In Arua, a border city in the West Nile sub-region of North-West Uganda, many people questioned whether COVID-19 vaccines might harm them. From the outset of Uganda’s vaccine roll-out in March 2021, people articulated fears that the government and medical authorities were deceiving them and lying about potential risks of the vaccine. Concerns took many forms but often included fears that Aruans may be an unsuspecting market for European products untested on African markets; that the government’s advice could not be trusted; that the vaccine could alter African DNA; or that vaccination could really be a means of inserting microchips into people’s bodies. Although seemingly alarmist, their fears could be read as critiques of racialized capitalist inequalities, mediated through government surveillance efforts targeted at Aruans.
Map credit: Dr. Anna Shoemaker
Mistrust grew following reports of patients dying from rare blood clots after taking the AstraZeneca (AZ) vaccine surfaced in Europe. The notion that some vaccines were effective while others might be deadly held particular resonance in Arua, since it chimed with people’s appreciation for longstanding regional inequalities in which the city was embedded with respect to the Ugandan state. Standards of clinical care in Arua have long been dramatically lower than in wider Uganda. Prior to COVID-19, the town had been the site of political opposition against the longstanding National Resistance Movement (NRM) regime. Aruans watched videos of President Museveni being administered a vaccine on national television, and many did not believe these messages were truthful. A female resident summarized this sentiment. “I know the President and the First Lady received the vaccine, but many people actually think the whole thing was a show—they don’t believe the first family took the vaccine and that what was administered to them was another harmless liquid.” Believing themselves to be deceived, few Aruans subsequently accepted a vaccine. As of April 2021, government data indicated that only 26% of registered health workers in Arua had been vaccinated.
The Acting District Health Officer of Arua City explained that low vaccination uptake was largely due to health workers’ “hesitancy.” Attempts to increase vaccine uptake in Arua focused on targeted messaging, including via radio and through signage which proliferated in public places. Yet this did little to allay Aruans’ fears that they were being deceived by government actors, as well as pharmaceutical actors who, concerned about profit-making, did not care for African lives. One elderly woman stated; “We believe they have taken vaccines that do not cause blood clotting. Yet what they have sent us is killing the people.”
Aruans’ ideas of deceit transformed into mass rejection of vaccines. Fears of manipulation made sense in the context of successive historical deceptions practiced by state and medical actors in a Ugandan borderland, and patterns of exclusion were unfortunately rehearsed during the Ugandan government’s COVID-19 response and vaccine roll-out. Drawing on ethnographic research conducted by Anguyo (within one zone of the urban municipality in Arua) and Storer (remotely with leaders across Arua) during the vaccine roll-out in Arua between 2020 and 2022, we link the region’s colonial and postcolonial history to people’s attention to overcome mistrust in actors and evidence. With local opinions pre-disposed towards mistrust, we show how a series of events came to affirmatively signal the potential lethal risks of vaccines. In so doing, we highlight a complex processual world of mistrust – a social realm itself linked as much to colonial deceptions as seemingly sensational rumours about vaccine conspiracies. Drawing attention to the intensity of deliberative processes undertaken by trusted kin and neighbours, we highlight the lingering after-effects of racialized and ethnicized state violence stemming from the colonial period. We bring attention to the long durée of deception onto which COVID-19 responses were embedded in Uganda.
Mundu Aro
Aruans quickly came to refer to COVID-19 vaccines as mundu aro or “the White man’s medicine.” The term, which can be used to refer to any new clinical intervention, signifies that a new treatment should be approached with caution. The application of this term to vaccines linked their administration to a sphere of recurring deceptions inflicted on the sub-region’s people since colonial occupation.
Beginning in the late 18th century, West Nile was subject to intrusions from slave raiders and ivory poachers, followed by Belgian and British colonising forces. Successive forms of terror marked the extraction of labor and resources to fuel profit accumulation and state-making far beyond the region’s limits. Under British colonial rule (1914-62), exploitative processes were institutionalized in forcible recruitment of men to plantations, or conscription in colonial armies.
It was against this legacy of extreme upheaval that mundu aro has been embedded. During the colonial period, the provision of health services for the region’s people was not prioritized by the British administration. The main service providers were Christian missions. State biomedicine came largely in the form of disease control, and it featured violent removals, exemplified by forcible resettlement within sleeping sickness campaigns and isolation in leprosy camps. At the same time, the presence of colonizers was associated with dramatic increases in death. Historian Anne King estimates that deaths from smallpox and meningitis reached 50% in some Aruan villages in the first decade of British occupation.
At independence in 1962, stark inequalities existed between the types of care available in wider Uganda and medical assistance in West Nile. As the birth region of Idi Amin, the region’s people suffered revenge attacks in the civil war which followed his ousting in 1979. Until the mid-1980s, many remained in international exile. After returning home, the region’s people were impacted by the continuing operation of rebel groups along international borders, and the civil war to the East in Acholiland. Road closures meant that West Nile was isolated from wider Uganda until the mid-2000s.
