Sabin’s New Director of Research Embraces Challenge of Global Vaccine Equity
On September 1, 2021, I joined Sabin as the new Director of Research, Vaccine Acceptance & Demand (VAD), which occurred in tandem with an international move from South Africa to the United States. Having lived in sub-Saharan Africa since 2010, I have grown a deep understanding of the existing structural and socio-cultural complexities that when combined with the fiscal constraints of low- and middle-income countries (LMICs), contribute to colossal health inequities in the region as compared to the Global North. The COVID-19 pandemic has only served to savagely exacerbate these preexisting inequities. I joined Sabin keenly aware that this new role would be challenging.
With the first COVID-19 vaccination given to a member of the U.S public on December 14, 2020, other upper-income countries quickly followed suit. By early February 2021, it was reported 55% of adults in the U.S had already received at least one dose of a COVID-19 vaccine. While I was grateful my American family and friends – most of whom are not frontline healthcare workers – were vaccinated and protected, from Johannesburg, I continued to count the rising numbers of colleagues in the healthcare sector – individuals I either knew personally or were within my professional network – who had contracted COVID-19, some dying, due to personal protective equipment shortages and being without access to a life-saving vaccine. South Africa, along with many other LMICs, was relying on the COVAX initiative, which pooled country resources to support COVID-19 vaccine development and ensure equitable vaccine access to all countries. However, with some key wealthier nations opting to secure vaccine product directly from manufacturers, COVAX struggled to obtain enough doses. The Global South was experiencing the downstream effects. While sitting in my living room, absorbing this news, I wondered, if we had received the supply, was South Africa’s healthcare system even prepared for the huge undertaking that is mass vaccination?
My time in Southern and Eastern Africa was spent conducting infectious disease prevention and treatment programmatic and operational research. My portfolio encompassed clinical research site capacity building for the conduct of HIV and COVID-19 vaccine clinical trials, including serving as a supporting role for the J&J ENSEMBLE Phase III study and the subsequent J&J SISONKE Phase IIIb open-label implementation study. I have seen repeatedly, first-hand, the barriers towards strengthening healthcare systems for optimal public health outcomes often belong to one of six core components or World Health Organization building blocks: service delivery, health workforce, health information systems, access to essential medicines, financing and leadership/governance.
Despite the global call for further health service integration, most recently being to integrate COVID-19 vaccination into the primary healthcare system, many LMICs do not have their public healthcare system structured horizontally. Traditionally, responses to complex health problems have used the vertical healthcare system approach, specializing on disease-specific programs and allocating resources towards attacking a singular issue. Countries may be ‘stuck’ in this model due to the pressures of meeting global disease prevention and treatment targets, as well as donor funding often being restricted to single-diseases – such as HIV, TB, malaria, and now COVID-19. Rather than building upon epidemiologic and structural synergies to create a ‘one stop shop’ for communities, this systems fragmentation, due to the nature of its completely divergent operations, creates overall financial, service and resource duplications.
Furthermore, sub-Saharan Africa has a deficit of 4.2 million health care workers, and this is estimated to increase to 6.1 million by 2030. Country-specific national development and strategic plans require a substantial growth and diversification in human resources, however there are personnel hiring limitations – both political and budgetary in nature – barring progress. Simply put, there is not enough manpower or funds to increase the human resources needed to implement set plans, often leaving LMICs to rely on current sources or humanitarian aid. One strategy being used is the scale-up of community health workers (CHWs) as part of ward-based outreach teams. These workers are responsible for contact tracing and counselling efforts. However, there are large provincial differences in contracting methods and salary within countries, and the current ratio of CHWs is far too small per population for impact, given their large and increasing scope of work.
