DO GOVERNMENTS HAVE ANY PRIMA FACIE DUTIES TO FUND INFLUENZA VACCINATION (FOR THE ELDERLY IN SA) AND ADULTS 65 YEARS AND ABOVE TO VACCINATE AGAINST INFLUENZA, RESPECTIVELY? Student full name: Ruach Sarangarajan Student number: 1655975 Submitted to the Faculty of Health Sciences, University of Witwatersrand, Johannesburg, in fulfilment of the requirements for the degree Master of Science in Medicine (Bioethics and Health Law). Supervisor: Dr Cornelius Ewuoso Qualifications: PhD Position: Senior Lecturer Date of Submission: 04 March 2023 i Academic Integrity Declaration I, Ruach Sarangarajan, (Student number: 1655975) am a student registered for MSc (Med) Bioethics and Health Law in the year 2023. I hereby declare the following: 1. I am aware that plagiarism (the use of someone else’s work without their permission and/or without acknowledging the original source) is wrong. 1. I confirm that the work submitted for assessment for the above course is my own unaided work except where I have explicitly indicated otherwise1. 2. I have followed the required conventions in referencing the thoughts and ideas of others. 3. I understand that the University of the Witwatersrand may take disciplinary action against me if there is a belief that this is not my own unaided work or that I have failed to acknowledge the source of the ideas or words in my writing. Disclosures: 1 I have made use of AI based large language model applications (such as ChatGPT, BERT, LaMDA, PaLM and LLaMa).2 Yes No✓ Specify: 2 I have made use of paraphrasing software tools (such as QuillBot, Parafrasist, Ivypanda, or the Yes No✓ Specify: 1 Students may talk to one another about their work and they may seek assistance from the academic staff of the Steve Biko Centre. Seeking the assistance of a Centre lecturer other than your unit/block head is discouraged and is only permissible with the consent of your unit/block head or the Centre Director. Assistance with spelling and grammar may be obtained from professional or non-professional language editors. Seeking assistance from other academics, lawyers or experts is prohibited. 2 Making use of these tools is prohibited. But, if you have done so, it is better to disclose this, than to try to conceal it. ii paraphrasing functionality in grammar assistance tools).2 3 I have made use of spelling and grammar assistance applications (such as Grammarly, Word spelling and grammar functionality, Grammarcheck, Writer, Zoho.) Yes✓ No Specify: Grammarly 4 I have made use of referencing software tools, (such as Zotero, Mendeley and EndNote) Yes✓ No Specify: Zotero 5 I have received assistance with my spelling and language from another person. Yes✓ No Professional or non-professional 6 I have received any other kind of assistance from another person, other than the unit/block head. Yes No✓ Specify: Signature: _____________________ Date: 04 March 2023 iii Dedication I would like to acknowledge and show appreciation for those who have made this lifepath before me possible, those who have enabled and ensured my success and prosperity, and those who have continued to walk beside me consistently. First and foremost, I give thanks and honour to God for being my provider, for blessing me with amazing career and academic opportunities, and for granting me the wisdom and strength to see this research project to completion. He has blessed my path so that everything I have been able to achieve in my academic career brings honour to Him. To my wonderful sister, Karisma Zanoncelli. My other half, my constant companion, my wealth of encouragement. Thank you for standing beside me through some of the toughest years, many tears and numerous pep talks. I never would have made it here without your support, and I am so blessed to have the closest friend a girl could have – a sister. To my incredible parents, I don’t know what I would have done without both of you. You’ve put up with so much for me this past year and have sacrificed so much for me to get to this point in my education. Thank you for all the support, even when it wasn’t apparent through your silent prayers. To my dad, Jaidevan Sarangarajan, thank you for your measured words of wisdom. You always know just the right thing to say, even when it’s not particularly what I’ve wanted to hear. It was exactly what I needed to hear. Thank you for accommodating my often-big emotions this year – I appreciate you treating me with such grace through this challenging period of my life. To my mom, Rajeshree (Ramona) Sarangarajan, thank you for always being so sensitive to me and my needs. I’m so blessed to have a mother who is always there to hold space for me with no reservations and no judgment. I appreciate how you gently push me to face my big emotions head-on. iv Finally, I want to thank my friends and family, who have supported and encouraged me throughout this challenging journey. It means more to me than any of you might realise, knowing that I have had so many special people in my corner, and your little uplifting talks have really kept me going! v Acknowledgements First and foremost, I want to express my appreciation to my supervisor, Dr Cornelius Ewuoso. Thank you for seeing the potential in me last year. Your belief that