?
The rule of law won. The institutions that had been so assiduously hollowed out under the nine years of his presidency had flexed their new-found muscle. The Constitutional Court had long held firm, the police were rather more wobbly, but despite much assegai-rattling by family members and the Zuma Foundation, into prison he went. No ANC leader expressed joy, only sorrow that the man had fallen so low; for people not in such elevated positions, it was a rare moment of jubilation in the midst of a global pandemic that has us locked down, again.
Protests that had been low key since he was arrested on Wednesday night exploded into an an orgy of looting, marching, xenophobic attacks, arson, truck-burning, stabbing and shooting, and blockading of roads and freeways (among others) by Sunday. It seemed – and Zuma’s allies and (adult) children were quick to preach the word – that he was so popular and such an object of sympathy that a spontaneous outbreak of bloody violence and theft was unavoidable, and a dark portent if Zuma was not immediately released. Prescience seemed to have replaced profligacy.
The stakes were (and remain) exceptionally high. Thanks in part to the commission of inquiry into state capture and corruption Zuma had both established and later refused to attend, Zuma is now known to have allowed the Gupta family, using organised crime money-laundering vehicles, to bankrupt the state. As has been noted, fish rot from the head. From the time that he was fired by former president Thabo Mbeki (in 2005) to date, Zuma has deployed his infamous Stalingrad legal strategy. In effect, he has been fighting every single item in court while adopting the victim stance of a man more sinned against than sinning.
Sadly, Zuma is not a Shakespearian hero, but a man of decidedly clay feet. For nine years as president, he outmanoeuvred pretty much all and sundry – he reshuffled cabinets to destabilise opponents; he forced the Whip and faced down multiple votes of no confidence; he allowed R50 billion to be stolen by his friends, the Gupta family – all now safely in Dubai – and ran state and party as both cash cow and defensive wall.
He met his match in Cyril Matamela Ramaphosa, who succeeded him as ANC and national president. Ramaphosa has moved with the cold, calculating methodology that proves him to be the real chess master (Zuma has a passion for the game). Ramaphosa has outmanoeuvred Zuma and many of his allies in the ANC (such as secretary general Ace Magashule). He has done this by trying to resuscitate the organs of state, investigation and prosecution that had been severely damaged by his predecessor.
The rule of law – which took a pummelling over the last decade – seems to be out of rehab. Zuma may only be in prison for a contempt charge – but the notion that the first ANC leader in orange overall would be Zuma was not a fantasy that played out as realistic in most imaginations.
Why the violence
Many reasons have been offered for the violence, looting, racist bile and bloodshed that erupted. These include:
the pent-up frustration of hungry and cold people facing few prospects for socio-economic improvement;
inequality and the gulf between the conspicuous consumption of the “made it” compared to others;
ethnic tensions within the ANC, with the president representing a “minority” tribe and apparently lacking legitimacy;
good old stereotypical Zulu nationalist violence was breaking out as it did in the early 1990s;
internal ANC factional tensions were spilling onto the streets; and more.
All of these have some truth. Yet none provides a narrative thread that ties together these disparate issues and scattered but clearly organised acts of violence. Part of the gap in our understanding is how a middle-of-the-night incarceration of Zuma – albeit done in the blaze of TV arc lights – led to such a widespread and destructive but apparently spontaneous outbreak.
This narrative suits Zuma and his supporters perfectly: pity for the victimised former president unleashed patriotic fervour that was unstoppable, proving his popularity and victim status. Family, the Zuma Foundation and others all began pumping out the narrative – much as Zuma’s daughter tweeted the video of a gun firing bullets into a poster of Ramaphosa. Subtlety did not play much of a role.
But when the Minister of State Security reported on the morning of Tuesday 13 July that her spies had managed to stop attacks on substations, planned attacks on ANC offices and in Durban-Westville prison, things began to look different. How did they know of the plans, and for how long? Who was doing the planning? How did they stop it?
When “impeccable sources in the intelligence service and law enforcement” warned of arms caches at Zuma’s home, Nkandla; when we recall that the police admitted to “losing” some 20,000 weapons in the 2000s, as had the State Security Agency, we are permitted to ask uncomfortable questions.
Suddenly the acts look rather more organised and rather less spontaneous.
Neeshan Balton, executive director of the not-for-profit lobby group, the Kathrada Foundation, has suggested that part of the strategy was a wildfire – strike lots of matches and just let them burn whatever is in their path to destabilise the democratic project.
This too is premised on the existence of a plan.
The danger with suggesting that this was not at heart a set of random acts by poor people who were overcome by emotion at the thought of Zuma in prison but rather a (more or less well) planned and executed attempt to destabilise the state is that rather than “joining the dots” as Public Enterprises Minister Pravin Gordhan advised, one may be constructing a crazy conspiracy theory.
The definition of insurrection is to rise against the power of the state, generally using weaponry. Conspiracies exist. From dark warnings of another massacre like the one at Marikana in 2012 should Zuma be touched, to planning sabotage against municipal infrastructure, and fanning the flames of xenophobic violence, it seems very difficult to ignore the planned insurrection at hand.
Poor and hungry people exist, and the state should be ashamed. But hungry people do not become violent looters on behalf of better-known looters who are in jail. They may well be available for mobilisation (looting, violence, marching) behind the organisers – but it is the organisers that need to be brought to book, and who must also face the rule of law.
Corruption thrives in a destabilised state with weak institutions. South Africa cannot be allowed back to that space because there will be no turning back.
South African riots and food security: why there’s an urgent need to restore stability
- Wandile Sihlobo
South Africans should not panic about the food system. But authorities will need to act swiftly and assertively to restore stability.
When South Africa’s president, Cyril Ramaphosa, addressed the nation on July 12 amid violence and destruction of property in parts of KwaZulu-Natal and Gauteng provinces, he warned of several risks if the situation was not resolved swiftly. One of them was food security.
A lot has been written about the acts of criminality and the disregard for the rule of law that’s swept parts of the country. Attention has also been given to the underlying factors that make the South African society so fragile. These include rising unemployment, inequality, corruption and poor service delivery.
In light of the ongoing state of turbulence it’s important to take a closer look at food security issues.
South Africa is generally a secure food country at a national level. On top of this it is a net exporter of agricultural and processed food products. Last year agricultural exports reached the second-highest level on record of US$10.2 billion following a favourable production season.
But food security is about more than just having sufficient supplies. It also requires food accessibility, affordability, nutrition and stability over time.
This is where the challenge lies.
Continued disruption will affect supplies given the specifics of South Africa’s food supply chains. KwaZulu-Natal, the epicentre of rioting and looting, is a major producer of various agricultural products such as sugar, milk and poultry products. The province also serves as an entry for imported food products, including wheat, rice, poultry products, and palm oils. Gauteng, the other province also most affected, is one of the major food processing hubs.
However, South Africa’s food supply chains are not concentrated in one particular province. The biggest risk in the short term is the free movement of goods, including food and agricultural produce on the roads, specifically to and from the Durban port, the entry and exit point for agricultural imports and exports.
The other risk relates to increased income poverty because of the destruction of businesses.
Food production and consumption
In the same year as record production figures, the country experienced an increase in hunger, as identified in the National Income Dynamics Study – Coronavirus Rapid Mobile Survey (NIDS-CRAM).. But this wasn’t necessarily an issue of food shortage or a rapid increase in food prices. It was mostly because people were out of work and had reduced means to buy food.
In 2021, South Africa again enjoyed another season of an abundant harvest following favourable summer rainfalls. This means that there are unlikely to be food shortages this year, but rather ample supplies for local consumption and export markets. This will be true for major grains, fruits, meat and various products.
Still, this doesn’t mean everyone in the country is food secure. Or that prices won’t rise rapidly.
There are long-standing challenges with income poverty in South Africa and the extent to which the poorest people are able to afford nutritious food. Still, food prices have only risen negligibly. South Africa’s consumer food price inflation was at 6.8% year on year in May 2021, from 6.7% year on year in April, according to data from Statistics South Africa. This is not an alarmist rate as we have seen double-digit inflation rates in years of drought such as 2016, where consumer food price inflation averaged 10.8% year on year.
The expectation is that consumer food price inflation could in fact soften in the second half of 2021.
