COVID-19 vaccination hesitancy in South Africa: Biblical discourse

the discourse of vaccine hesitancy. Contributions: This article applies a qualitative descriptive phenomenological approach and seeks to address the conspiracy theories and the use of Bible verses as discourse on vaccine uptake.


Introduction
It has been over three years since the World Health Organization (WHO) declared the outbreak of COVID-19 to be a Public Health Emergency of International Concern in March 2020 (WHO 2020:1). Since March 2019, the world has experienced much uncertainty, as a result of changing COVID-19 evidence, new and emergent strains of the virus and an ever-shifting landscape of travel bans and lockdowns (Kumar et al. 2022(Kumar et al. :1300. Ensuring a solid understanding of, demand for and acceptance of current and forthcoming COVID-19 vaccines is critical to personal health, protecting the most vulnerable populations, reopening social and economic life and potentially achieving population health and safety through immunity (Gottlieb, Pantell & Solomon 2021:2). The development of COVID-19 vaccines has indeed generated a renewed sense of hope for many who have been devastated by the loss of lives and livelihoods as a result of the disease. COVID-19 was not foreign to South Africa, as the first case of COVID-19 was reported on 05 March 2020, and the first death attributed to COVID-19 recorded on 27 March 2020 (Broadbent, Combrink & Smart 2020:2). The South African government reacted swiftly to the pandemic by initiating moderate lockdown, which was later followed by the implementation of full lockdown that prohibited people from leaving their homes for any nonessential purpose (including exercise) and providing a restrictive list of essential activities, shutting down most economic activity (South African Government 2019).
Vaccination is considered to be one of the greatest achievements of public health (Pelčić et al. 2016:516). According to the Centers for Disease Control and Prevention ([CDC] 1999:241), vaccination programmes have contributed to the decline in mortality and morbidity of various infectious diseases and are credited with the elimination of poliomyelitis in America and the worldwide eradication of smallpox. To be successful in reducing the prevalence of vaccinepreventable diseases (VPDs), vaccination programmes rely on a high uptake level (Yoda & Katsuyama 2021:48). In addition to direct protection for vaccinated individuals, high vaccination coverage rates induce indirect protection for the overall community or herd immunity, by slowing the transmission of VPDs, thereby decreasing the risk of infection among those who remain susceptible in the community (Fine, Eames & Heymann 2011:911). According to Omer et al. (2009Omer et al. ( :1981, a high rate of childhood vaccination coverage in most developed countries indicates Churches have always been regarded as a safe haven during calamities. This changed during COVID-19 lockdown when churches were forced to shut down. The COVID-19 pandemic has posed a new normal to the world at large, calling for immediate action from authorities and introducing vaccination as an antidote. However, some religious practitioners as a vehicle of change through the institution of the church have been acting on the contrary because it discourages the uptake of vaccines, leading to vaccine hesitancy. COVID-19 vaccine hesitancy has been observed in the Christian community because Christians use Bible verses as a scapegoat for not getting a jab. There is a chasm that exists between faith and science, and it perpetuates the discourse of vaccine hesitancy. that vaccination remains a widely accepted public health measure (Dubé et al. 2013(Dubé et al. :1773. However, these national estimates may hide clusters of under-vaccinated individuals (De Serres et al. 2013:990;WHO 2014:14); this could be supported by the recent outbreak of VPDs including measles, poliomyelitis and pertussis in several parts of the developed world that has been linked mainly to under-vaccinated or nonvaccinated communities (Dubé et al. 2013(Dubé et al. :1774. Cooper, Van Rooyen and Wiysongel (2021:920) attested to the fact that South Africa is not exempt from vaccine hesitancy, and they further suggest that vaccine hesitancy is a developing phenomenon in the country. In a study conducted by Wiysonge et al. (2012:2), it was found that vaccine hesitancy was identified among parents as one of the main challenges facing vaccination programmes. According to Schoub (2011:519) vaccine hesitancy was also highlighted as playing a significant role in the various measles outbreaks in South Africa between 2003 and 2011. Wiyeh et al. (2019:6317) and Burnett et al. (2015:922) reported that there was a worrying and increasing trend of Internet-based antivaccination lobbying in South Africa. This vaccine hesitancy in South Africa will remain a concern, moreover, when looking at the fact that the COVID-19 lockdown and restriction rules and regulations have been lifted on 23 June 2022. This vaccine hesitancy will further be orchestrated by the recent reverse judgements from Commission for Conciliation, Mediation and Arbitration, which has ruled mandatory vaccination to be unconstitutional and all employees who have been fired to be reinstated to their respective employment (BusinessDay 2022; Eyewitness News [EWN] 2022).
This study seeks to argue that different factors orchestrate vaccine hesitancy, which is also knitted within the individual belief system. According to MacDonald (2015:4161), vaccine hesitancy refers to a delay in acceptance or refusal of vaccination despite the availability of vaccination services. Vaccine hesitancy is complex and context-specific, varying across time, place and vaccines. It is estimated that over 3.5 million people have died of COVID-19 worldwide (Mathieu et al. 2021:197). The safe and effective COVID-19 vaccines are vital for curtailing the pandemic. However, this depends on a sufficient number of people being vaccinated to generate herd immunity (Corcoran, Scheitle & DiGregorio 2021:6614). Globally, religious conservatism, including evangelical and born-again Christianity, is associated with lower levels of trust in science, rates of vaccine uptake, vaccine knowledge and higher levels of vaccine hesitancy (Turner 2017:1). Olagoke, Olagoke and Hughes (2021:65) recently found that religiosity is negatively associated with plans not to receive a COVID-19 vaccine. One religious worldview especially hostile to science and vaccines is Christian nationalism (Baker, Perry & Whitehead 2020:587).