These conflicts razed state hospitals, but there have been stark improvements to public and private sector provision in Arua over the last two decades. Still, mundu aro remains linked to ill-being, as Aruans regularly lament the failure of clinics, actors, and drugs to alleviate their afflictions. Presently, examples of deception abound: from corruption scandals at Arua Referral Hospital; to drug stock-outs and rumored circulation of counterfeit drugs; to the sudden disappearance of international NGOs after project budgets vanish; to the theft of medical technologies. Aruans are forced to navigate the biomedical infrastructure, and must continually seek assurances from kin as to which doctors, medicines, or clinics can be trusted within town, or even travel to Kampala (or beyond) to seek out better quality care. In spite of Aruans adept negotiations, in the face of highly fragmented health infrastructure, biomedicine often fails to meet many people’s needs. Mortality rates remain significantly higher than the rest of Uganda.
Uganda’s Militarized COVID-19 Response
The Uganda government’s COVID-19 response mirrored histories of (post)colonial deception. Extended lockdowns were imposed on Aruans when not a single case had been registered in the region, and they resulted in significant socio-economic hardships. A common refrain uttered by Aruans throughout was “will we die first of COVID or of hunger?”. Most Aruans feared contracting either COVID-19 or passing the virus to elderly relatives, and they diligently embarked on sanitation and distancing measures which had been used under the threat of Ebola (2018-19) and during outbreaks of cholera, which frequently affect the inner-city municipality. Yet, state imposed lockdowns and curfews policed by the military were understood widely not as health protections, but as an extension of authoritarian tactics of an increasingly violent regime. Beliefs were bolstered when state-sponsored food aid did not reach West Nile. Aruans perceived support to be directed tactically by the NRM regime for political gain ahead of the general elections (held in 2021).1 Amidst a response understood to be a politicized reaction to a virus largely spread by rich Ugandans, Arua was the site of significant resistance to the construction of quarantine centers and the instigation of curfews. Politicians, ignoring histories of state violence, invoked this non-compliance to further stigmatize the region. In what was interpreted by Aruans as a pointed remark, President Museveni compared the threat of COVID-19 to Amin’s rule.
For Aruans, following from lockdowns which were widely perceived to be as much about political manipulation as disease control, many interpreted the vaccine roll-out as emblematic of intersecting international and national inequities. At the receiving end of a global system of power where production and patents are concentrated in the minority world, Uganda’s roll-out was characterized by delays and supply side issues. By the start of September 2021, and as citizens of Western countries were receiving their second doses, the Uganda government was struggling to provide vaccines to its citizens. The supposed risk of the AZ vaccine brought additional complexities to these struggles, and it was assumed that Arua would receive the worst vaccine stock. As Leach and McGregor have explored in this series, local and structural factors co-mingled to produce vaccine fears. In Arua, it was assumed that “bad” vaccines were being sent to the border town from the regime, echoing longstanding realities of unequal care which have characterized the experience of everyday life and emergencies along a state periphery for the last century.
Questioning Vaccines
The medical anthropologist Susan Reynolds-Whyte proposed long ago that communities in Uganda seek to minimize the uncertainties of affliction by questioning misfortune, applying a pragmatic approach to new diseases and treatments. Whyte’s work illustrates how the subjunctive mode has long structured Ugandans’ responses to new disease outbreaks. Even in the face of global rumours about vaccine efficacy, Aruans did not simply reject vaccines. Rather, they assessed the evidence with reference to their perceived exclusion from global and national decision-making – questioning whether accepting a vaccine was the right thing to do when state and medical actors could not necessarily be trusted. Clues to this processual construction of trust can be found within Lugbarati (the dominant language spoken in Arua). I trust you is connotated by apita, (api means satisfaction). Evidence is edazani (manifestation) or edapiri (to show or to prove). These terms expose how trust does not involve a simple acceptance of facts, but rather an incremental journey, which requires gradual movement towards a position in the face of localised observations.
The sense of inquisition was visible among members of the homes throughout Anguyo’s ancestral village. Under extended lockdown restrictions, homes regularly became animated with contested discussions of the potential dangers of a foreign technology. Anguyo observed that neighboring homes tackled the challenge of whether to accept a vaccine as groups assembled within a homestead, sometimes by convening formal meetings to mine through available evidence. Patriarchal and gerontocratic logics often structured who had the final say in homesteads. Anguyo’s own father explained to him: “My son, I know you are well-educated, but I am not taking your advice to have the coronavirus vaccine. I want to follow my instinct.” In the face of a health threat, elders’ pulled rank to ensure the safety of their kin: their historical experiences conditioned distilling a cautious approach among family members.