Therefore, Ramaphosa’s emphasis on the risks to food security in his address on July 12 was primarily focused on KwaZulu-Natal. The main challenge is a disruption due to the looting spree, forcing companies to avoid volatile areas so as not to expose their property and employees to danger. It is far from clear how long the unrest in KwaZulu-Natal will last.
Menacingly, no one can tell with certainty if waves of protest will not spill over to other provinces in ways that disrupt business and supply chains and affect livelihoods. If the wave of violent protests continues unabated, it could pose a risk to food security, with the poorest people most affected as their employment and livelihoods will suffer. Small businesses in particular might be forced to close given the scale of the continuing violence.
But South Africans in other parts of the country that have not seen outbreaks of looting and violence should not panic about possible food shortages.
Production patterns
KwaZulu-Natal has been the most affected by the violence. But the province isn’t the epicentre of agriculture in the country. It isn’t an anchor to the South African food system. Provinces in central South Africa – the Free State, Gauteng, Mpumalanga, North West and Limpopo – hold far more key positions. This is because of their abundant agricultural production and food processing capacity.
Maize meal and wheat flour – both staple to most South African diets – are primarily produced in the Free State, Mpumalanga, North West and the Western Cape. These provinces account for over 60% of production of each of these grains, and process over 50% of them.
KwaZulu-Natal processes roughly 8% of the 11.5 million tonnes of maize consumed in South Africa each year. In wheat, KwaZulu-Natal processes roughly 21% of the annual consumption. The numbers vary per product, but the point here is that food supply chains are not concentrated in one particular province.
There is no risk of food shortage currently from other anchor provinces. But the risk comes when there is no fuel for transport within the country, given the force majeure that the refinery in Durban has declared. It is South Africa’s largest refinery, accounting for 35% of the country’s refining capacity.
I highlight this because a large share of South Africa’s food is transported by road.
In the case of trade, the current disruptions weigh even more heavily on businesses and farmers in agriculture. On average, 75% of the country’s grains are transported by road annually. These are largely exported through the Durban harbour. The same is true for imported food products such as rice, wheat and palm oil, among other products. The volumes are also large for horticulture, specifically citrus, a leading exportable agricultural product in South Africa.
The burning of trucks on the roads and the blocked routes to the ports will prove costly to businesses and harm South Africa’s reputation as a global supplier in various value chains. This will also negatively affect the province’s food supply chains.
This needs urgent intervention, especially as agricultural products are perishable and the country is entering an export period for citrus in a year of a record harvest.
As South African authorities grapple with achieving stability, there needs to be a deeper introspection about ensuring that the country creates an environment conducive for businesses to thrive. And that it addresses the social ills that underlie instability and disregard for the rule of law.
In the near term, South Africans should not panic about the food system. But authorities will need to act swiftly and assertively to restore stability.
From the flames of looting to democratic regeneration
- Tracy-Lynn Field
Over the past week, democratic constitutionalism and the rule of law have undergone a massive stress test.
The power to determine the outcome of this stress test can never lie in the efficacy of the police services or the defence force. It lies with the choice of the people of South Africa.
Apocalyptic. This is just one of the words used to describe the destruction of property and tragically, life, that has ensued in the wake of the mad outburst of collective energy in South Africa over the past week.
Whether you choose to see the blockading of roads and burning of trucks that have throttled critical supply routes and the violent razing of shopping malls and warehouses as a form of protest, a coordinated strategy of economic sabotage, or simply the unsurprising response of a population seething under the harshness of life in one of the most unequal societies in the world the impact is the same: shock, disbelief, despair, trauma.
Perhaps most fearful is the thought that what has gone up in flames and lingered for a moment in a searing pall of black smoke is the hope of South Africa’s constitutional democracy itself. Unless we stop the violence, unless we bring in more troops and declare a State of Emergency, some have said, our underlying democratic order — instituted with such hope and fanfare almost 30 years ago — is at stake.
And this is true. Over the past week, democratic constitutionalism and the rule of law have undergone a massive stress test, caught between those who wish for a broad-ranging and thoroughgoing destruction and breaking down, and those who wish to continue to struggle forward. But the power to determine the outcome of this stress test can never lie in the efficacy of the police services or the defence force. It lies with the choice of the people of South Africa. All 58 million or so of us.
In the weeks before the eruption of the worst violence of South Africa’s democratic history I had been painstakingly writing an academic article about democratic sovereignty and the possibility of transformative change. To do this, I engaged with scholarly debates about “transformative constitutionalism”.
Mirroring the material and visceral struggles that have played out on the streets this week, this debate is polarised: On the one hand, “constitutional abolitionists” see the 1996 Constitution as a betrayal and argue for a wholesale overhaul to the philosophical, historical and cultural basis of the South African governing order. On the other, “constitutional optimists” are faithful to the Constitution itself as a moral, political and jurisprudential lodestar for South African society.
Neither position is correct, however, because the moral and political lodestar is the South African people itself, thedemosof self-governing equals who came into beingthroughthe Constitution in a quest to rule themselves. While thedemoscan be guided by constitutional values and the incremental and accumulating constitutional jurisprudence of the courts, or by the much older values of ubuntu and other occluded epistemologies, it is the choice of the present generation of South Africans that matters.
With the flames of looting starting to die down, what emerges from the ashes is that the vast majority of South Africans choose regeneration over destruction. Through their actions and reactions, physical and verbal, the majority of South African people across racial, gender, ethnic and class lines are exercising their constituent sovereign power to say (reflecting back the words of an exhausted President Cyril Ramaphosa): “This is NOT us.”
A WhatsApp message this morning from a friend who has been in the thick of the conflict in KwaZulu-Natal says it all: “We have not slept since this started. Now we pray for peace and a miracle. We are resilient people. Let’s hope they are done and we can start to rebuild.”
We are a resilient people.
As the people who are now inspiring hope and courage get to work on mopping-up operations and help those at the coalface of the devastation, it is worthwhile to recall why the South African democratic constitutional order was hailed as a miracle. It was a miracle because there was no pre-existing basis to talk of a South African “people”; we were a mishmash of different races, classes and ethnicities with vastly conflicting worldviews. We were bitter enemies driven apart by walls of fear.
The naysayers of South Africa’s experiment in inclusive democracy have been quick to give up, pointing to the democratic deficit associated with the drafting of the 1996 Constitution and the way it was bound to the terms of a negotiated settlement, the continuing and even deepening inequalities that the constitutional order has failed to address, and the immense challenges that still lie ahead. But they have underestimated the extent to which the South African peoplearebeing knitted together and are coming into being through our collective experiences of triumph (Rugby World Cup!) and suffering (looting, Eishkom, Day Zero, and the days-of-our-lives State Capture Commission, to name but a few).
The South African people choose regeneration and hopefully, when the next election rolls around we will remember those who affirmed protest, but called for restraint and those who preferred the way of destruction.
Affirming democratic regeneration does not mean we don’t need change or that we should not be urgently interrogating the effectiveness of our democratic institutions to stem the looting culture that has bedevilled our country’s progress for so many years — at all levels of society, in government and the private sector and across all lines of difference.
We need to find ways of holding accountable those who grab without regard for others and who thereby destroy what is in the common and public interest. To do this we must use all the forms of governance that a system of self-rule allows, including protecting functioning systems of customary law. We are resilient people, but we need leaders who will take this kind of change forward.
We are a resilient people. We have gone through a lot, but we somehow always come out on the other side. May the flames of democratic regeneration burn bright in our country. South Africans, we can do this thing.
The vulnerable points in South Africa’s fuel supply chain
- Rod Crompton
The glaring failure by authorities to secure an area notorious for attacks on trucks prompts questions about, at best, utter ineptitude, or at worst, complicity
Oil companies and governments are usually awake to the strategic role played by liquid fuels and have special measures to protect supply and logistics. Much of South Africa’s measures are apartheid era hangovers that have eroded with time. Periodic risk assessments have been done, but many assumed a calm society. It seems there was inadequate attention given to the risks imposed by a broken social compact.
So where do the biggest risks lie?
South Africa has always been heavily dependent on imported fuel. Its synthetic fuel (from coal) capability – developed during the apartheid era to overcome the oil sanctions imposed by the United Nations – accounts for the balance.
