The “politicized” doses of anti-COVID-19 vaccines in Tunisia

Many believed that the Tunisian Prime Minister, who is simultaneously the Minister of Interior, had deliberately thwarted the vaccination campaign in Tunisia in a plot to dispose of the Minister of Health who is close to the President of the Republic. This incident contributed to spiking popular anger, which erupted on July 25, 2021 in the form of demonstrations in the streets, culminating in burning some of the headquarters of the “Islamic Ennahda Movement.” Subsequently, the Tunisian President, Kais Saied, declared the Parliament “frozen” and announced that he would assume both the country's executive and legislative powers “for the sake of saving the country.”
2021-11-06

Mohamed Rami Abdelmoula

Journalist from Tunisia


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A vaccination center in the Tunisian “Ben Arous” governorate. Photo from the website of “Inkyfada”.

This publication has benefited from the support of the Rosa Luxemburg Foundation. This text may be reproduced in part or in full, provided the source is acknowledged.

At the beginning of June 2021, the Scientific Committee for fighting Covid-19 in Tunisia announced that the country was observing a fourth wave of the epidemic. The daily toll gradually rose from 1,512 infection cases and 66 fatalities on the first of June to 1,997 infection cases and 89 fatalities in middle of the same month, then 5,921 infection cases and 116 fatalities on the first of July, and reaching 7,878 cases and 164 fatalities in the middle of July.

In the country of 11 million people, more than a quarter of a million people have contracted COVID-19 and more than 7,000 people have died of corona-related complications in the span of only two months.

This terrifying rise in the epidemic’s toll almost brought the health system to a breaking point, especially in the most densely populated areas of Tunisia, where the hospitals reached maximum capacity and the oxygen supply was no longer sufficient. At a later time, news uncovered that Tunisia was once a producer of large quantities of medical oxygen until the 1990s, when the country gave up its manufacturing, leaving the local market at the mercy of two foreign companies. As the health system grappled, the country suffered some excruciating days amid sorrow, pain and anger. People searched, often in vain, for a bed in an IC unit or for a dose of medical oxygen in public health institutions. Otherwise, they would have to pay exorbitant amounts of money – that is, if they were privileged enough to have or find that kind of money – to get treatment in private hospitals or to buy an oxygen concentrator at exaggerated prices, if they could find one at all… The rise of a fourth wave of the epidemic ushered the political crisis to a climax by the middle of the summer of 2021, becoming one of the main direct factors leading to the eruption of the situation on July 25.

The conflict between the President of the Republic on the one hand, and the heads of Parliament and government on the other hand, had effectively paralyzed the political life, disrupting the state’s functioning at a time when the country most needed the collaborative efforts of the three presidencies and both the executive and legislative authorities, in order to efficiently combat the pandemic. These intertwined crises left the Tunisians feeling abandoned and left to fend for themselves, believing that the vaccination process would take years to be completed, rather than a few months. When the ministry of health announced that it would organize a fast and intensive vaccination campaign for all age groups in the first and second days of Eid al-Adha, citizens finally felt optimistic, especially that they could just show up, instead of having wait to get an appointment by SMS.

On the day of Eid, and despite the sanctity of the occasion, tens of thousands of Tunisians headed to the vaccination centers, piling up in endless, unorganized queues in the searing heat, only to discover that several of the vaccination centers that were supposed to be part of the campaign were closed (vaccination centers were insufficient in the first place, with a total of 29 vaccination centers allocated to 11 million citizens nationwide). Some of the open centers had not received any vaccine doses yet and some others had only a few hundred doses to give. The overcrowding and chaos were accompanied by a near-total absence of security around the centers. In the afternoon, the Ministry of Health announced that the vaccination centers had limited capacity and therefore the second day of the campaign would be allocated exclusively to the citizens 40 to 50 years old. In the evening, the ministry made a contradictory announcement, declaring that it was annulling the entire campaign due to “the chaos that ensued and the disregard of health protocols at the centers.”

After this futile campaign, Tunisians felt humiliated by a reckless government that treated their health and safety with total disregard. The Prime Minister at the time, Hisham Al-Mashishi, tried to dampen public anger by dismissing the Minister of Public Health, stating that he had not been consulted about this flash campaign in advance and that there was no formal correspondence with the Ministry of Interior so as to provide security at the centers. Soon enough, the falseness of Al-Mashishi’s statements was exposed, as the correspondences in this regard were leaked, and as those spread all over social media websites, popular anger mushroomed. The fact that Al-Mashishi was not only the prime minister, but also the acting Minister of Interior, prompted many to believe that he had deliberately thwarted the vaccination campaign in a plot to dispose of the Minister of Health who is close to the President of the Republic.

