Q&A with Prof Linda-Gail Bekker

Siyabuya expert panel member, Professor Linda-Gail Bekker, is the Director of the Desmond Tutu HIV Centre at the Institute of Infectious Disease and Molecular Medicine, University of Cape Town and Chief Research Officer of the Desmond Tutu Health Foundation. 

She has also been co-lead in the Sisonke Phase 3B study which has seen the vaccination of 500 000 health care workers against Covid-19 in South Africa. 

Professor Bekker answers questions about what lies ahead as warnings sound of a looming fourth wave of Covid-19.

Q: Does the wave of rising Covid-19 death and infections in Russia, for example, where vaccination rates are still greater than in South Africa, presage a likely fourth wave scenario for South Africa?

A: So, the question is what do we do when vaccination rates are low and we’re facing a potential fourth wave? I think we have to take lessons, not only from the countries that have got insufficient vaccine coverage, but also look at the countries that have had better vaccine coverage and there’s no doubt that the higher the vaccine coverage you have the better the story.

Scandinavian countries come to mind, and in particular Denmark, where they really have had a great vaccine campaign. People have stepped forward and that country has been able to say we can actually relax our restrictions now. Of course, they are moving into winter and will also see an uptick of infections there. 

The important thing to recognise, first of all, is this vaccine has an impact on death and severe disease. People who are not vaccinated are not going to be protected from death and severe disease, so the unvaccinated are going to continue to have those problems. 

It does not prevent infection entirely but we reduce the likelihood of mass infections if we have really good vaccine coverage and the reason for that is that the virus will exploit any gaps in immunity. 

If we can get the bulk of the population to not be what we call a “naive population”, in other words, sitting ducks for the virus, then you reduce the overall viral load in that community. It is a simple principle.

And, no, we won’t stop infections entirely, but we will reduce infections and therefore the possibility of severe disease and death if we have our vaccinations up a great deal more.

The first thing is to appeal to people that it is in their own best interest get vaccinated because then if the infection does occur you’re less likely to end up in ICU and on a ventilator.

Secondly if we can get more people vaccinated, we will have reduced the chances of cluster outbreaks and the transmission of the virus much more, but it’s important to really close those gaps and the way we do that is we make sure that there’s a mass vaccination.

If you like, think of yourself as surrounding yourself with a hedge. If we all have a little hedge around us even though some virus might get over that hedge, if enough of us have hedges around us we just start to come together and you actually build a wall and that’s really what we’re hoping to do if that analogy is something people can align with. 

I’m worried that the fact that we now actually do have supplies of vaccines but I’m hearing that the queues are dwindling and people are not stepping forward.

We need to appeal to people’s self-interest. I want to keep myself out of ICU therefore I need to step up, but we also have to build confidence around the vaccine itself. 

So, if fear of ending up in ICU is greater than my fear of the vaccine, we almost have to tip that balance in a way. I don’t really want to be a fear-monger, but I do want to reassure people that their fears against the vaccine are largely over-estimated.

I think there is anxiety that is directed towards the vaccine that is over-emphasised and unwarranted and that’s where we have to hear people’s fears and then come to them with arguments that show that vaccines, by in large, are safe. They are a cornerstone of our public health measures.

We use vaccines everywhere and anywhere. We give them to our children.  Those of us who are mothers queued up with our babies to have them vaccinated believing, and rightly so, that this was a very important public health measure for our children.  Now we’re adults and somehow the fear grows. 

Yes, we understand that people say will this is a new disease and the vaccines are very fresh and new, but there is no reason to believe that these vaccines which are built on the same principles are somehow going to behave differently to other vaccines than we’ve had in the past. 

That’s where we have to build confidence again. 

Q: Initially some of the hesitancy came from people being suspicious about the speed of the development of the vaccine but now there are billions of people who have been vaccinated and there is no evidence to show significant risk. Why are people still hesitant in the face of this?

A: I think vaccines get a heavy rap and I’m not entirely sure why that is. Many new pharmaceuticals come onto the market and we take them willy-nilly and yet vaccines get a much tougher run-around in order to meet the safety bar and the acceptance bar.

I am not entirely sure why. That said I do think there is this extraordinary anti-vaccine lobby that is well organised. I cannot for the life of me understand what their nefarious reasons are for doing this. At best it’s a travesty, at worst it’s criminal because people make bad decisions and potentially lose their lives because they listen to that kind of propaganda.

You don’t have anti-Panado lobbyists. You don’t have anti-chemotherapy lobbyists, but we have anti-vaccines. I haven’t got to the bottom of what their motivation is but they absolutely prey on the fears that people may have and grow those fears.

To an unsophisticated person [a vaccine] is almost quite miraculous. You get a little thing in your arm and then this thing protects you. But one needs to understand that the vaccine is just the beginning of the story. Your own immune system actually does the work and it’s a brilliant concept. 