Fears are confirmed
Writing about the dissonance between discourse and accusation, the anthropologist Isak Niehaus argues for an exploration of the evidentiary terrain where terrors are transformed into “subjective realities.” This intervention elucidates an important omission with regards to the neglected evidentiary terrain where occult fears become plausible truths. The notion of subjective realities usefully draws attention to, in this instance, the gap that exists between seemingly sensational vaccine anxieties linked to purported government lies and people’s actual health-seeking behavior.2 Amidst familial and neighbourly searches for definitive evidence, a particular interpretation of local events would proffer ultimate evidence that vaccines delivered to Arua could kill.
In April 2021, three nurses reportedly died after accepting a vaccine, which was presumed by vocal members of the Aruan public to be of the AZ brand. The reactions of close family, knowledgeable about the circumstances of the deaths, confirmed the lethal potential of vaccines, localising global panic about AZ vaccines as a real risk to Aruans. Declarations at funerals were particularly formative in shifting public opinion. For West Nilers, funerary rites involve trusted relatives accounting publicly and systematically for the care provided to the deceased before death. This process is intended to bring calm and solace to grieving relatives. If the cause of death is deemed suspicious – that is, in the event of a sudden passing where no prior health condition was known – burials become occasions to ascertain wrongdoing.
The eulogy at one of the nurses’ funerals (19th April 2021) is instructive. In the speech of a close relative, her passing was explicitly linked to the acceptance of a vaccine. The relative explained that the deceased had been well and had even shared food with her the evening before her death. Because of her work as a nurse, she accepted a vaccine from a government health facility, lest she lose her job. Soon after, her condition began to deteriorate, and she passed away later that same day. For those listening, this trajectory followed a well-known sequencing of suspicious deaths – of rapid deterioration and sudden death – which is attributed to deaths from ingesting poison. The message was clear: the vaccine had poisoned the nurse. Anguyo charted how the cause of death quickly circulated beyond the homestead, and around neighbourhoods in Arua town. Delivered by a member of kin, the message was trusted by onlookers and urban residents. It had an authenticity that superseded the distanced information claims of state and health actors. A revised version of the eulogy, delivered at the official funeral ceremony presided over by the clergy and attended by local government officials, attributed the deceased’s death to underlying health issues. Yet fears of a killer vaccine had been confirmed, and the official story was assumed by most to be a further deception.
On Coloniality and Mistrust
In a retrospective analysis of the Ebola response in West Africa, the anthropologist Eugene T. Richardson cautions against the erasure of the longue durée in analysis of trust. He demonstrates how dehistoricizing resistance to health policies occludes a focus on legacies of oppressive dynamics and institutional corruption that produce mistrust. In approaching vaccine hesitancy, there is a risk that scholars repeat extractive tendencies by foregrounding discourses about vaccines, rather than processes of evaluation through which potential dangers circulate around communities. There is also a risk that peripheral communities become associated solely with conspiracies, which can perpetuate stigmatizing caricatures within national health-policy imaginations.
Colonial legacies resound through subjectivities through which groups question evidence. People must invest extensive labor in accepting or refuting the possibility of a myriad of dangers which could be associated with a locally disembedded medical intervention. The need to validate information is a product of longstanding regional minoritization perpetuated by state authorities, including the medical establishment. Unacknowledged events including forcible recruitment, denial of consent, circulation of fake medicines, unclear explanations of treatment, and a structural silence on responding to health needs mean that sensibilities are tipped in the balance of mistrust. Yet there was nothing inevitable about available vaccines in Arua not being accepted. Tragic events served to confirm public opinion. Communications that skimmed over this social fabric of deliberation were ultimately ineffectual against a historically-formed terrain which promoted the need to question.
NOTES
1 Non-political actors such as entrepreneurs and NGOs were however allowed to distribute relief aid.
2 These were all fears reported by Aruans in the study, and echo those recorded in the published literature on vaccine resistance in Uganda. We note if these rumors were accepted as true, then surprisingly little resistance has been reported from the country.
About the Authors
Elizabeth Storer is a Research Fellow at the Firoz Lalji Institute for Africa, London School of Economics. She is a geographer whose research focuses on the reproduction of inequalities through Global Health interventions, particularly at state borders. With Nikita Simpson, Elizabeth co-edits this Theorizing Trust Series.
Innocent Anguyo is a researcher at the Firoz Lalji Institute for Africa, London School of Economics, with an interest in politics, livelihoods, health and migration. He has worked as a consultant for the Government of Uganda, Samuel Hall International, and several UN agencies. He holds postgraduate qualifications from LSE, the University of Oxford, and City, University of London.
Funding Acknowledgments
This research was funded by an AHRC-DfID Collaborative Humanitarian Protection Research Programme, ‘Safety of Strangers: Understanding the Realities of Humanitarian Protection) (2019–2021) (AH/T007524). Additional funding was provided by an EU Horizon grant (101016233) on Pan-European Response to the Impacts of COVID-19 and Future Pandemics and Epidemics (PERISCOPE).