This incident contributed to spiking popular anger, which erupted on July 25, 2021 in the form of demonstrations in the streets, culminating in burning some of the headquarters of the “Islamic Ennahda Movement.” Subsequently, the Tunisian President, Kais Saied, declared the Parliament “frozen” and announced that he would assume both the country's executive and legislative powers “for the sake of saving the country.” Yet, even before this incident, the “politicization” of vaccination was quite obvious through every phase of the vaccination process in Tunisia.

The preparatory period: High hopes and an endless wait

On August 19, 2020, Al-Hashemi Al-Wazir, member of the Scientific Committee to fight COVID-19 and General Director of the Pasteur Institute specialized in vaccines and biomedical research, announced that Tunisia will begin clinical trials to develop an anti-COVID vaccine. The announcement sparked the ridicule of some and the enthusiasm of others, but it was generally not taken very seriously. Indeed, the research did not go a long way, and soon the issue was forgotten, as neither those who announced it nor the media nor the public ever addressed the issue again. Once again, Tunisians, both in positions of authority and the general public, were waiting patiently for the results of the clinical trials that were being carried out in developed countries.

On the day of Eid, and despite the sanctity of the occasion, tens of thousands of Tunisians headed to the vaccination centers, piling up in endless, unorganized queues in the searing heat, only to discover that the several of the vaccination centers that were supposed to be part of the campaign were closed, while some of the open centers had not received any vaccine doses yet and some others had only a few hundred doses to give; all with a near-total absence of security.

As the vaccines became available on the market, Tunisians thought that salvation was near. The government of Hisham al-Mashishi (September 2, 2020 - July 25, 2021) and the Scientific Committee talked enthusiastically about plans, endeavors and negotiations to buy vaccines... However, their words had far more momentum than their actions. Autumn passed, then winter, without a single dose of the vaccine entering the country for various reasons (Tunisia received the first shipment of vaccines on March 9, 2021, comprising 60,000 doses of the Russian Sputnik vaccine). The primary reason is that rich countries have signed outrageous contracts that give them priority in acquiring large doses of the vaccines that far exceed the needs of their populations, while the poor and marginalized countries are left high and dry at the mercy of the wicked.

The second reason has to do with the government’s tardiness in contacting the vaccine manufacturers, as it was relying mainly on the expectation to receive doses from the COVAX platform, in addition to donations from “friendly and brotherly” countries, while giving less importance to direct purchases from manufacturers. The third reason pertains to the bureaucratic procedures that accompany the importing of vaccines, such as the formal authorization of vaccines or granting the manufacturers temporary licenses to promote their vaccines in Tunisia after examining the products by the competent scientific authorities. This also includes fulfilling the conditions that COVAX imposed on Tunisia, such as ratifying a law that exempts vaccine companies and the manufacturers of COVID-19 antiviral drugs from legal liability for any medical risks that might arise due to their use, which was actually done by Tunisia on February 19, 2021.

On the practical level, the EVAX digital platform for supervising all aspects of the vaccination process was launched on January 20, 2021. The platform allows residents who wish to receive the vaccine to register for it (via its website or by SMS). After they fill out some information about their health status and medical history, the platform directs applicants to the vaccination centers closest to their homes, and informs them of the appointments of both of their doses.

The rise of a fourth – and brutal - epidemic wave shot the political crisis to a climax by the middle of the summer of 2021, becoming one of the main direct factors leading to the eruption of the situation on July 25.

Promoting the vaccination campaign was limited to the mainstream media, social media, and some banners and posters in public administrations and city centers, excluding the poor popular neighborhoods and rural and remote areas where illiteracy and poverty rates are high, where access to information is limited, and where registering via an online platform or through text messages seems complicated or far-fetched for some. The state had already predetermined who had top priority in receiving vaccination: health workers, the elderly over the age of sixty, individuals with serious chronic illnesses, individuals with severe disabilities, and then security forces and army members.