I am capable of a career in academia brought me here today. I appreciate all the academic support, timely words of encouragement, and the many hours dedicated to this project's success. I could not have done this without you. Second, I would like to thank the Director of the Steve Biko Centre for Bioethics and the Head of the Department, Professor Kevin Behrens, for treating me as more than just a number. Thank you for investing so much in my academics and in my future. The Centre is truly blessed to have you. Third, I want to extend my appreciation towards my undergraduate supervisor and lecturer, Dr Kyrtania Pather. Thank you for your constant academic support throughout my journey at the University of Witwatersrand, Johannesburg, South Africa. I truly appreciate your kind heart and your passion for your students. You have really inspired me and motivated me to reach for my dreams and never give up. So, thank you. Finally, I would also like to extend my appreciation towards the following Departments for their support during my academic career: • The Steve Biko Centre for Bioethics • The Department of Family Medicine • The National Research Foundation (NRF) • The Postgraduate Merit Award (PMA) vi Table of Contents Academic Integrity Declaration .............................................................................................. i Dedication ................................................................................................................................ iii Acknowledgements ................................................................................................................. v Abstract .................................................................................................................................... ix Acronyms ................................................................................................................................. xi Chapter 1: Introduction ........................................................................................................... 1 1.1 Background ................................................................................................................................ 1 1.2 Literature Analysis & Critique .................................................................................................. 4 1.3 Research Question ................................................................................................................... 9 1.4 Thesis Statement ...................................................................................................................... 9 1.5 Research Aim ............................................................................................................................ 9 1.6 Rationale ..................................................................................................................................... 9 1.7 Research Design & Methods ................................................................................................. 10 1.8 Research Objectives ............................................................................................................... 12 1.9 Argumentative Strategy .......................................................................................................... 12 1.10 Research Outcomes and Outputs ...................................................................................... 14 1.11 Limitations .............................................................................................................................. 15 1.12 Ethical Approval .................................................................................................................... 16 CHAPTER 2 ........................................................................................................................... 17 AVAILABILITY AND AFFORDABILITY OF THE INFLUENZA VACCINE ................... 17 vii 2.1 Introduction ............................................................................................................................... 17 2.2 Afro-communitarianism in African Scholarship ................................................................... 20 2.3 Solidarity in Ubuntu Philosophy and Afro-communitarianism .......................................... 25 2.4 Reciprocity and Afro-communitarianism .............................................................................. 29 2.5 Distributive Justice and African Moral Philosophy ............................................................. 31 2.6 Government's Responsibility to Fund Influenza Vaccination ........................................... 34 2.7 Institutions’ Responsibility to Ensure Availability of Influenza Vaccines ......................... 41 2.8 Encourages Governments to Make Arbitrary Health Decisions ....................................... 44 2.9 Moving From Rhetoric to Action ............................................................................................ 46 2.10 Supporting Elderly Health Needs in this Argument is Misguided .................................. 47 2.11 Conclusion.............................................................................................................................. 