But the risk to imports seems low. The world is awash with oil and refined products . This is due to the slump in demand triggered by lockdowns to contain the spread of Covid-19. There seems little risk of global shortages, apart from the usual refinery fires and supply disruptions.
The OPEC cartel still tries to manipulate prices. At the same time they don’t want to strangle demand. In addition its power has been tempered by a massive increase in production by unconventional producers, such as the fracking industry, in the US. North America is now one of the world’s largest producers of oil.
This leaves frontline security risks to fuel supply in South Africa. Fears that the country would run out of fuel arose last week following an outbreak of looting and infrastructure destruction. Most of the destruction was centered in the country’s economic hub Gauteng and Kwa-Zulu Natal on the east coast and home to one of Africa’s largest harbours.
From the patterns of violence over the past week it appears that the threats to fuel supply are land based. They come from following types of groups:
organised crime (mafias). The South African construction industry has been beset by local racketeering mafias armed with automatic weapons demanding “protection” money.
small time thieves
occasional looters, and
weak or complicit policing. The institutional weakening of law and order that took place during the “state capture” period associated with President Jacob Zuma’s term of office, may have been a contributory factor.
The attacks that have taken place seem to have been made by one or more of these groups acting in concert – by design or by coincidence. Which groups are involved can depend on local conditions.
Who is, and who isn’t, doing the damage
The fact that certain groups managed to close the economic umbilical cord – the main road from South Africa’s largest port in Durban to its industrial heartland, Gauteng – for several days reveals some level of organisation and determination as well as the weakness of the authorities.
Most of South Africa’s fuel is delivered by ship. Unlike countries like Somalia and Nigeria, South Africa’s domestic mafias have not yet expanded into piracy.
Crude oil is delivered by very large vessels to the single buoy mooring off-shore Durban which is visible from shore.
But no nefarious groups have yet shown any marine proclivities. In addition, crude oil has no immediate local value given that it still needs refining. The single buoy mooring seems low risk for the time being.
What about the risks to refineries?
The immediate threat to a refinery is a workforce that cannot get to work and back. The next threat is posed by capacity. Refineries produce large volumes. If their downstream distribution network is obstructed, they have to close for fear of drowning in their own product.
This is what lay behind the decisions by Shell and BP to close their refinery in Durban last week.
South Africa also imports petroleum products, delivered by ship to the main ports Durban, Richards Bay and Cape Town, where it is discharged through loading facilities into nearby storage tanks in the harbour area.
To steal that fuel you need at least one large truck. This wouldn’t be easy to sneak into a harbour, unless the security at the harbour gates is complicit. Most of this kind of theft has been more along the lines of fraud in the paperwork, such as false volumes, which the oil companies are continually countering.
From the storage depots the fuel is loaded onto road tankers for delivery to service stations and customers. This is where the fuel logistics chain is at its most vulnerable. To restock service stations in and around Durban, private security services have since late last week been escorting road tanker convoys with the law and order authorities unseen.
Road tankers are slow soft targets often moving through built up areas.
The rioting and insurrection in KwaZulu-Natal started with the torching of more than 20 trucks on the main road from Durban to the industrial heartland at the sleepy town of Mooi River. Attacks on trucks have happened repeatedly at this location for several years. It is inexplicable that law enforcement authorities appear to have done nothing about it.
It is such a glaring oversight that it prompts questions about, at best, utter ineptitude, or at worst, complicity.
A lot of people know about fuel’s explosive qualities and although there are those who might take a chance, stealing petroleum products is more the preserve of mafias. This was evident in the theft of several million litres from a pipeline at Van Reenen – some 270 kms from Durban – where several large road tankers were arranged to cart the fuel away.
The state owned pipeline operator, Transnet Pipelines, has reported an “unprecedented increase” in incidents of pipeline theft in recent years.
The point is that arson attacks on fuel installations is literally sending money up in smoke, which even criminals don’t like. Not so, insurrectionists.
Inland there are further storage depots in the logistics chain. They are required by law to install certain protective measures. These appear to have either worked, or they haven’t been on the radar of those seeking to do damage.
From these depots fuel is road-hauled to service stations and retailed to motorists.
Because South African law prohibits motorists from filling their own vehicles, service stations normally have several pump attendants on hand and are well lit at night, making them relatively safe. In the current round of unrest many service station proprietors have locked up shop, making it difficult for thieves to access underground storage tanks.
South Africa will need to reassess it’s risk profiles at each link in its on-land fuel supply chain. Currently the most vulnerable seem to be the refineries, road delivery, and the transport corridor from Durban to Gauteng – both pipeline and road.
What drove South Africa’s recent violence and looting and what to do about it
- Ozayr Patel with David Everatt
Pasha 117: South Africa's recent violence is a cause for concern but there are opportunities to build a stronger nation.
After former president Jacob Zuma was recently arrested for contempt of court, South Africa went into disarray. Widespread looting, vandalism and violence broke out. Two provinces – Gauteng, the country’s economic hub, and KwaZulu-Natal, on the east coast – bore the brunt of this. What was initially premised on Zuma’s arrest transpired into something much more coordinated, controlled and dangerous.
Many reasons for the violence have been noted. These include:
the frustration of hungry and cold people whose prospects were already constrained by the pandemic;
inequality between rich and poor;
tensions within the governing party;
stereotypical Zulu nationalism; and
racial tensions in the country.
It cannot be ignored that these incidents speak of insurrection - which means to rise against the power of the state, generally using weaponry. In today’s episode of Pasha, David Everatt, a professor of urban governance at Wits University, discusses the elements that led to the violence and how the government must deal with it.
TB prevention has relied on the same vaccine for 100 years. It’s time for innovation
- Bavesh Kana
BCG remains the only widely available vaccine for TB but the COVID-19 vaccine shows that there is capacity to rapidly create new vaccines.
TB is one of the oldest infectious diseases in recorded history. Most of the people who are ill with TB live in low- and middle-income countries where this disease is one of the leading causes of death. This is particularly distressing given the fact that TB is preventable, treatable and curable. But there’s currently only one vaccine approved against TB. And it is 100 years old. The first dose of the Bacille Calmette-Guérin (BCG) vaccine was administered on July 18 1921. The Conversation Africa’s Ina Skosana poses key questions to Bavesh Kana, one of South Africa’s leading TB researchers.
It’s been 100 years since the BCG vaccine was first used to vaccinate against TB. Why haven’t there been any breakthroughs since then?
The BCG vaccine was developed from a strain of bacteria referred to as Mycobacterium bovis. These organisms closely resemble the bacteria that cause tuberculosis disease in people (Mycobacterium tuberculosis) and are usually found in animals that have tuberculosis-type disease.
The vaccine was generated over a period of 13 years (roughly from 1908 to 1921) by two French scientists, Albert Calmette and Camille Guérin, hence the name – Bacillus Calmette-Guérin.
At the time, they couldn’t have known that it would become one of the most widely administered vaccines in human history. BCG has been used all over the world to protect against the development of TB. However, because TB has primarily been a disease of the poor, there has been insufficient investment in the development of new vaccines over the past century.
Currently, BCG remains the only widely available vaccine for TB. This is sad, as the rapid mobilisation to develop a COVID-19 vaccine over the last year has demonstrated that the world has the capacity to rapidly create vaccines. Yet a new TB vaccine has languished for decades because of poor funding, insufficient resources and diminished political will. Millions have died, something I believe that we now appreciate with a new urgency in the context of COVID-19.
Vaccine innovation is needed for TB because the protection provided by the existing vaccine wears off over time, and it’s not completely effective in adults.
Developing vaccines and treatment is an incredibly costly undertaking. Conducting multi-centre clinical trials to demonstrate safety and efficacy in different populations over a period of years can cost billions. This requires concerted investment through partnerships with all stakeholders including the governments of TB endemic countries.
How effective is the vaccine?
BCG is usually administered only in infants, immediately after birth, in countries that have a high incidence of TB. The vaccine then produces an early immune response that has been demonstrated to protect children against severe forms of TB. In particular, BCG protects very well against the development of disseminated forms of TB. Usually TB occurs in the lungs, but the bacteria can also be found in other parts of the body – this is called dissemination. In children, the bacteria can be found in the brain – this is called TB meningitis. The BCG vaccine is very effective at protecting against TB meningitis and is a great example of how vaccines can be of huge benefit.