Phase One of the vaccination process: Fatally slow and inefficient

This period extends from the beginning of March to the beginning of July 2021. The vaccination process against COVID-19 began in Tunisia on March 13, 2021. The Tunisian state’s policy in selecting the vaccines was simple and “pragmatic”. Whenever the World Health Organization approved a new vaccine, the Tunisian state authorized its use just a few days later. Seven different vaccines have been administered in Tunisia to date: Pfizer/BioNTech, Sputnik V, Johnson & Johnson, AstraZeneca, Moderna, Sinovac and Sinopharm.

This flexible policy enabled Tunisia to secure a share of the vaccines through COVAX, while enhancing its chances of obtaining donations from other parties, and - in theory - securing sizable quantities of vaccine when concluding contracts with several manufacturers at the same time, instead of relying on one sole supplier. The cost of these vaccines, their storage conditions and even the minimum and maximum time intervals between the two doses for each vaccine differ, which reduces the financial and logistical burdens. In Tunisia’s circumstances, the country does not have the luxury of engaging in the struggles among major powers, hence, it can’t exclude certain vaccine manufacturers while endorsing others. According to the former Minister of Health, Faouzi Mehdi, “the orders placed by the Ministry of Health amount to 16.9 million doses, of which 9.1 million doses are direct purchases, 3.5 million doses are obtained through the African Initiative and 4.3 million doses are obtained via COVAX.”

Initially, 39 centers were assigned for the vaccination campaign, but the number slowly, yet steadily, grew as more vaccine doses were imported and as the number of people who had registered via the EVAX platform increased (in August 2021, the number of vaccination centers exceeded 400). However, the centers were mainly concentrated in the governorates’ centers (provinces) and districts (administrative subdivisions within the same governorate). To encourage the population to get vaccinated, the Minister of Health, the official spokeswoman for the ministry, as well as members of the scientific committee for fighting COVID-19, all received their vaccine doses during the first few days of the campaign. To further encourage hesitant and skeptical citizens, the media covered the vaccinations of the Prime Minister, the Speaker of Parliament, the Mufti of the Republic and several well-known artists.

Only the President of the Republic refused to receive the vaccine during that early phase, saying that he should wait for the rest of the population to receive it before him. His gesture was applauded by many as a sign of altruism, reflecting a high sense of responsibility, while others considered it nothing but empty populism and an irrational decision, especially in a country experiencing a multidimensional crisis that may exacerbate should the presidency office become vacant (the president didn’t receive his first dose of the vaccine until July 12, 2021).

Despite providing the necessary human and health resources, allocating several vaccination centers and welcoming volunteers into the vaccination campaign on April 29, 2021, the rate of vaccination remained very slow during the first three months of the campaign. 39 days after the launching of the campaign, the number of people who had received vaccines reached only a quarter of a million, and it wasn’t until May 10, that is 58 days after later, that the number reached half a million. It took 82 days to bring the number of doses administered to one million doses.

Promoting the vaccination campaign was limited to mainstream media, social media, and some banners and posters in public administrations and city centers, excluding the poor neighborhoods and rural and remote areas where illiteracy and poverty rates are high, where access to information is limited, and where registering via an online platform or through text messages seems complicated or far-fetched for some.

A major reason for the low turnout is related to the availability of vaccines. People would think, “Why should we register on the platform when there are scarce or no vaccine doses available?” Other reasons include the lack of confidence in the existing government at the time, in addition to some obstacles and aversions. For example, some people refused to receive the Russian or Chinese vaccines because their use is unauthorized in the European Union and other Western countries.

The issue of abuses in the vaccine registration platform has been raised on social media since the early days of the vaccination campaign. It has been found that some of those who had received vaccination doses in the initial phase as health workers were actually not part of the health sector at all. The Ministry of Health consequently had to verify the professional status of those who had registered as priority candidates for the vaccine.

 Real or fabricated “scandals” were also exposed in the context of political polarization. At the beginning of March 2021, one of the members of parliament raised questions about vaccine doses donated by the UAE to Tunisia, which the President of the Republic had received without informing the Ministry of Health or public opinion about who these doses were intended for. The President’s opponents took advantage of this issue to accuse him of corruption and, thus, shake his popularity. The Prime Minister at the time, who had an open conflict with the President, ordered an immediate investigation into the matter, but soon the dust settled, revealing that only 1,000 doses of vaccine were received in November 2020, none of which were administered yet. They were rather entrusted to the Military Health Department, pending examination and licensing for their use in Tunisia. A few weeks later, the anti-corruption organization “I Watch” uncovered a report which stated that a parliament member, deputy of the Ennahda Movement, had received a dose of a vaccine without applying through the registration platform or waiting for her turn. Supporters of Ennahda tried to deny the news, but it turned out to be true, and the PM was forced to apologize, while her friend, the director of the health center who gave her the vaccine, was fired from her position.