Christian nationalism
Christian nationalism is 'an ideology that idealises and advocates a fusion of civic life with a particular type of Christian identity and culture' (Baker et al. 2020:588). It is estimated that strong supporters of Christian nationalism make up roughly 20% of the United States (US) adult population (Whitehead & Perry 2020:5). Historically, Christian nationalism has been conflated with evangelicalism, which is an umbrella term for conservative Christianity (Baker et al. 2020:588). Whitehead and Perry (2020:6) estimated that approximately half of US evangelicals are Christian nationalists. Evangelical Christians typically emphasise conversion, missionary work, biblicism (that is, seeing scripture as the sole authority for belief and action) and crucicentrism, which is the belief in Christ's sacrifice on the cross as atonement for human sin (Wellman 2008:15).
According to Whitehead and Perry (2020:7), Christian nationalism is positively associated with identifying as 'Bible-believing' and as a biblical literalist, believing that the Bible is the literal word of God. They are further associated with believing that the nation is on the brink of moral decay and that 'God requires the faithful to wage wars for good' (Dahab & Omori 2019:1727. Christian nationalists demand that their brand of Christianity be the sole source of moral authority for the government and reject all competitors, including science (Baker et al. 2020:588). These Christian nationalists are significantly more likely to support creationism being taught in public schools, reject evolution, view scientists as hostile to faith, respond incorrectly to scientific questions on topics that are religiously contentious (e.g. evolution) and hold anti-vaccine attitudes (Baker et al. 2020:589;Perry, Baker & Grubbs 2021:930;Whitehead & Perry 2020:15). Before COVID-19, Whitehead and Perry (2020:16) found that Christian nationalism had the secondlargest association with antivaccination attitudes after race, and it was the strongest predictor of believing that vaccines cause autism, that children are given too many vaccines, that vaccines can affect your reproductive system and that they do not help protect children. It is not surprising, then, that Christian nationalists did not respond favourably to scientific recommendations regarding how to reduce the spread of COVID-19. It expressed the belief that as God's chosen people, they would be protected and privileged if they upheld their identity as a Christian nation with biblical principles (Baker et al. 2020:589;McDaniel, Nooruddin & Shortle 2011:205), and this did not lend itself well to COVID-19 preventive healthcare measures.