49 CHAPTER 3 ........................................................................................................................... 50 ACCEPTABILITY OF THE INFLUENZA VACCINE ........................................................ 50 3.1 Introduction ............................................................................................................................... 50 3.2 Incompleteness in Convivial African Scholarship ............................................................... 52 3.3 Global North Comparison of (Mode of) Being and Incompleteness ................................ 58 3.4 Grounding the Duty to Vaccinate in Incompleteness and Conviviality ............................ 60 3.5 Does Acceptability Imply Vaccine Mandate? ...................................................................... 64 3.6 Is the Project’s Approach Misguided? .................................................................................. 66 3.7 Are There Valid and Ethical Justifications to Refuse Vaccination? ................................. 67 3.8 Conclusion ................................................................................................................................ 68 viii 4.1 Introduction ............................................................................................................................... 70 4.2 Recommendations .................................................................................................................. 70 4.3 Conclusion ................................................................................................................................ 75 ix Abstract In this dissertation, I draw on the thinking about solidarity, reciprocity, distributive justice, incompleteness and conviviality grounded in African philosophy broadly, including African ethics, African epistemology, African aesthetics, African metaphysics and African logic, to name a few, to argue that institutions, particularly the South African (SA) government, have a prima facie responsibility to fund the influenza vaccination for adults 65 years and above. Equally, I draw on the moral norms arising from the same values grounded in African philosophy to argue that adults 65 years old have a prima facie duty to vaccinate against influenza. These claims address three core issues relevant to fostering influenza vaccine access: availability, affordability and acceptability. While the former claim ensures that influenza vaccinations are affordable and available to the target population group, the latter underscores the obligation of adults 65 years and above to vaccinate to address acceptability issues. Although the dissertation focuses specifically on the South African government to defend its core thesis, I believe the arguments can reasonably be adapted to address the responsibilities of other African governments and older persons in other regions. Notably, these responsibilities are that the SA government should make influenza vaccines freely available for adults 65 years and above in public and private health facilities, provided financial allocation and their extant relationships allow for this. Additionally, the SA government has a responsibility to improve influenza vaccine procurement and availability in the country, preferably through increasing manufacturing capabilities. Furthermore, the dissertation argues that adults 65 years and above have a prima facie responsibility to vaccinate against influenza. Notably, adults 65 years and above have a duty of conviviality to act in ways that limit harm to them and others. This project is intrinsically valuable to promote epistemic justice, thereby contributing towards the decolonization of the global healthcare system. Moreover, this project has social significance in contributing to mitigation efforts against future public health challenges associated with population ageing in resource-limited developing African nations, wherein the impact of population transition will be most felt. x Word count: 226 Keywords: African ethics; conviviality; decolonization; distributive justice; incompleteness; influenza vaccine; reciprocity; solidarity xi Acronyms SA South Africa OAG Old Age Grants GAVI Global Alliance for Vaccines and Immunisation WHO World Health Organisation CDC Centers for Disease Control and Prevention OECD The Organization for Economic Cooperation and Development SAHPRA South African Health Products Regulatory Authority 1 Chapter 1: Introduction 1 1.1 Background 2 Influenza-related complications/deaths occur more in adults 65 years old and older. 3 Throughout this dissertation, we will use the short-hand elderly as synonymous to adults 65 4 years and older. It is also a large contributor to the global disease burden through continual 5 cyclical outbreaks (World Health Organization (WHO), 2020a). Some symptoms of the 6 seasonal infection of the respiratory pathway include fever withbody aches, sore throat, cough, 7 rhinitis, congestion and fatigue (Centers for Disease Control and Prevention (CDC), 2022b). 