However, this immunity usually wanes in adolescence and thereafter. Protection by BCG in adults is highly variable – ranging from 0% to 80% depending on the country and environment. The reasons for this remain a mystery and much effort has been placed recently in developing biomarkers that will identify which new vaccines will eventually yield long-lasting immunity. Biomarkers are signals that one can pick up in blood or other clinical specimens that give a predictive sense of whether a vaccine is going to work. If a certain set of signals in blood predicts good protection, we can check if a new vaccine also induces the same set of signals.
How close are we to a new TB vaccine? What are some of the promising developments?
We still have some way to go. Recently, there have been two promising developments.
The first is a study that demonstrates that re-vaccination with BCG does indeed provide protection against TB disease. This is exciting as BCG is an approved vaccine and if this approach demonstrates sustained durable protection, rolling out mass vaccination campaigns will be easier than starting with a novel vaccine.
The second comes from a study that demonstrates a new vaccine from GSK (M72/AS01E) gave good protection in a clinical trial setting. In 2020, this vaccine was licensed to the Bill & Melinda Gates Medical Research Institute for continued development.
Despite the critical role of the PHRU as part of the national and international Covid-19 response team, it was not spared during the recent unrest.
Loss of scientific equipment, research and infrastructure as well as threats to researchers’ safety compromises the ability to conduct the clinical research needed to address the pandemic and epidemics like HIV and TB.
More than 15 years ago, the Perinatal HIV Research Unit (PHRU) established its first adolescent and HIV research clinic in Kliptown, quite literally doing ground-breaking research on the ground. We chose Kliptown because of its historical significance as well as the desire to dignify this auspicious square with the clinical science that it deserved. Right across from our offices and clinic, 76 years ago, in this square now known as Walter Sisulu Square, the Freedom Charterwas signed, setting out the aspirations of the opponents of apartheid.
The Freedom Charter emphasised a non-racial society, liberty and individual rights. This Charter is seen by many as the foundation of South Africa’s 1996 constitution. In the spirit of this legacy, we established the Kliptown Research Clinic employing almost 50 people with more than 80% of employees living in the surrounding areas. We never lost sight of the significance of having our research site on the square.
Significant too, is the research we have done here, that has had a global impact. Established in 2008 as the Kganya Motsha (translated as “shine young one” in Sesotho) this site was the first in Soweto to provide youth-friendly HIV prevention, outreach, HIV testing services and psychosocial support to adolescents and young people. We extended this to doing medical research and exploring whether a gel containing an antiretroviral agent, tenofovir, could be used as a vaginal microbicide to avert HIV in young women.
We too have enrolled in pivotal HIV vaccine efficacy trials that contribute at a global level to the scientific assessment of what it will take to mount an immune response adequate enough to prevent HIV acquisition. Soweto is an HIV transmission hotspot and the most densely populated geographic location in South Africa. Given the high HIV prevalence and incidence, and lack of acceptable prevention modalities, a moderately efficacious preventative HIV vaccine or long-acting pre-exposure prophylaxis (PrEP) would be a critical contributor to ending the HIV pandemic. We are proudly trying to find the HIV holy grails, and our site is critical to this endeavour.
Although we have been part of the two most important and largest HIV vaccine trials in Africa, more recently and maybe more importantly, when Covid-19 struck our country, we rapidly availed ourselves to conduct the first-ever Covid-19 vaccine trials in South Africa. We were involved in the Chadox/Astra-Zeneca study that showed significantly reduced efficacy against the so-called South African or Beta variant.
We contributed to the selection of Covid-19 vaccine candidates for the South African national vaccine roll-out by implementing the Ensemble trial of J&J’s single-dose Ad26 vaccine. This trial was the precursor to Sisonke, the study which made 500,000 Ad26 vaccines available to healthcare workers as an implementation study when the government’s roll-out faltered. The Kliptown staff supported the vaccination drives at Chris Hani Baragwanath Academic Hospital and a private facility in Lenasia.
Our site, headed and run by a predominantly female team, has forged relationships with the tenants on the square and supported local entrepreneurs to ensure we can all co-exist and thrive together in the Kliptown community.
The Perinatal HIV Research Unit (PHRU) Centre entrance wall that was vandalised to gain entry to the clinic. (Photo: Anusha Nana)
Tragically, Walter Sisulu Square and the surrounding businesses were some of the worst-hit places in Gauteng during the recent violent and destructive riots. Shops and medical practices were looted, some burnt to the ground, and owners and tenants left destitute. Barely any of the tenants of the Square’s office building were left unscathed. Many of these businesses provided much-needed services to the community, including our clinic and neighbouring establishments such as New Heights which provide entrepreneurial and life skills courses witha special focus on women, youth and the unemployed.
Despite the critical role that we play as part of the local and international Covid-19 response team, our site was not spared during the riots. Opportunists broke into our main facility and stole all electronic equipment, including desktop computers, laptops, printers, mobile phones, televisions for participant education and a washing machine used to ensure sanitised staff scrubs.
They also took all our stethoscopes, blood pressure machines and space heaters. It will be difficult to restore the functioning of this once vibrant floor, as the taps stolen from the Square’s main restrooms and vandalised toilets have resulted in the water supply for the entire building having to be turned off.
With no water access and absolutely no ablution facilities in the entire building — a worrisome health hazard to the already traumatised tenants amid the third wave, this will impact on our ability to restore clinical research. Although we have suffered a chronic lack of access to adequate basic services to the building, we have always made a plan.
For example, the facility has been without electricity since 15 December 2020. We installed generators to run the research freezers and fridges in which the vaccines are stored but this came at an estimated cost of R4,000 a day in diesel. When nothing was done to rectify the situation, we were forced to hire private contractors to connect the site to the main power supply. However, we had to dip into the minimal resources that we had to do this and now do not have sufficient funds to extend this to the other tenants who remain without power.
Clinical science does not operate in a vacuum and is part of the ecosystem of communities. Loss of infrastructure and equipment, threats to researchers’ safety, and an inability to keep research clinics open in the field compromise our ability to do the clinical research needed to address this current pandemic and other pandemics or epidemics like HIV or TB. Loss of this ability makes us all the poorer.
So, despite all our challenges: looting, poor infrastructure support, security concerns, we are resilient and resourceful. We remain committed to Kliptown, because of our passion, a sense of community and love for the research we do. We will rebuild our site. Science can have setbacks, Kliptown can have setbacks, but our phoenix will rise again. Much like the phoenix — the long-lived bird that cyclically regenerates or is otherwise born again — we will obtain new life and will continue to make a global impact.
Anusha Nana, Erica Lazarus, Fatima Mayat and Ravindre Panchia are with the Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand. Professor Glenda Gray is with the PHRU, the South African Medical Research Council and a Research Professor at Wits University. This article was first published in Daily Maverick/Maverick Citizen.
Building an art gallery in the midst of war in Zimbabwe
- Tinashe Mushakavanhu
Gallerist and writer Robert Huggins and his wife, the artist Helen Lieros, have passed away.
After being disenchanted with his work as a detective inspector in Rhodesia’s British South Africa Police, Derek Huggins quit his job and in 1975 decided to open an art gallery. The venture, Gallery Delta, is now an important institution in Zimbabwe’s art history. His partner and collaborator was his wife, Helen Lieros, a talented artist in her own right.
While we knew that a tiny gallery of three rooms in the midst of conflict and war and sanctions would not make a living for us … in those years it was run as a voluntary, part-time, weekends, nights occupation.
After running the gallery for 46 years, the couple have died in Harare, a week apart, but their legacy will live on.
In the four decades of their stewardship of the gallery they were involved in the curation, organisation, presentation and promotion of approximately 500 exhibitions. Their art magazine, placed in schools, became a vital resource for artists and art historians in Zimbabwe.
A love story
Huggins, born in Kent, England, moved to Rhodesia when he was 19 to join the British South Africa Police. He writes of his experiences in his 2004 book, Stained Earth. And Lieros, who was of Greek parentage, was born in Gweru, Zimbabwe, where she was a school teacher.
They met at a police station where Huggins was based, while Lieros was engaged as a composite artist who drew images of suspects. Their romance blossomed and they married in July 1966. As a union they extended their influence, amplified everything they achieved and uplifted everyone they interacted with.