The government’s media campaign to raise awareness on the necessity of registering on the EVAX platform, despite all the efforts made, has remained essentially traditional and elitist. Tunisians were very reluctant to register during the first few months after the platform’s launch, and the number of registered people did not reach one million until April 9, 2021, although registration had been open since January 20. The reasons for the low turnout are multiple. First, there was a general apprehension concerning the possible side effects of vaccines. Social media websites echoed these concerns, Facebook being the primary space that hosted discussions, debates and questions about the various stakes and outcomes of the vaccination campaign. Even the selfies taken by citizens, as they extended their arms to get vaccinated, played an important role in “positively infecting” others, encouraging them to register for vaccination.

Another reason for the low turnout is related to the availability of vaccines. People would think, “Why should we register on the platform when there are scarce or no vaccine doses available?” Other reasons include the lack of confidence in the existing government at the time, in addition to some obstacles and aversions. For example, some people refused to receive the Russian or Chinese vaccines because their use is unauthorized in the European Union and other Western countries, which might disrupt travel to these countries or require long quarantine periods.

There were also those who did not know how to register on the online platform, or did not have the technical tools to do so, while there were others who were denied registration because they don’t have ID numbers. Naturally, the rates of illiteracy and poverty, as well as the remoteness of the nearest vaccination centers, all play a role in the failure of many residents to receive the vaccine, or their lack of interest in it altogether. To mitigate this situation, the health authorities started mobile vaccination campaigns since last May, targeting the areas where the registration rates on the EVAX platform were low. In these campaigns, health workers would simply register citizens for vaccination on the spot. In spite of these efforts, the number of people registered on the platform remained below expectations, amounting to less than three million people, until July 4, 2021.

Phase Two of the vaccination process: A “presidential” and popular uprising

During the first phase of the vaccination campaign, the President did not play a big role in the efforts to bring in vaccines or organize their distribution to the population. But, with the obvious fumbling of the campaign since the end of last spring, more voices have called for greater engagement by him. As the fourth epidemic wave rose in mid-June 2021, causing terrible fatality rates in light of the low vaccination rates, the voices calling for the president's intervention grew more urgent, even angrier.

On July 5, 2021, President Kais Saied stepped in, organizing an emergency meeting of the National Security Council, after which a number of measures were decided. The most important of those measures were: intensifying diplomatic efforts to accelerate the process of bringing in vaccines; dividing the country into several medical districts; forming work teams that include people from the military, the security forces and the healthcare sector, under the leadership of the Director General of Military Health; recruiting the recent graduates of the medical and paramedical staff in the vaccination campaign and in medical tasks related to combatting the epidemic; and finally, targeting priority regions where infection has widely spread by sending them teams of field workers.

The illiteracy and poverty rates, as well as the remoteness of the nearest vaccination centers, all play a role in the failure of many residents to receive the vaccine, or their lack of interest in it altogether. To mitigate this situation, the health authorities started mobile vaccination campaigns, since late May.

It was clear that the President of the Republic, relying on the support of the army, had decided to play a decisive role in managing the epidemic. Following the issuing of these aforementioned decisions, President Saied made a speech, in which he said that “losing the battle was the result of a number of political choices that did not take into account the most basic human rights, but rather focused only on narrow partisan interests that do not consider the wellbeing of human beings.” Not only did the president snatch the initiative from the government, but he held it and the parties supporting it - namely Ennahda Movement – responsible for the failure of the vaccination campaign. In the midst of the disarray of the epidemic, no one expected that this small step was a prelude to a much bigger turning point ahead.