Christian vaccine hesitancy in the South African context
The surveys conducted by Cooper et al. (2021:920) found that the majority of South Africans were ready to accept a suitable COVID-19 vaccine once it was developed (Thinane 2022:11). Similarly, a study by Burger et al. (2021:4) found that about 71% of South African adults responded positively to taking a COVID-19 vaccine once it was available. However, the arrival of COVID-19 vaccines was met with growing hesitancy and refusal in South Africa (Thinane 2022:12).
In most societies, religious organisations are very influential, and the role they play or their impact on members of the society can neither be downplayed nor undermined (Netshapapame, Mavhandu-Mudzusi & Ndou 2021:2;Thinane 2022:1). Africans in general (Agbiji & Swart 2015:2;Mbiti 1999:4), including South Africans, are deeply religious (Chukwuma 2021:1). Antivaccine views and vaccine hesitancy were not foreign to South Africa, as is congruent to other forms of resistance from other countries. Thinane (2022:3) cited that South African churches had been vocal because they had been encouraging congregants to take the jab, and churches were also used as vaccination sites. In his study, Thinane (2022:2) found that even though churches were used as vaccination sites to increase vaccine uptake, the vaccination process was countered with social hesitation because of conspiracy theories undermining the medical scientists' achievement. Pelčić et al. (2016:516) cited that vaccinations have played a significant role in the history of public health because they have over time protected societies from preventable diseases and saved lives. Nevertheless, resistance or hesitancy to vaccinations has also existed since the development of the first vaccine (Thinane 2022:1). According to Cooper et al. (2021:921), there was always hesitation and rejection of vaccines in global outbreaks. Vaccine-preventable diseases such as measles, H1N1, human papillomavirus, polio and many other diseases have recently experienced mistrust, hesitation, questioning and resistance worldwide. Stern and Markel (2005:611) reported that vaccine reluctance, safety concerns and many other challenges countered vaccine initiatives.
According to Grabenstein (2013Grabenstein ( :2011, Berenbaum and Boden (2013:65) and Palazzani (2018:2), there are exceptions of churches that traditionally rejected vaccination, citing that is against their beliefs and citing the following scriptures: Matthew 10:7-8, Mark 2:17, Mark 5:34, 1 Corinthians 3:16 and many others (Berenbaum & Boden 2013:67). Pelčić et al. (2016:517) reported that Catholics regard abortion as immoral and further expressed critical concern that certain vaccines are obtained from aborted foetal tissue. These vaccines will include but are not limited to vaccines against rubella (Meruvax, M-R-Vax, Rudivax), chickenpox vaccines (Varivax) and vaccines against hepatitis (Vaqta and Havrix) (Thinane 2022:8). Wombwell et al. (2015:597) posited that if Catholics were to agree with the use of these types of vaccines, this would create an impression that they passively support abortion (Wombwell et al. 2015:598). However, it must be observed that as of a 13 January 2021 statement on a public platform, Pope Francis reportedly urged Catholics and others to be vaccinated against COVID-19. Thinane (2022:9) further argued that there have also been numerous influential archbishops and clerics frequently telling their flocks not to take a jab and discouraging them even from wearing face coverings. Some Protestant churches consider these measures as disrespectful to God, for he is supreme and he will protect them (Hussain et al. 2018:4). Mud (2021:30) refuted said views, arguing that God has given medical doctors wisdom to research and discover medical interventions that can prolong livelihoods. Trout (2021:1) cited that the African Christians Democracy Party (ACDP), one of the opposition parties in South Africa, has since the advent of the COVID-19 pandemic been at the forefront of activism against vaccines and mandatory vaccination. The ACDP was responsible, together with other applicants in several litigations, for forcing the government and South African Health Products Regulatory Authority to roll out ivermectin as an alternative treatment for COVID-19 (Trout 2021:2). One of the prominent citizens of South Africa, Chief Justice Mogoeng Mogoeng, who is a devoted Christian, has also been sceptical about the vaccine, as he has been captured praying at a Gauteng government event held at the Tembisa Hospital in Ekurhuleni, saying (News24 2020): I lock out any vaccine that is not from you, if there be any vaccine that is of the devil, meant to infuse triple-six in the lives of people, meant to corrupt their DNA, any such vaccine, Lord God Almighty, may it be destroyed by fire, in the name of Jesus. (p. 1) Some claimed Mogoeng was confusing people who are already hesitant about a vaccine, while others said his prayer had been misinterpreted. However, former Chief Justice Mogoeng Mogoeng has stood firm after widespread criticism of his public prayer, where he prayed for any 'devilish' COVID-19 vaccine to be destroyed by fire (News24 2020:1). Eyewitness News (EWN) (2021:1) covered a story of protesters in both Johannesburg and Cape Town who were all refuting the use of vaccines, citing that they cannot stand and watch Africans being used as guinea pigs for testing these drugs. The given fact can be supported by the following excerpts by EWN (2020:n.p.): 'I'm not happy at all! I mean, this feels like the 1980s all over again when the AIDS pandemic just broke out in South Africa; we are not guinea pigs.' 'The vaccine should be tested first on members of parliament and ministers' children, not on poor people. We are clear, comrades, we don't want this vaccine [trial].' 'We are not going to follow a vaccine, because we as traditional healers believe that our traditional medicine is not given a chance.'