I first met them in the early 2000s when I worked as a publishing assistant at Weaver Press, a small publishing house in Harare. Gallery Delta, their enterprise, has always been a favourite venue for book launches in the city. People would congregate there to hear authors read and for the free wine.
In 2018, as an academic researcher, I found a collection of letters between Huggins and the celebrated writer Yvonne Vera deposited at Amazwi South African Museum of Literature. For the past three years we have been exchanging emails, or if I am in Harare, drinking and bonding over tea while we discussed this book of letters I am editing.
The First Act
Gallery Delta’s formative years were at Strachan’s building in Manica Road (now Robert Mugabe Road) in downtown Salisbury (now Harare). It was a new, radical space in a city whose art world revolved around the National Gallery of Rhodesia (now the National Gallery of Zimbabwe) under Frank McEwen, who was at the time invested in promoting the country’s Shona stone sculpture tradition while neglecting other art forms. There were small art organisations and societies but no art schools or other exhibition galleries to talk about.
Huggins said of the time: “Consequently, we looked for young, talented and aspiring Africans who would rather be painters than sculptors. They were almost non-existent. There were few facilities for serious art study. It meant commencing at the beginning to encourage and promote a new movement in painting. One of the ways in which we undertook this was to promote a Young Artists exhibition at the beginning of every year but nonetheless few, if any, good African painters emerged at this time.”
For Huggins and Lieros, building a community was at the core of their work. Before opening the gallery they had been members of The Circle – a radical group of 12 painters. The group was responding to the political chaos of the decade – as a liberation war was being fought by Zimbabweans against white minority rule – but it also became a collective means to deal with the unrest. It was this spirit the new Gallery Delta fostered.
From its inception The Gallery also served as an alternative venue for art exhibitions, multiracial theatre and jazz performances during this tense environment prior to independence in 1980. But when the owners of the Strachan building decided to sell, they were forced out and had to look for a new home.
The Second Act
In 1991, Colette Wiles, daughter of the painter Robert Paul, offered Gallery Delta the old, dilapidated house at 110 Livingstone Avenue in Harare, which had been his home for nearly 40 years until his death. Built in 1894, it lays claim to being one of the oldest surviving buildings in Harare. From 1991 to 1993, Gallery Delta – with the help of architect Peter Jackson, and many others – repaired and restored the house to its original appearance, and built an adjoining amphitheatre.
Gallery Delta today.Screengrab/Granadilla Films
Besides teaching, mentoring and supporting the production of new art, Gallery Delta also produced and published a visual art magazine under the title of Gallery. This was a 32 page, glossy quarterly publication, edited by art critic Barbara Murray, and for a short time by the publisher Murray McCartney, which ran to 31 issues. Each edition of the magazine had a print run of 1,000 copies.
Copies of Gallery were distributed free to schools and libraries, and it has become a vital research tool for students and collectors interested in the development of contemporary painting in Zimbabwe in the 1990s. The magazine is fully digitised and freely available.
Several contemporary Zimbabwean artists have passed through Gallery Delta, as students or exhibitors. These include Berry Bickle, Andy Roberts, Greg Shaw, Lovemore Kambudzi, Cosmas Shiridzinonwa, Gina Maxim, Misheck Masamvu, Chiko Chazunguza, Masimba Hwati, Hilary Kashiri, Portia Zvavahera, Rashid Jogee, Admire Kamudzengerere, Richard Mudariki and many others.
The Third Act
What does the future hold for Gallery Delta? In 2008, in response to the dire economic situation in Zimbabwe at the time, the privately owned gallery was given over by deed of donation into trust to create the Gallery Delta Foundation for Art and the Humanities, governed by an independent board of trustees.
A new generation of stewards will now have to carry forward the work that Derek Huggins and Helen Lieros started. As their late friend Friedbert Lutz said:
Gallery Delta is a bit like a lighthouse which stands there quietly and flickers its light in spite of all the storms we have gone through, yesterday, today and maybe tomorrow.
Covid-19 in children: the South African experience and way forward
- Tendesayi Kufa-Chakezha, Cheryl Cohen and Sibongile Walaza
Schools are not driving the COVID-19 pandemic and can safely remain open provided people stick to the non-pharmaceutical interventions for COVID-19 prevention.
Since its emergence in late 2019, SARS-CoV-2 has caused illness (COVID-19) and death in all countries in the world. The restrictions put in place to reduce the spread of this virus have devastated economies and livelihoods the world over. By the end of June 2021, the World Health Organisation estimated that there had been 180.4 million cases of COVID-19 and 3.9 million associated deaths globally.
From the outset, communities were concerned about the impact of SARS-CoV-2 on children. This was justifiable because many other respiratory viruses such as influenza and respiratory syncytial virus disproportionately affect children. With their immature and developing immune systems children have larger amounts of virus in their respiratory tract and release the virus from there for longer durations. This puts them at the centre of transmission of those viruses – to each other at schools and to adults and siblings at home. It was not surprising that early interventions to delay the spread of COVID-19 included shutting down schools.
But COVID-19 has bucked this trend of affecting children more than adults.
SARS-CoV-2 is known to infect children of all ages, from newborns to older adolescents and teens. But children have not been the drivers of the COVID-19 pandemic to date.
This is because children are less likely to:
be infected with the SARS-CoV-2 virus when exposed to it;
Our surveillance data in South Africa indicate that this lower risk of infection, disease, death or transmission experienced by children is age-dependent. Among children, the likelihood of infection, disease or death generally increases with age. Older teens and adolescents are acquiring COVID-19 at rates similar to adults in some instances. This routine surveillance has been in place since the beginning of the COVID-19 pandemic. The aim is to monitor disease trends in children and inform policy around prevention, care and treatment for children.
The South African experience
By mid-June 2021, South Africa had conducted 12.3 million tests and detected 1.8 million cases. Children 19 years or younger accounted for 13.4% of tests conducted, 10.2% of new cases reported, 4.2% of COVID-19 associated hospital admissions and 0.7% of COVID-19 associated deaths. This is despite children this age accounting for 36.6% of the South African population.
This age group was 3.7 times less likely to test for COVID-19, 5.7 times less likely to test positive for COVID-19, 13.3 times less likely to be admitted to hospital with COVID-19 and 6.7 times less likely to die in hospital once admitted compared to adults older than 19 years.
The data to date has not shown or suggested an association between case or admission rates with the opening and closing of schools in the country.
Given the adverse social and psychological impacts of closures on schools, it is encouraging to know that schools are not driving the COVID-19 pandemic. They can safely remain open provided there is implementation of and adherence to non-pharmaceutical interventions for COVID-19 prevention.
First, the increased case rates in older teens and adolescents, at rates similar to adults older than 19 years in the third wave, requires monitoring. Since the onset of the third wave to the peak, the fraction of all COVID-19 cases aged 19 years or younger was averaging 14.6% as opposed to around 9% in the first and second waves. Half of the cases were occurring in older teens and adolescents 15-19 years, bringing the case rate in this group on par with adults older than 19 years.
This could have been as a result of:
generally increased testing in children in the third wave. More testing would pick up more cases, including mild or asymptomatic ones.
increased testing in response to cluster outbreaks in schools, leading to more testing among symptomatic or mildly symptomatic children and adolescents
increasing vaccination rates among adults, leaving younger individuals contributing more cases; and
the Delta variant itself – which may have a greater predilection for children, although there is not yet any conclusive data to support this.
Second, infants under the age of one have experienced higher hospital admission rates compared to other children, especially after the second wave. In our most recent report, infants made up 2.2% of cases 19 years or younger but contributed 19.3% of the admissions and 31.8% of deaths in this group.
It is unclear why these infants are admitted to start with or what the causes of deaths are. Generally infants are much more likely to be admitted with non-COVID-19 conditions compared to older children. There is routine testing of all admissions at many hospitals, so it is possible that many of these admissions are for other reasons, with COVID-19 an incidental finding. More data are needed to investigate reasons for admission in this age group.
Lastly, children with underlying conditions made up 19.3% of children admitted with COVID-19 but 56% of those who died. The most commonly reported underlying conditions among those admitted were chronic respiratory diseases, diabetes, HIV and tuberculosis (active and previous). HIV, diabetes and tuberculosis were common among those who died.
What about vaccination?
