The Double Democratic Bind: Challenges to Enacting Mandates and Combating Misinformation.

CONTEXT: Wealthy countries vary considerably in terms of how well they have been able to inoculate their populations against COVID-19. In particular, democracies have been constrained in their abilities to implement vaccine mandates, given enshrined protections of civil liberties and individual freedom in such regimes. While scholars have begun addressing the democratic constraint on vaccine mandates, less attention has been paid to the additional challenges democracies face in constraining the spread of vaccine misinformation-particularly misinformation that spreads online. METHODS: This study combines large-N cross-country analysis with a case study of Germany to illustrate the "double bind" that democracies face when it comes to containing both the spread of disease and the spread of misinformation through social media. FINDINGS: The cross-national analysis confirms that democracies have been less likely to enact vaccine mandates, and they have also been relatively more hesitant to restrict what people can see and share online. The case study of Germany highlights the normative and the procedural constraints underlying such decisions. CONCLUSIONS: These findings show that resources are often not the binding constraint on effective disease control, raising questions regarding the ability of high-income democracies to respond effectively to future public health emergencies.

Confronting 'chaos': a qualitative study assessing public health officials' perceptions of the factors affecting Tanzania's COVID-19 vaccine rollout.

OBJECTIVES: Mass COVID-19 vaccination in Africa is required to end the pandemic. In low-income settings, street-level bureaucrats (SLBs), or public officials who interact directly with citizens, are typically responsible for carrying out vaccination plans and earning community confidence in vaccines. The study interviewed SLBs to assess their perceptions of the factors affecting COVID-19 vaccination rollout in Tanzania. METHODS: We interviewed 50 SLBs (19 rural; 31 urban) responsible for implementing COVID-19 vaccination microplans across four diverse regions and districts of Tanzania in September 2021. Moreover, we conducted six in-depth interviews with non-governmental organisation representatives and seven focus group discussions with health facility governing committees. We asked for their perceptions of factors facilitating and challenging vaccine rollout according to three preidentified domains: political, health system and community. We analysed translated transcripts using a thematic analysis approach. RESULTS: Political factors facilitating mass vaccination included the executive leadership change from a denialist president to a president who accepted vaccines and promoted transparency. Global integration, commercially and politically, also motivated vaccine acceptance. Political challenges included community confusion that emerged from the consecutive presidents' divergent communications and messaging by prominent religious antivaccination leaders. Health system factors facilitating vaccination included scaling up of immunisation sites and campaigns. Urban district officials reported greater access to vaccination sites, compared with rural officials. Limited financial resources for paying healthcare workers and for transport fuel and a lack of COVID-19 testing compromised mass vaccination. Furthermore, SLBs reported being inadequately trained on COVID-19 vaccine benefits and side effects. Having community sources of accurate information was critical to mass vaccination. Challenges at the community level included patriarchal gender dynamics, low risk perception, disinformation that the vaccine has satanic elements, and lack of trust in coronavirus vaccines. CONCLUSION: Mass COVID-19 vaccination in Tanzania will require greater resources and investment in training SLBs to mitigate mistrust, overcome misinformation, and engage communities.

Coping with Denialism: How Street-Level Bureaucrats Adapted and Responded to COVID-19 in Tanzania.

CONTEXT: This article aims to highlight challenges and adaptations made by local health officials in Tanzania in working to contain and manage COVID-19. METHODS: The study takes an inductive approach, drawing on the reported experiences of 40 officials at different levels of government across four purposefully selected regions in July 2020. Interviewees were asked about the guidance they received to contain COVID-19, the source of that guidance, their challenges and successes in implementing the guidance, and if and how they adapted the guidance to their particular setting. FINDINGS: The interviews depict considerable challenges, including a lack of supplies and resources for implementing infection control, surveillance, and mitigation practices and dealing with fear and stigma. At the same time, they also provide evidence of innovation and adaptation among street-level bureaucrats. Respondents overwhelmingly praised the president, whose limited national response is seen as helpful for reducing fear and stigma. CONCLUSIONS: Other scholars have highlighted the potential dangers of street-level discretion if local officials "make policy" in ways that contradict their agencies' stated goals. In contrast, our study suggests benefits of autonomy at the street level-particularly in contexts where the central state was relatively weak and/or acting against the public interest.

Life under lockdown: Illustrating tradeoffs in South Africa's response to COVID-19.

This research note sheds light on the first three months of the COVID-19 outbreak in South Africa, where the virus has spread faster than anywhere else in the region. At the same time, South Africa has been recognized globally for its swift and efficient early response. We consider the impact of this response on different segments of the population, looking at changes in mobility by province to highlight variation in the willingness and ability of different subsets of the population to comply with lockdown orders. Using anonymized mobile phone data, we show that South Africans in all provinces reduced their mobility substantially in response to the government's lockdown orders. Statistical regression analysis shows that such mobility reductions are significantly and negatively associated with COVID-19 growth rates two weeks later. These findings add an important perspective to the emerging literature on the efficacy of shelter-in-place orders, which to date is dominated by studies of the United States. We show that people were particularly willing and able to act in the provinces hit hardest by the pandemic in its initial stages. At the same time, compliance with lockdown orders presented a greater challenge among rural populations and others with more precarious livelihoods. By reflecting on South Africa's inequality profile and results of a recent survey, we demonstrate how the country's response may deepen preexisting divides. This cautionary tale is relevant beyond South Africa, as much of the continent - and the world - grapples with similar tradeoffs. Along with measures to contain the spread of disease, governments and other development focused organizations should seriously consider how to offset the costs faced by already marginalized populations.