Authors: Sheba Mohammid and Daniel Miller

Open access image by Volodymyr Hryshchenko.

Right now, Trinidad and Tobago are suffering amongst the highest death rate from Covid in the world. As small islands, everyone seems to know people who have died. According to a Trinidadian doctor specialising in this field one reason for this is co-morbidity with diabetes, obesity and hypertension. Diabetes is also the leading co-morbidity factor in Europe^[1]. These are exactly the health conditions our final ASSA project in Trinidad is focusing on. Yet we would estimate perhaps half the population is resistant to getting the Covid vaccination, either not having it (48.3%), or being vaccinated only because of pressure, such as keeping their job. In response Sheba Mohammid has focused on researching the reasons people remain opposed to vaccination even in such tragic circumstance, as part of her online ethnographic in Trinidad.

The first thing that became clear in Sheba’s investigations was a fundamental problem with research on this topic. She began, as most researchers would, by asking the people concerned. People gave her many reasons for not being vaccinated, but it soon became obvious that when one reason no longer applied, the emphasis was shifted to another. For example, a person might say they didn’t want AstraZeneca and were waiting for Pfizer. But when Pfizer came along, they give an entirely different reason based on some nurses not being vaccinated. It gradually became clear that what people say in answer to this question is based on the pressure to legitimate their actions. The way these various forms of rationale are replaceable suggests that a deeper investigation was required.

The second stage of her research then tried to focus on two main issues that had developed as possibly the core underlying reasons for taking this stance, using additional evidence from their wider discussions and concerns. The first is general fear and mistrust that the vaccine might itself make one ill. The second was a general resistance to top-down assertions that the facts were clear and that they should take the vaccine. Indeed, it is likely that a response such as fact-checking would only harden the resolve to resist those people from above who cannot be trusted and keep insisting that only their facts were the true facts. By contrast, the stories that made them more fearful of vaccination came not from government, but from people more like themselves. Yet it was also clear that this opposition to authority was different from other regions. The people in Trinidad did not call themselves anti-vaxx or associate with US opposition movements to the vaccine about which they were well informed.

The third stage, began with a realisation that these oppositions may have deeper roots that relate more to local cultural values. The US movement is a more organised opposition reflecting the current degree of politicisation in the US. Danny’s conversations with people in Ireland suggest that an important factor there is the degree of personal support that people opposed to vaccination give each other in the community. Trinidad turns out to have its own quite specific reasons for opposing the vaccine, less political than the US and more individualised than Ireland for opposing the vaccine. In each region      there are deeper resonances that may account for the local resistance.

The traditional relationship in Trinidad between health and the body is not a culture of preventative medicine but rather “If it eh broken, why fix it.” Healthcare is often framed as problem-solving medical intervention that seeks to ease the consequences of an illness and is a last resort. Medicine then is largely framed as curative and many people recount how they avoid health tests saying that they “have one life to live and doh want to know,” but will only seek medical care as a treatment if they feel all else has failed and they are now willing to go to the doctor for help. Indeed, patients may then complain when a doctor merely gives them a painkiller that they could get over the counter  since they expect a special injection. But otherwise, in deeper discussion and sustained participant observation as to why people have not taken the vaccine, they insist that `Ah Good’ – basically they are feeling fine and they fully intend to remain feeling fine. So, at that stage why take a risk by being injected with something that at least some other people are saying, especially on circulating social media, that will itself harm your health.

Sheba interviewed doctors regarding diabetes and hypertension who regularly underscored that a main challenge is this lack of preventative healthcare that is in fact a key challenge to the health system. This idea of “being good” intersected with the insights she gleaned on how people refuse to take high blood sugar or pressure seriously if on the surface they seem fine and thus the proliferation of these “silent killers” in the population.  She found that it was the norm that if participants were taking something to keep healthy it should be a natural food or substance that has no associations at all with becoming ill and seem to pose no risk. This meant that an illness which has an asymptomatic phase such as Covid19 would be particularly devastating, because as long as people feel good, they are confident that they cannot be a danger to others or contract it themselves if they spend time with people who seem asymptomatic. In the meantime, it is taking the vaccine that represents risk, not the failure to have taken it. Appearance matters and there is considerable stress on showing to others that one is healthy, while even talking about ill health and medicines ‘kills the vibe’ and should be avoided unless one is actually ill. This study also showed us that our original plans for helping to improve diet in relation to diabetes would probably not have worked, at least in this context, and a different approach is now being considered.

Clearly these generalisations only apply to some of this population. But it may be an important underlying part of the culture surrounding the body and health. Extrapolating from this conclusion, it would seem that research based simply on asking people for their reasons for not taking the Covid vaccination, or worse still projecting upon them one’s assumptions, are not likely to be helpful. A more anthropological insistence on taking vaccine hesitancy seriously and finding the deep roots that sustain it in people’s values and wider attitudes may be required for each region of concern.

^[1] Corona. G. et. al 2021 Diabetes is most important cause for mortality in COVID-19 hospitalized patients: Systematic review and meta-analysis Rev Endocr Metab Disord Jun;22(2):275-296.

doi: 10.1007/s11154-021-09630-8.

Fig 1: Screen showing Covid-19 prevention messages in a UN office in Ouagadougou. Photo credit: Charles Somé.