South African children are not yet eligible for COVID-19 vaccination and may not be for a while. The reasons for this include the lower risk of disease and the need to prioritise the elderly; limited information on the efficacy and safety of the vaccines in children; and limited number of vaccines which are licensed for use in children.
Some countries in Europe and North America have opened up vaccination to children 12-16 years although coverage in this age group is still low. As more children are vaccinated in these countries, more data on side effects and effectiveness will be collected and many lessons to inform rollout in South Africa will be learnt.
In the South African setting, there is a case for the expedited vaccination of children with underlying conditions and older teens and adolescents based on burden of cases and hospitalisations in these two groups respectively.
Until then the onus is on everyone to ensure vaccination of adults around children to achieve herd immunity, and adherence to non-pharmaceutical intervention to reduce transmission in the community and spillover into schools.
Everything you need to know about vaccines — our only viable strategy for living with Covid-19
- Lucy Allais, Shabir Madhi, Imraan Valodia, Alex van den Heever, Martin Veller and Francois Venter
We are likely to keep being hit by further waves of this virus until at least all adults have immunity.
Our only hope for getting the pandemic under control is for as many people as possible to be vaccinated against it as quickly as possible.
Most importantly:
Vaccines will give you near-complete protection against severe illness and dying from Covid.
Vaccines are safe. All vaccines used in the vaccination programme in South Africa have undergone extensive trials and have been proven to be effective and safe.
The risk of serious side effects is similar to the chance of being struck by lightning, and side effects are treatable and generally go away on their own.
It takes time for vaccines to start working well — usually about two weeks, and their working steadily improves after this.
Vaccines differ in how well they protect against infection and mild Covid. Most vaccines will require at least two doses and provide good protection against severe illness from Covidtwo weeks after your first shot.Until you are fully vaccinated you should continue to take the same precautions as if you are unvaccinated.
Vaccines are our best hope in fighting Covid
Having caused at least four million recorded deaths worldwide, and probably almost200,000 excess deaths in South Africa(the official figure of 65,000 almost certainly understates the true picture, which is more accurately indicated by what is called “excess mortality’’), the Covid pandemic is one of the worst in history.
After 18 months of worldwide infection and deaths and with 10-15% of survivors experiencing the unpleasant “long Covid’’ symptoms, as well as severe social, economic, and educational disruption, it is clear that the novel coronavirus, SARS-CoV-2, which causes Covid-19, is not going to go away. But, as terrible as the pandemic has been, the good news is that a number of very effective vaccines have been developed.
As we can see from the devastating third wave South Africa has been reeling under, we are likely going to keep being hit by further waves of this virus that will cause further unnecessary suffering and death until at least all adults have immunity. Our only hope for getting the Covid pandemic and its severe health, social and economic consequences under control is for as many people as possible to be vaccinated against it as quickly as possible.
How do vaccines work?
Our bodies have many processes that detect and fight infection and disease: together these are called the immune system. When our bodies become infected, some cells figure out how to fight the infection, and if they are successful, and we survive, our bodies develop the memory of how to produce these cells that know how to fight this specific infection, usually far more efficiently and speedily the second and subsequent time round. This is called immunity.
Vaccinations are a way of triggering the body to develop an immune response to a particular disease without having to actually get the disease — a kind of fake first infection.
Traditionally, vaccines contain a component of the virus or other microorganism, or the organism in a weakened or killed state. The body then is able to recognise the virus when we are infected and respond to it, as if it was exposed the first time. The most recent mRNA technology, which is used in some of the latest vaccines, uses genetic material that tells our bodies to produce a protein of the virus which then stimulates the immune response.
Vaccines are one of the most successful, and safest, interventions medicine has ever come up with. They have eradicated dangerous infectious diseases such as smallpox, have controlled polio, and have saved billions of lives from measles, tetanus, pneumonia, hepatitis and diarrhoea. They have dramatically decreased viruses responsible for some cancers. They are also safe — bad side effects are very rare and the risk of developing severe illnesses is much smaller than the bad effects of the diseases the vaccines prevent.
Vaccines were not invented by Big Pharma and they are not unique to Western medicine — the first recorded use of something similar to vaccination was in China in the 16thcentury.
Will I immediately have protection?
No. Immunity takes time to build up in the body.
For most Covid vaccines it takes at least two weeks after the vaccine has been administered for you to start developing immunity. Most vaccines will start providing some protection against severe illness two weeks after the first dose. However, good protection generally requires at least two doses of the vaccine, and will start materialising 7-14 days after the second dose.
All vaccines work very well against severe Covid, irrespective of the variants (different versions of the virus) that are circulating. They differ in how well they protect against infection and mild Covid (usually sniffles, tiredness and other flu-like symptoms).
At the moment, two vaccines are being used in SA — both excellent choices.
The J&J is being used as a single shot; the Pfizer as a two-dose schedule, several weeks (minimum three weeks) apart. Other excellent options, mostly two-shot, are being evaluated. Don’t stress about which one is best — the best one is the first one you can get.
Even though you have had a vaccination, you should continue to act as if you do not have immunity until three weeks after your first (J&J) or second shot (Pfizer).
Do not assume you have enhanced immunity straight after getting your jab. Continue to take precautions. Mask when indoors with people and always open windows in rooms and vehicles.
We have seen many people get sick in those two weeks while waiting for their immunity to kick in, either infected just before or after their shot.
How safe are you once you are fully vaccinated?
All the vaccines currently in use give excellent protection against severe illness and death — they keep you out of hospital and off a ventilator.
We have less good information on how likely you might be to get a mild infection of Covid, and it is possible that you could get infected. We have seen many people get mild “breakthrough’’ infections even after the full two weeks after vaccination. Often this will be so mild that you don’t know you have it; some people get worse infections which can feel like a bad cold, but they usually recover after 2-3 days.
The possibility of being mildly infected means that when you are with people who are not fully vaccinated, you should continue to take precautions of masking, opening windows and avoiding being together indoors or in a vehicle, because you could infect those who are not protected. Even though it is possible to get Covid mildly once fully vaccinated,we now know that fully vaccinated people are less likely to spread the virus.Also, vaccines will differ in how well they protect against infection and mild Covid, which also depends on which variants are circulating.
We are still learning how best to deal with these mild infections, especially with the new, hyper-transmissible Delta variant. It is possible we may need additional shots for better protection, whether of the same vaccine or a different one. Stay posted.
Should I expect side effects?
You may feel no effects at all. But side effects can include having a sore arm where you were injected, getting a headache, or having a fever, for a day or two. The side effects experienced are much milder than getting severe Covid (some of the authors have had this experience). Also, these side effects generally indicate that the vaccines are inducing an immune response and doing what they are meant to do.
Severe allergic reactions are very rare, but can occur after any vaccination; if they occur, the healthcare provider who administered the vaccine can immediately and usually effectively treat the reaction.
The Pfizer vaccine can cause an allergic reaction which is easy to treat, and very rarely can cause inflammation of the heart, which normally goes away quickly.
The J&J vaccine has a very rare effect of blood clotting, and can be serious; Covid causes this effect far more often, though, so the benefits far outweigh the risks. Recently, the J&J vaccine has been associated with a very rare syndrome causing weakness, called the Guillain Barre Syndrome. This syndrome is also seen in patients who have had the flu and other viruses, and is treatable.
Are there any people who should not get vaccinated?
No. But some people may not respond — not everyone’s immune system learns equally well from vaccines.
People who have conditions involving immune suppression — for example, someone who has had an organ transplant and is taking immunosuppressant drugs to stop their body from rejecting the new organ, or people on chemotherapy or taking immunosuppressives for other condition like rheumatoid arthritis — may not develop as good immune responses from vaccines. We are learning, though, how to amend the doses so these people can get better protection — so watch this space.
In addition, people with severe allergies may want to avoid the Pfizer vaccine, or ensure that the person giving the vaccination is ready in case of a reaction.
What is the Delta variant? What is the story with these Covid variants?
Like all viruses, SARS-CoV-2, the virus which causes Covid, changes and develops. When a version develops that has important differences (for example, that increases its transmissibility, virulence or relative ability to evade immune responses), it is given a new label, such as the Delta version of Covid, which has been hitting South Africa hard.
TheDelta variantis two-fold more infectious than the original SARS-CoV-2 virus, which is why it has been spreading so quickly. So far the vaccines are still working well in protecting against severe Covid due to variants, but vary in how well they protect against infection and mild Covid from different variants.