Methods Locality
The sample comprised all participants from African (Zion), Lutheran, Presbyterian, Roman Catholic, Methodist and Charismatic churches in Thulamela Municipality. The researcher used purposive sampling for participants.
Data collection was carried out using in-depth interviews with congregants, and written informed consent from the participants was obtained. Participants were assured that their participation was voluntary, and they could withdraw at any time. Appointments for the interviews were made with each participant at a venue they identified as safe, private and disturbance-free. All interviews were transcribed verbatim and transcripts were coded following steps for the interpretative phenomenological analysis approach as described by Neuman and Reed (2011:113).
To ensure trustworthiness in this study, the researcher applied Lincoln and Guba's model (as cited in Polit & Beck 2017:787). Prolonged engagement with the participants during the indepth interviews ensured truth value. The researcher reflected by writing field notes during and after the interviews. Regular discussions among researchers enriched the process and improved credibility. Applicability was ensured through a wellthought-out sample and a dense description of the research methodology. Replication is possible because of a dense description of the study and data. Authenticity is evident in the quotes that enrich the findings. Ethical clearance to conduct the study was sought from the University Ethical Committee.

Findings
This section discusses the findings of the study. People are hesitant to take the vaccines, and they cite different reasons for their denial to be vaccinated.

Factors associated with vaccine hesitancy
According to a study conducted by Syed Alwi et al. (2021:1) in Malaysia, it was found that the following were reasons for people not taking the vaccine: the speed with which vaccines were developed, vaccine side effects, religious and cultural reasons and conspiracy theories. Similarly, in South Africa, a report by Cooper et al. (2021:930) indicated that several peers reviewed surveys such as the COVID-SCORE global survey, which was explicit that South Africans were ready to accept a suitable COVID-19 vaccine once it was developed; however, as reported in a Malaysian study, South Africans have refused to take vaccines for similar reasons articulated in the survey (Burger et al. 2021:10;Letšosa 2021:7).

The vaccine is the mark of the beast 666
The following excerpt shows hesitancy because vaccines are being used as the mark of the beast, as stipulated in Revelation 13:16-18: 'I'm not going to be vaccinated; my pastor has said this thing in advance, [that] we must not get vaccinated because these people want to inject us with these 666 mark of the beast. Because my pastor has said so, I am not going to take this vaccine; I'm not preparing myself to be injected with the 666 marks.' (T.G., Charismatic, six years of pastoring experience) 'My God will protect me; I went to the church and my pastor prayed for me, and he has also given me the water that I must use at home. So when I go out, I drink the water that I've been given to me by my pastor; when I come back from the crowd, I also drink the prayed water.' (S.S., Charismatic, seven years of pastoring experience) 'If it means that I need to resign from my work, I will rather resign; I am not going to take this vaccine. My church is against vaccination, so I will stand by my belief. The bishop has categorically said that he has seen this sickness coming in his prayer, but we are not going to be killed by it, for us is to believe in Christ and all is going to be well.' (D.V., Charismatic, three years of pastoring experience) These excerpts are congruent with the literature that pastors are exercising pastoral power over their flock. Foucault (1998:777) cited that pastors are using biblical texts to sustain forms of ritualisation and superstitious belief over the congregants. Pastors are using Revelation 13:18 as referral scripture, which is being used out of context. Theologian Breaker (2021) clarified it, mentioning that the 666 mark of the beast will only come after the rapture, which brings light to this conspiracy theory that the vaccine is an agent of the 666 mark of the beast from the devil. On the contrary, Dr Sherri Tenpenny, a medical doctor and antivaccine advocate, made a connection between the vaccine, 5G Internet and metal objects sticking to the bodies of vaccinated people, which further raised the question of metal in the vaccine (Senokoane 2021:1). This experiment of money sticking to the area where a vaccine has been injected has further orchestrated fear of getting vaccinated, citing that it is indeed an agent 666 mark of the beast (Senokoane 2021:2).