A few days ago, I came across a rather unusual document. It is a compilation of different technologies put together by the European Investment Bank, entitled Covid-19: Africa’s digital solutions[1]. It was published last year, with the support of the United Nations Development Programme (UNDP), and it sets out to identify the digital solutions currently on offer in the response to Covid in Africa. Several things strike me as I read this document: firstly, the breadth of these initiatives seems to reflect a faith in the ability of technology to respond to the health crisis. The inventory reports that about 100 digital solutions have already been ‘implemented’ or tested as of 20 June 2020. It also gives an estimate of the investment needed to implement such ‘high-impact’ solutions.

Then, there are different types of tools being promoted in different countries. There are collaborative tools such as Zoom and Skype, which have multiplied greatly, and use messaging apps such WhatsApp in professional contexts such as education, has also gone up. Traditional media, such as television, for example, has remained important due its ability to reach a great number of people during the crisis. Innovations also include tracking applications based on geographic information technology for epidemic surveillance purposes. On page 15 of the document, contact tracing apps are described as follows: “These applications, which often use geolocation data from telecommunications companies, help to identify contacts of people who have tested positive and help to locate areas where the virus is spreading.” We learn that applications have been developed and put to use in Kenya, Morocco and Rwanda among other countries. FabLab, an innovation hub in Kenya, has developed an application called Msafari, which can track public transport users.

Other digital tools have been used for mass communication and self-assessment of risks and symptoms. In Sierra Leone, for example, an existing public platform using unstructured supplementary service data (USSD) has been expanded to allow citizens to self-assess their symptoms and get alerts on developments on the COVID-19 front in the country.

The use of drones has also been experimented with to deliver pharmaceutical products or to transport PCR tests from remote areas to laboratories in big cities like Abidjan in Côte d’Ivoire or Kigali in Rwanda.

But are all these innovations and techno-digital solutions going to make a difference in the medium or long term? Firstly, let us recall that there is a gap between the international presence and publicity around various technological innovations, some of which can even be award-winning, and what actually happens on the ground.  Throughout our 18 months of fieldwork in Yaoundé for the ASSA project, we noted this significant gap, which says something about the difficulty of digital applications and solutions when it comes to capturing the attention of users.

The profile of a young Snapchat user in Cameroon. The screen shows various COVID-19 messages superimposed onto a photo of the user. Photo sent to the author by research participant.

In most of these countries, although tracking applications were received with curiosity, they nevertheless worried public opinion because they raised problems of data use and privacy. Not only are they worrying, but they are not always seen as appropriate solutions for the local context. Interfaces such as the one in the picture above, where COVID-19 related messages fit into the user interface seamlessly, work well in the context because they fit into the social media landscape. Young people want to show concern about the virus and they might adopt features of a social media network that support COVID-19 messaging for a few hours occasionally during the outbreak. But for that, they also need to be reminded by other channels of support and communication that the crisis is still there. The resonance of this issue is strongly linked to the strategic orientations of African countries in terms of their politics, economic situation and sensitivity to innovations.

Another part of the current debate concerns the mistrust of not only technological solutions but also of vaccines against COVID-19. For example, medical anthropologist Alice Desclaux and a team of French researchers [2], who undertook an exploratory study among 215 people in four African countries this year, found that 2 out of 3 participants said they would refuse to be vaccinated against Covid-19. They say: “reasons for refusal included firstly fear of any side effects hidden by the pharmaceutical companies, and secondly the perception of the vaccine as a tool in a plot by Bill Gates to reduce the African population or by a coalition of the powerful (states, global institutions) to enslave populations and ensure a “new world order” using corrupt authorities in African countries (“coronabusiness”). The study also found there was a preference for endogenous solutions to control SARS-CoV2, such as traditional medicine or the protection provided by religion.” There is therefore an urgent need to study more seriously the sources of the constant doubt surrounding the surveillance of epidemics, which are reflected and accentuated at pivotal moments such as Ebola or recently, Covid-19.

The central hypothesis of this is that the operational responses of nation-states are aligned with a policy of systematically using surveillance (biometric) and the tracing of infected persons (mHealth) as the preferred institutional response to emerging epidemics. However, this response has underestimated the capacity for the circulation of alternative interpretations of epidemics favoured by an abundance of content conveyed via social networks and smartphones. The direct access of the public to this content reinforces a widespread suspicion of local governments that are seen as corrupt and that accept servile compromises with the leaders of large pharmaceutical groups to the detriment of ‘African solutions’. Therefore the solution for helping people accept technological and digital solutionism to the crisis is not just to blame them for pharmaceutical nationalism, or their non-openness to innovations, but rather like anthropology and the ASSA team’s approach, making an effort to understand and carefully analyse not only people’s perceptions of the vaccine and the Covid outbreak, but also the intertwining of the logics behind them.

References

[1] European Investment Bank (EIB): Africa’s digital solutions to tackle COVID-19, found at: https://www.eib.org/en/publications/african-digital-best-practice-to-tackle-covid-19

[2] Desclaux A, 2021, « Covid-19: En Afrique de l’Ouest, le vaccin n’est pas le nouveau « magic bullet », available at: https://vih.org/20210202/la-mondialisation-des-informations-et-la-fabrique-des-opinions-sur-les-traitements-du-covid-en-afrique/