Scientists are working on vaccines that might work better against infection and mild Covid irrespective of mutations of the virus. It may be that we need to get a booster vaccine every few years to deal with new variants, particularly if one is at high risk of getting severe Covid. But equally, it is possible that the current vaccines may be enough.
What is the difference between the different vaccines?
There are 19 different vaccines currently used around the world against Covid, and more are being tested.
The vaccines mostly being used in South Africa at the moment are made by Pfizer and Johnson & Johnson (J&J). These vaccines work in very different ways. While more traditional vaccines use a component of the virus or a weakened or killed version of the virus which stimulates your body to develop an immune response, the Pfizer vaccine uses a copy of a molecule in our bodies called RNA which causes cells in our bodies to produce the protein that our immune system responds to.
The RNA vaccines do not in any way affect or alter your genes or your DNA. All the vaccines eventually get your body to respond in a similar way to how it would if infected — to produce cells and antibodies that can fight Covid-19. The advantage of the RNA vaccines is that RNA is easier to design and can be produced very quickly. Also, since it does not require the production of any form of the potentially very dangerous virus, it is also safer to produce.
It is not very easy to compare how well the different vaccines work because the trials in which they were tested used different groups of people at different places, involved different variants of the virus and used different study methods. But both J&J and Pfizer are working very well and giving people good protection against severe Covid-19, including the variants of concern identified to date.
How were the vaccines developed so quickly and should this worry me about their safety?
Covid is a new kind of coronavirus, but coronaviruses are not new — the common cold we get every winter is often caused by one of the coronaviruses. This is part of what enabled vaccines to be developed so quickly. Also, huge amounts of funds and resources were mobilised very rapidly, which enabled swift development of the vaccines.
The vaccines have been thoroughly tested in multiple trials.
More than three billion doses of vaccine have been administered worldwide and in the US 150 million people are fully vaccinated. In the UK, about 55% of the population — about 36 million people — have been vaccinated. This is an extremely safe intervention.
How long will immunity last?
We do not yet know. It is possible that we will need to get a booster vaccine every year or two to keep up our immunity. Modelling studies suggest that people might require booster doses every 2-3 years to protect against severe Covid. To protect against infection and mild Covid might require annual boosting. We will find out over the next two to three years. The focus of vaccination is likely to be centred around protecting against severe Covid and death, rather than preventing infection and mild disease.
The myth of ‘herd immunity’
Some commentators still maintain the aim of vaccination is to develop population-wide immunity, or “herd immunity”. This is when enough people have immunity that the microorganism stops being able to circulate at all. Herd immunity was an aspirational goal until the virus started showing the ability of mutating, causing it to become more transmissible and relatively resistant to antibodies induced by past infection and by vaccines.
Consequently, it is unlikely that herd immunity will be achieved with this virus any time soon, and it will probably circulate, mutate, and recirculate throughout our lifetime, reinfecting us several times, like all the other coronaviruses. Luckily, individual protection against severe illness is still possible with the current vaccines even with the mutations that have occurred. Those who do not get vaccinated will face an increased probability of infection and potential severe illness as variants of the virus continue to circulate. This risk will increase as society returns to normal.
But it is likely that everyone, unless they hide behind a wall for the rest of their lives, will eventually get the virus. It’s all about how badly you get it — whether you get it vaccinated or unvaccinated.
Do I need the vaccine if I have already had Covid?
Having had Covid definitely does provide short-term protection from severe illness, as the vaccines do, but there is no evidence that it is better than the protection acquired from vaccines (and the consequences, as we have noted, are severe).
It is early days yet, and we will have more data to guide things, but we are aware of many cases, including among our colleagues, where people have had a second case of Covid, occasionally severe.
If you have had Covid, the good news is you have lots of protection from severe illness in the short term. However, adding a vaccine on top of this may well stimulate a slightly different response (and augment an already primed immune system), and mean you enjoy additional protection. As we point out, the vaccines are very safe, and Covid does dreadful things, occasionally even in people with prior infection, so it is worth getting the vaccine as an additional precaution. One should wait for 2-3 months after having Covid before getting a vaccine, and you probably only require a single shot.
How do I sign up and find a vaccine site?
TheElectronic Vaccination Data System (EVDS)offers online registration for vaccinations and identifies vaccination sites. Once registered on the system you will be allocated an appointment at a nearby vaccination site. You could also select which site you prefer. The registration system is becoming more flexible to enable more accessibility to getting vaccinated
Will I have to pay?
No. No one has to pay. If you do not have medical aid you will have free access to public sector vaccination sites. If you have medical aid it will cover the cost at the public sector or the private sites; you will not need to pay upfront. The government is in the process of setting up arrangements to ensure that all public and private sector sites can be accessed regardless of medical scheme membership.
Can I find a site vaccinating on weekends?
While many public sector sites are presently not working on weekends, many private sector sites are available. The government is working to achieve uniform coverage throughout the week. It is therefore important to get regular updates on weekend availability.
I’m waiting for my appointment but my friend just walked in and got a vaccine
Some vaccine sites have been allowing those who are registered in the system to come for a walk-in without an appointment. Which sites are doing this, and the extent to which the appointment system is being used, seems to be changing all the time. You might wait in a longer queue if you do a walk-in.
Finally, until you and the people you interact with are all fully vaccinated…
Continue to wear your mask when indoors and to keep windows open. Covid is an indoor respiratory virus: it is spread in the air, and it collects indoors where windows are closed. You are unlikely to get it outside, and opening windows in rooms, cars, taxis and buses makes everyone much safer. As you are fully immunised only two weeks after receiving your second vaccine dose, take this into account when making decisions about interacting with people.
Lucy Allaisis professor of philosophy jointly appointed at Wits and Johns Hopkins University;Shabir Madhiis dean and professor of vaccinology at the Faculty of Health Sciences at University of the Witwatersrand, and director of the SAMRC Vaccines and Infectious Diseases Analytics Research Unit;Imraan Valodiais dean of the Faculty of Commerce, Law and Management, and director of the Southern Centre for Inequality Studies, University of the Witwatersrand;Alex van den Heeveris an adjunct professor and holds the chair of Social Security Systems Administration and Management Studies at the Wits School of Governance;Martin Velleris the former dean of the Faculty of Health Sciences at the University of the Witwatersrand;Francois Venteris a professor of medicine at Ezintsha, Faculty of Health Sciences, University of the Witwatersrand.
Leave no one behind: We must urgently address vaccination of undocumented migrants and asylum seeker
- Jo Vearey, Sally Gandar, Rebecca Walker, Thea de Gruchy, Fatima Hassan, Tlaleng Mofokeng, Pinky Mahlangu, Nicholas Maple, Francois Venter and Sharon Ekambaram
We call on Acting Health Minister Mmamoloko Kubayi to do the right thing to ensure the Covid-19 vaccination programme is inclusive.
Without this we will fail to achieve population immunity, variants will continue to emerge and we will all suffer. Civil society and the research community are here to help, but we need a seat at the table.
Everyone, everywhere has the right to the highest attainable standard of health. But we don’t have to look too far to be reminded of how many people living in South Africa are left behind due to our failures to ensure not only timely and appropriate healthcare, but also the underlying determinants of health.
And the national response to Covid-19 — particularly ourvaccination strategy— is no different.
Amplification of inequalities
People living and working on the margins of society — physically and socially — remainthe most affectedby our public health failures, and — as the past 18 months have clearly shown us in the most painful ways — this is mirrored in thecontext of Covid-19. We know the pandemic has amplified the stark inequities that characterise South Africa and the world, most recently illustrated by vaccine inequity related to accessglobally,continentallyandnationally.
Of the 4,695,719 individuals who had received at least one vaccine dose in South Africa by21 July2021, 34% (1,599,581) have medical aid (representing a fifth of the population who have medical aid), while only 6.09% of the uninsured population — those reliant on the public health system — had been vaccinated. The total percentage of people in South Africa on medical aid is just16%. We believe this is because more supplies than needed have been sent to private sites, while the number of people without insurance are also being restricted from getting vaccinated at those sites, with priority given to members.
Details of this are only now emerging, hence the urgent need for the government to indicate the supply allocations of each and every vaccine site in the country. There is anationalroll-out — private vaccine sites should not be privileged in the programme.