Soon, the President’s decisions began to pay off. Several military medical units were stationed in the areas most affected by the spread of the epidemic, or in the regions with least access to vaccination. Those units effectively contributed to the vaccination of groups that had, until then, remained overlooked by the campaign. In parallel, vaccines began to flow into the country - mainly through the COVAX initiative and donations from various countries – simultaneously as the country was seeing tragically record-breaking infection and fatality rates. Millions of doses were collected by the health authorities, registration rates improved, and the number of the vaccine doses administered rapidly increased. Within two weeks (5 to 19 July 2021), the number of registered people went from 3,045,810 to 3,538,909 people, and the number of doses increased, from 1,972,036 to 2,385,176 doses. The remarkably rapid progress of the vaccination campaign was attributed to the efforts made by the Tunisian President, which upset his political opponents in the government and Parliament who tried to blame him for taking longer than he should to begin to take action. Some claimed that the president’s ability to secure large quantities of vaccines was due to his affiliation with regional political axes and certain international powers. With the president’s growing popularity, the issue of the vaccination campaign moved to the center of an open political struggle that culminated on the day of Eid al-Adha, with the progress of the aforementioned rapid vaccination campaign. The failure, or perhaps the thwarting of this campaign due to the government’s deliberate inaction was the last straw that led to the breakout of popular anger that had been simmering for months.

On July 21, 2021, the day after the Minister of Health was dismissed by Kais Saied's opponent, Prime Minister Hisham Al-Mashishi, the President’s office announced that the management of the health crisis would be assigned to the Military Health Department, in cooperation with the civilian health authorities. Thus, President Saied nipped the government’s rebuttal in the bud, while seizing the management of the most important file in the country; one which was the biggest concern of all Tunisians at the time... It was one final step before President Saied took over all authorities and declared an exclusive management of the epidemiological crisis starting from the evening of July 25, following a series of shocking decisions he had made.

On August 2, the Presidency of the Tunisian Republic announced that Tunisia had received a total of six million vaccine doses in the form of donations from “friendly and brotherly” countries, and therefore, that the vaccination process would be accelerated. Indeed, an open day for vaccination was announced on Sunday, August 8 - in addition to the usual daily campaign - for the people who fall in the age group over 40 years of age. With the collaboration of the workers of public health, military health and volunteers, the vaccination open day turned out to be a success, with more than half a million people vaccinated in one day, which encouraged the presidency to organize another open day on the following Sunday for those over the age of 18, and, indeed, more than half a million people were given vaccine doses within just a few hours the following week. Afterwards, it was decided that more open days would be held starting from August 29 for all age groups, and that vaccinations would soon include the age group between 15 and 17, after obtaining the approval of their legal guardians.

The pace of daily vaccination also intensified, with some 60 thousand to 100 thousand people coming in daily. In order to increase the number of vaccination centers, private pharmacies were authorized to vaccinate. The initial target was to completely vaccinate 50 percent of the population (Tunisians and resident foreigners regardless of their legal status) before October 15, 2021. The target appears to be on the right track to fulfillment, as the number of those who have completed their vaccination has reached more than 3,806,200 people (until September 28, 2021), while 5,033,603 people have already received at least one dose.

President Saied made a speech in which he said that “losing the battle was the result of a number of political choices that did not take into account the most basic human rights, but rather focused solely on narrow partisan interests.” In the midst of the disarray of the epidemic, no one expected that this small step was a prelude to a much bigger turning point ahead.

This “vaccine surge” can be explained as the result of three simple factors: first, increased fear of the virus after the significant losses in lives due to the fourth wave of the epidemic; secondly, the elevated confidence in the country’s political leadership after the latter was able to secure vaccines and manage the epidemiological crisis; and finally, social simulation, as the more people were coming in to take the vaccine, the less hesitant other people would be to take it, and the more attentive they would be to its importance.

The rapid progress of the vaccination process since the President of the Republic and the military establishment took over the management of the epidemic crisis has saved thousands of Tunisian and contributed to raising the public’s morale. It has also contributed to making the subsequent epidemic waves less difficult for the people and the health institutions. These are undeniable facts. However, there is a negative – even, potentially dangerous- flipside to this situation that may not seem particularly important at first glance. There is a political and “ideological” price for the implementation of the “iron fist”; that is the exclusivity of authority over vital files. In the collective subconscious of people, certain convictions -some old and rooted in the collective imagination - have begun to seep in. For example, the belief that instead of political institutions, crisis management requires powerful figures who take matters into their own hands, whereas the separation of powers leads to failure. In addition, the positive aura that currently surrounds the military as an institution of exemplary efficiency, discipline, and dedication, as opposed to the apathetic and undisciplined civilian institutions, may turn into a heavy shadow that lurks over the Tunisian scene. 

The content of this publication is the sole responsibility of Assafir Al-Arabi and Rosa Luxemburg Foundation cannot accept any liability for it.

Translated from Arabic by Sabah Jalloul
Published in Assafir Al-Arabi on 30/09/2021

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