In addition to the above barriers, understanding why a patient seeks or refuses available health services requires the understanding of complex health-risk and health-seeking behaviors influenced by factors at multiple levels. To move the needle, knowledge gained from inter- and intra-personal and social systems are critical to understand individual and community-level beliefs surrounding those contexts and the associated-behavioral action (absent or implemented). This knowledge will inform community-centric approaches to increase vaccine acceptance and vaccination uptake. For example, individual-level factors affecting access to healthcare services may be an individual’s knowledge base and beliefs, including religious beliefs and interactions with traditional healers, which are guiding forces informing decision-making. In settings like South Africa, where the unemployment rate for adults is 44.4% and youth aged 15-24 years is at an all-time record high of 64.4%, it is critical to meet the people where they are to provide vaccination rather than to expect citizens to travel to a vaccination site. Limited personal resources (e.g.; transportation costs, ability to leave work and/or household duties) and lack of mental resilience within marginalized communities already combatting much hardship (e.g.; food insecurity, unstable housing, and limited access to affordable transportation to healthcare facilities) affect health-seeking behavior. Literature has shown that patient convenience and accessibility strategies have worked historically, as relating to decentralized, community-based HIV and TB treatment initiation.
When SISONKE vaccinated its first participant on February 17, 2021, it broke ground, globally, as a method of fast-tracking COVID-19 shots into the arms of ~480,000 frontline healthcare workers while bureaucratic red tape remained firmly wrapped around the continent. I bore witness to and have immense appreciation for the tireless champions and advocates for the voiceless. With the right interdisciplinary leadership, including public-private partnerships; correctly pooled resources and sense of urgency, the unthinkable greatness happened, and seemingly overnight. SISONKE is a glowing example of utilizing already established platforms and adapting them to current needs. This case highlighted the success of combining resources from government institutions with the knowledge from highly experienced HIV/COVID-19 clinical trials networks to quickly facilitate the operation of mass vaccination sites nationally.
Having assisted with the site operations at Chris Hani Baragwanath Academic Hospital – the world’s third largest hospital, the demand for vaccination often greatly overwhelmed the amount of vaccine product we could provide. Staff had to play the proverbial ‘rock-paper-scissors’ to determine who would stand on a chair and share the news by megaphone to the throngs of healthcare workers eagerly waiting for their turn, some of whom entered the line at four o’clock in the morning, three whole hours before site staff arrived. The phrase, We do not have enough vaccinations today for all of you, please come back tomorrow; served to further break mental resilience amongst our already burnt-out health workforce, and that experience will stay with me forever. To be clear – this site was arguably the highest performing site nationally, extremely organized, and staffed by incredible and overworked individuals. There was simply a limit per day in how much vaccine product could be delivered to site, reconstituted and drawn into syringes by the number of pharmacists available and delivered by the number of certified vaccinators available. Unfortunately, hearing of these delays, compounded by the temporary pause in administration of the J&J vaccine issued by the Food and Drug Administration to further investigate six cases (in hundreds of thousands of people) of adverse events relating to a rare blood clot, inevitably raised suspicion in the general population who were waiting for their phased-in turn for vaccination.
As the tides begin to change from lack of vaccine supply within LMICs to active supply by Q1 2022, as promised by COVAX, the focus needs to shift towards ensuring this supply efficiently makes it into the arms of the people located within differing communities across the globe. My new role with Sabin sits squarely in this critical space through facilitating the gathering, dissemination, and translation of evidence-informed knowledge on the drivers of vaccine acceptance, demand and uptake into action-oriented agendas. In creating partnerships with diverse, external stakeholders – both global and local in nature, there will be a collaborative strategic impact on the field, both from a higher level down to a more granular, culturally relevant context. My VAD portfolio currently includes overseeing Sabin’s Social and Behavioral Research Grants Program and other grant-partnered projects, and assisting with the further establishment and steering of the Vaccination Acceptance Research Network (VARN) and its Inaugural Annual Conference, inclusive of its recently-launched Call for Papers.
New endeavors with global partners are already starting to take shape, and I look forward the cross-pollinating strategies across Sabin’s program teams and networks serving to support both COVID-19 vaccination and routine immunization efforts. As the overall health system capacity builds and a flexible approach addressing local social contexts is employed, a vaccination system will become more sustainable. Until then, we are in for a bumpy ride, while more individuals who are desperate to receive their jab, contract and succumb to COVID-19 and additional vaccine-preventable diseases. The time to act is now, and I am excited to help Sabin lead the way.