Additionally, for all people living in South Africa, the Electronic Vaccination Data System (EVDS) for vaccine registration is in fact becoming a barrier to getting vaccinated, which explains why so many people over 60 have also not yet registered on the system and why some provinces are now taking “walk-ins”.
However, with no oversight mechanism, the effectiveness of the regulations islimited. Regardless, for any vaccination programme to be effective, we must vaccinate everyone if we are to reach the level ofpopulation immunityneeded to break the chain of transmission — and fast. The spread of the Delta variant makes this even more urgent.
The speed at which the third wave has swept across the country demonstrates, in real time, why we cannot wait to act. Where there’s a safe vaccine and where there are people at risk, we must vaccinate. This is Public Health 101:leaving anyone behind leaves us all behind.
And this includes upholding thepresident’s promise to“make the vaccine available to all adults living in South Africa, regardless of their citizenship or residence status. We will be putting in place measures to deal with the challenge of undocumented migrants so that, as with all other people, we can properly record and track their vaccination history. It is in the best interests of all that as many of us receive the vaccine as possible.”
An increasingly restrictive and dysfunctional immigration regime in South Africa that disproportionately affects black African non-citizens, as well as widespread incompetence andcorruptionwithin the Department of Home Affairs (which has on numerous occasions been found to be in contempt of the Constitution), means that many migrants and asylum seekers in South Africa struggle to access valid documentation.
These challenges have been compounded by theclosure— in some cases the illegal closure — of a number of refugee reception centres. Those that had remained open before the pandemic have been closed since March 2020. This has left those hoping to apply for or renew documents to deal with a poorly designed online application and renewal system instead. With the permit extensions granted during lockdown due to expire at the end of July, and no plan in place to prepare for this,further challengesare anticipated.
Home Affairs itselfadmitsthat it faces an insurmountable backlog of asylum claims and other applications. Due to its increasingly ineffective and dysfunctional systems, many non-citizens find themselves rendered undocumented by the very state system through which they seek to regularise their stay. This is unacceptable and the lack of political will by the state to fix the system is nothing short of xenophobic.
Languagelike “illegal” and “illegality”, and that used by government officials claiming that those without documents are undeserving of basic rights — including access to healthcare and the vaccine — highlights the cruelty of such a system.
Acting Minister Kubayi has not only perpetuated the short-sightedness, xenophobia and Afrophobia of health ministers who havepreceded herin terms of understanding movement and migration as a determinant of health, but, critically, seems to have missed a Public Health 101 briefing as part of her rapid induction into the world of pandemics. Whiletweeting about the “coffee generation”getting vaccinated, Kubayi — who is bound by the prescripts of the Constitution and the decisions of the National Coronavirus Command Council — appears to be out of her depth.
On 23 July 2021, the acting minister was asked by the media how people without state-issued documentation — including anestimated 12%of South Africans without identity documents — can register in the country’s vaccination programme which is only possible through theEVDS.
Shockingly,Kubayi responded that, contrary to thepresident’s promise made in February, she would “have to get guidance in terms of theunregisteredbecause we are dealing within the government systems and provision of services. We follow the laws of the country. So you have to be a documented person in the country. If you are undocumented it means you are illegal in the country. So it’s a different case. We have responsibility to those who are known to the state, by the state.”
In a situation where theforeign embassiesof wealthy nations are vaccinating their own citizens here in South Africa, we urgently need to vaccinate everyone at risk, as recommended by the World Health Organization and other expert bodies, to achieve global immunity. Fuelling anti-poor foreigner sentiments with public statements like this goes against all globally accepted principles of public health risk and need. It is also contrary to guidelines for an effective pandemic response in which clear statements outlining the importance of including everyone — including refugees, asylum seekers and migrants — have been made by theAfrican Commission, theInternational Organization for Migration, theUN Refugee Agencyand theInternational Labour Organization.
Urgent need for firewalls
We know our frontline healthcare staff are overstretched and the priority is processing as many adults as quickly as possible through vaccination sites, even walk-in sites.
The best way to ensure healthcare workers can meet their responsibilities to patients under the National Health Act, including in relation to the reporting and treatment ofNotifiable Medical Conditions(Covid-19 is a “category 1” Notable Medical Condition), is to ensure they arenot asked to act as immigration officials. Denying care, including life-saving vaccines, to people will only further burden the healthcare system and the responsibilities of healthcare workers down the line as Covid-19 outbreaks continue among communities who are unvaccinated by a state strategy of only vaccinating “its own” (and those with papers).
We need alegal, policy and humanitarian firewallthat will protect all people without documents. We need to ensure people are willing to access vaccination sites without fear of being arrested or harmed in any way. Given the violence of the past weeks, we do not need to unnecessarily add more health risk to the system by turning people away from vaccine sites.
Basic public health logic maintains that we need everyone in our country to be vaccinated so that we can mitigate this pandemic — and for this reason we also want to know what the public health and other experts on the Ministerial Advisory Committee have advised the government on this matter. Have our local and global experts stood up for the rights of all people living here, or only some? The public needs to see all the committee’s advisories now.
We must avoid making the mistakes of the past. The years of Aids denialism should remind us that we mustn’t forget how the impact of poor decisions is felt decades later; lives lost due to poor and ill-informed and xenophobic decisions, which go against all public health advice, cannot be recovered later. We mustdraw on the lessons learntfrom the global response to HIV.
For many years there have been calls to developmigration-aware health systems, in which population movement is central to the design of health interventions, policy and research.Researchclearly indicates this means establishing a national migration and Covid-19 task team and developing a basic “scorecard” to guide responses; this should include implementing systems to ensure that undocumented persons can access Covid-19 services, including vaccination programmes, and face no penalties when doing so.
We must ensure everyone has access to life-saving technologies, including vaccines: in a pandemic, effective health interventions belong to everyone. Denying access not only undermines the Constitution and international health law, it also means the national response to Covid-19 will fail.
As such, we echo thestatementby United Nations human rights experts on the universal access to vaccines, and we remind the state that it has “an obligation to ensure that any Covid-19 vaccines and treatments are safe, available, accessible and affordable to all who need them.
“This is particularly relevant to people in vulnerable situations who are often excluded from health services, goods and facilities, including those living in poverty, women, indigenous people, people with disabilities, older persons, minority communities, internally displaced people, persons in overcrowded settings and in residential institutions, people in detention, homeless persons, migrants and refugees, people who use drugs, LGBT and gender-diverse persons.
“Many of them may have lived experience of poverty and find themselves in situations where they are most likely to be exposed to the risk of contagion, yet the least likely to be protected from Covid-19 or supported by adequate and timely tests and health services.”
It is imperative that access to Covid-19 vaccines and treatment are provided to all without discrimination and prioritised for those who are most exposed and vulnerable to Covid-19.
We call on Kubayi to do the right thing and follow international guidelines to ensure the Covid-19 vaccination programme is inclusive. Without doing so, we will fail to achieve population immunity, variants will continue to emerge and we will all suffer. Civil society and the research community are here to help, but we need a seat at the table to do so.
Public Health 101: A cheat sheet for Acting Minister Kubayi
The immediate obligations of the state include the guarantees of non-discrimination and equal treatment, as well as the obligation to take deliberate, concrete and targeted steps towards the full realisation of theright to health;
Followexamplesfrom other countries and adapt administrative systems to allow everyone to register for vaccination regardless of the documentation system;
Urgently publish advisories of the Ministerial Advisory Committee to aid transparency; and
Establish a national migration and Covid-19 task team to support equitable action.
Jo Vearey, Director, African Centre for Migration & Society (ACMS), Wits University; Sally Gandar, Scalabrini Centre of Cape Town; Rebecca Walker, independent researcher and African Centre for Migration & Society (ACMS), Wits University; Thea de Gruchy, African Centre for Migration & Society (ACMS), Wits University; Fatima Hassan, Director, Health Justice Initiative; Dr Tlaleng Mofokeng, United Nations Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health (The views expressed herein are personal and do not necessarily reflect the views of the United Nations); Pinky Mahlangu, Medical Research Council; Nicholas Maple, African Centre for Migration and Society (ACMS), Wits University; Francois Venter, Director, Ezintsha; and Sharon Ekambaram, Lawyers for Human Rights.