[Physician Edward] Jenner [the inventor of the vaccine concept including the smallpox vaccine] and his cadres who put this together are extraordinary and we celebrate them every day when we give a dose of polio vaccine or we give somebody  a chickenpox vaccine or a measles vaccine.

None of us have to worry about smallpox anymore because of the miracle of vaccines. 

Yet that story somehow gets lost and then we have all this negativism. 

A bad publication many years ago linked the MMR vaccine to autism. That’s been retracted and it has been declared null and void. There is no substance to it and yet that kind of stayed the course. It’s a shame on so many levels and I don’t fully understand why vaccines get a particularly heavy knock.

Q:  Siyabuya advocates for active citizens making a difference so how do we we give people advice about what to do in your own home, in your own neighbourhood and in your own street to convey confidence and to get people to cross their own little Rubicon and be vaccinated? 

A:  The first thing is that testimonial is incredibly powerful, right? So peer-to-peer conversations: “I’ve had it. These are the symptoms. I had a very sore arm for two or three days, but the arm got better and here I am, all is well.”

We should be honest about how the immune system does respond in very rare circumstances in a way that is too vigorous, and people have ended up with, for example, this phenomenon of thrombosis with thrombocytopenia. 

In some very rare individuals we are seeing a version of that but it can be picked up and can be managed. People are now being managed very, very effectively and efficiently and that in no way negates all the benefit of people getting a vaccination and getting on with their lives.

And that’s the message we have to get out to our families or friends and to the people on the street because each of us can be a really good ambassador one-on-one because people get tired of hearing me drone on and on.

I think hearing a personal testimony from somebody you know and trust is incredibly powerful… we know the power of peer support and peer influence. So, I absolutely encourage each individual to become an ambassador. 

Your voice counts.

Q: How should people view these rare risks versus not getting vaccinated and succumbing to Covid?

Well, we know that particularly in a wave we are all at terrible risk of incurring Sars-Covid 2. It is reduced if you had Covid before, but re-infection does happen. 

Obviously it’s reduced if you get vaccinated so if you are sitting there with and you’ve never been exposed to Covid and you haven’t had a vaccine and there is a wave… You know I found that in my own family we did everything we could according to the book in terms of non-pharmaceutical interventions and it came into our home by error and we all went down with it in a couple of days. I was shocked.

We’ve seen that and many families have given that testimony and sadly many families have lost multiple members of their close family as a result.

In our household it was a young person who brought it in and their lives need to carry on. The whole NPI (non-pharmaceutical interventions) restrictive lockdown cannot go on year-on-year for young people. There is no blame, but the fact is that this is a highly transmissible airborne disease and therefore very difficult not to allow transmission when it takes off. 

On the other hand, we are seeing these cases of rare clots in one in 10 million, or one in eight million. You’re talking about extraordinarily rare. If you had a Lotto ticket you would think you really hit the jackpot!  

[The rare clots] it doesn’t catch you by surprise anymore. You go “Oh, my goodness, I think this may be the situation, I need to treat this in a particular way” and outcome are very different.

People are recovering fully and getting on with their lives again with no sequelae [ongoing conditions related to the illness]. So, I think it is important that we are honest on the one hand, but, on the other hand, again very clearly stating the risk and the benefit ratio which falls firmly in favour of vaccinations still at this time. 

Q: How do we approach the issue of vaccine mandates? Do we get to a point where the public health interest overwhelms individual choice?

A:  I would hope not. I think it is probably public that I led a proposal for the University of Cape Town… what drove that decision was really that I see students struggling. That I see another academic effort going down the tube and this is a real effort to say we urgently need to get back onto campus for the sake of our whole focus which is to educate young people.

But I would really hope that on the other hand we would not have to rely on a mandate,

particularly countrywide, and I do still value the power of people making a choice for themselves that they believe is in their best interest.

So, I would love to say let’s really find ways to encourage people to step up in voluntarily because I think then their hearts are in it and they are likely to influence other people and people don’t feel that they’re being steamrolled and they are willingly participating in something that is good for themselves and for their families and for the country. 

And that is a much healthier way to go about it than to say to people you know we are going to prosecute you if you don’t do it. 

Just think about the whole mask situation. When we were asked to wear masks for the good of each other it was done quite willingly. I think when there was a feeling that I’m going to get locked up or fined if I don’t then you start to feel that resentment and a bit of pushback from the public.  

So, I do think if only we could do this in a voluntarily manner we could negate the need [for a mandate] and again I look at Denmark. 

The population stepped-up absolutely willingly in the most extraordinary way. They have moved on, their lives have moved on. They really are essentially back to normal. That is the Holy Grail. 

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