The speed at which the vaccine has been developed
There was a concern that HIV and AIDS has been around and killed many people, and to date, there is no vaccine in sight. The reason people are hesitant to take the vaccine is attributed to the speed at which this vaccine has been developed: 'I'm not going to be vaccinated by something that is not thoroughly researched and tested. For how long people have been sick with HIV and AIDS and to date no vaccine has been made? What is happening with this COVID that just came yesterday, and today they want us to be vaccinated? I'm not going to be vaccinated myself; I'm not trusting this research vaccine.' (A.F., Charismatic, nine years of pastoring experience) In his address, former Minister of Health Dr Zweli Mkhize mentioned that the vaccine was still in the research phase but safe to be used (Belseck 2021:2). This utterance has also contributed to the delay of uptake because people were questioning the rush to inoculate people with a vaccine that had not gone through thorough quality assurance. The finding of the research corresponds with Burger et al. (2021:10) and Letšosa (2021:7), who argued that because of various reasons, people either refused or were reluctant to take the COVID-19 vaccine, including its safety and the speed at which the vaccine has been developed.

Culture as barrier
Traditional healers have been at loggerheads with the government because they were not given chance: 'I don't trust this vaccine. This COVID is just like any other flu, so I'm going to steam myself using medicinal plants like mugwibiri, mubomo and tshiumbeumbe. I trust my medicinal plant because I have been using them long enough and I trust them. These research findings agree with the conclusion of Cordeiro- Rodrigues and Metz (2021:59) in the sense that the usefulness of traditional African healers in helping to mitigate the effects of the pandemic has been neglected. They argue from an ethical perspective that these healers can and should have an important role in informing and guiding local communities in Africa on how to prevent the spread of COVID-19, and traditional African healers have some unique cultural capital for influencing and enforcing preventive measures to be adhered to.

Christian belief
Christianity has been the scapegoat for not wanting to get a jab; they believe that their body is the temple of God, and God will protect them against COVID-19. This can be supported by the following quotes: 'Luke 1:37 says, "for nothing is impossible with God", so even in this time, I believe in God to protect me throughout this pandemic, so I'm not going to take any vaccine. I trust in God to protect me. If God will, we will be healed and be protected, so no vaccine for me.' (K.T., Charismatic/Main Line, 13 years of pastoring experience) 'People lack faith -the Bible says whatsoever we ask God believing, believe that you got what you have asked for; even amid this pandemic, I'm still believing God to carry me along to protect me against this virus, so I'm not going to take any vaccine; my God will see me through.' (R.E.G., Charismatic, eight years of pastoring experience) According to Whitehead and Perry (2020:7), Christian nationalism is positively associated with identifying as 'Biblebelieving', and as biblical literalists, believing that the Bible is the literal word of God. Christian conservatives are resisting vaccines, a worrisome factor to health professionals striving to reach herd immunity (Baker et al. 2020:588).

Conspiracy theories
In one of his speeches, the president of South Africa, Cyril Ramaphosa, shed some light on the fact that men are hesitant to take the jab because of the fear that they will become sexually impotent, which he deemed fake news and not to be taken seriously. Respondents, meanwhile, expressed belief in conspiracy theories: 'This is a Chinese virus -they've manufactured it to kill us, but we are believing God that they will never kill us. This thing, they've started it in China and then they've created this immediate vaccine, so these people are in business, and then they want to use us as their guinea pig. I refuse to vaccinate, and I will continue with my prayer.' (S.A.L., Charismatic, 13 years of pastoring experience) 'No way, I'm not going to vaccinate, because I'm told that people who are going to be vaccinated, after two years there will be dying, so I'm going to wait until two years to see what's going to happen. After three years, then I will check and see if can be vaccinated.' (C.K., Charismatic, 14 years of pastoring experience) The findings of this research agree with the study conducted by Runciman et al. (2021:14), who found that people believe Western countries want to kill Africans, track them and manipulate them with this vaccine. They further found that there are people who believe that COVID-19 has been manufactured to depopulate the nations, while others say it is a money-making scheme.

Conclusion
In public health history, vaccinations have been seen as very helpful, as they help protect societies from preventable diseases and save many lives around the world. For vaccination to be effective, it needs broader coverage to achieve herd immunity, and that can be achieved with the help of all involved in society. However, vaccine resistance and hesitancy have been experienced over time, which is connected with the COVID-19 vaccine. Hesitancy regarding COVID-19 vaccines has been observed in the Christian community because of Christians using Bible verses as a scapegoat for not taking the jab which is meant to eliminate the disease. This agrees with the statement that some religious practitioners are either directly harming public health or indirectly undermining the public health response to COVID-19. Hence, there is a need for collaboration between faith and science and religion, as a technology of power can also be a vehicle of change in addressing the negative attitude of not taking up the vaccine and redressing the biblical discourse thereof.