8 For most, influenza is a mild disease, and recovery spans between two days to two weeks 9 (CDC, 2022b). However, vulnerable populations, particularly older adults are prone to 10 developing complications from influenza including pneumonia, myocarditis, encephalitis, 11 multiple organ failure and even death (CDC, 2022b). About 50%-70% of influenza 12 hospitalizations and 90% of influenza-related deaths are adults 65 years or older (CDC, 2019). 13 As age increases from 65 years old, the risk of hospitalization due to complications and 14 influenza-related mortality significantly increases. 15 The term vaccine access needs to be unpacked. I conceptualize vaccine access in the same 16 way it has been described by Di McIntyre, Michael Thiede and Stephen Birch (2009) as 17 consisting of three dimensions – affordability, acceptability and availability. This description 18 presents access as encompassing key issues concerning the cost of vaccines (who is 19 responsible for bearing this cost?) and the individual’s responsibility to vaccinate. Increasing 20 influenza vaccine access for the elderly will play a critical role in limiting influenza's impact on 21 this population. 22 Although the effectiveness of different influenza vaccines varies, vaccination remains the best 23 preventative method against the influenza virus. Current vaccines can decrease the risk of 24 infection between 40% and 60% during seasonal outbreaks (CDC, 2022a). Recognizing this, 25 the WHO (2020b) recommended – during the global COVID-19 pandemic – that two 26 population groups be prioritized above other groups for seasonal influenza vaccinations: 27 2 healthcare workers and older adults. Other risk groups for vaccination prioritization include 1 young children, pregnant women, and individuals with illnesses such as HIV and tuberculosis 2 (McMorrow et al., 2019). Furthermore, in 2018, the WHO developed the Global Influenza 3 Strategy 2019-2030 with three goals: (i) decrease seasonal influenza burden, (ii) reduce the 4 risk of zoonotic influenza, and (iii) alleviate the impact of influenza pandemics (WHO, 2019). 5 Consequently, increasing influenza vaccination uptake through easy access to the same by 6 the older adult population will be pivotal in reducing influenza-related complications or deaths 7 and realizing the WHO Global Influenza Strategy 2019-2030. However, global influenza 8 vaccination in adults 65 years and older has either decreased or remained low. For example, 9 in Germany in 2020, only 47% of adults aged 65 years and older were vaccinated against 10 influenza (The Organization for Economic Cooperation and Development (OECD), 2018). 11 Vaccination rates for older adults in Spain rapidly declined from almost 75% in 2009 to below 12 58% in 2014 (Dios-Guerra et al., 2017). Most low- and middle-income countries have limited 13 data – owing to a lack of surveillance – on influenza vaccination coverage and uptake, 14 especially for the specified risk groups (Duque, McMorrow and Cohen, 2014). A 2016 review 15 found that only five African countries - Côte d’Ivoire, Egypt, Libya, Mauritius, and Tunisia – 16 have influenza vaccination policies (Hirve et al., 2016). South Africa only has influenza 17 vaccination guidelines (South African Health Products Regulatory Authority (SAHPRA), 2020). 18 There is a need for a more intentional strategy to increase influenza vaccine access and foster 19 its uptake amongst older adults, particularly in developing nations in Africa. Ethics, activism, 20 and vaccine campaigns will play essential roles. This project is primarily normative, exploring 21 how ethics can be engaged to increase influenza vaccine access and foster its uptake in older 22 persons. Importantly, there are various contributing factors for decreasing vaccination 23 coverage against influenza in older adults. One factor is vaccine hesitancy – defined as the 24 “delay in acceptance or refusal of vaccination despite the availability of vaccination services” 25 (MacDonald, 2015). Reasons behind influenza vaccine hesitancy include concerns about 26 vaccine efficacy and safety, fear of side effects (Rikin et al., 2018; Teo et al., 2019), belief that 27 3 influenza is not dangerous (Teo et al., 2019) and even misbelief that the vaccine is harmful or 1 causes influenza itself (Rikin et al., 2018), preference for natural immunity and a low sense of 2 collective responsibility (Nicholls et al., 2021). A significant factor equally identified by a 3 national Australian workshop is an equity gap in vaccine coverage and promotion between 4 infants and adults, exacerbated by systemic reasons such as a lack of randomised control 5 trials, ageism and lack of adult vaccination record systems (MacIntyre et al., 2016). An equity 6 gap occurs when children have higher vaccine uptake rates than adults because there are 7 more vaccine promotion initiatives aimed at them than at adults, creating vaccine coverage 8 disparities between these age groups and further exacerbating the effects of ageism 9 (MacIntyre et al., 2016). 10 Age- and literacy-related factors must also be recognized, such as a decline in physical and 11 mental functioning, living arrangements and social support (Nicholls et al., 2021). Elderly who 12 are single or live alone have a lower chance of vaccinating compared to those who are married 13 or co-habit (Nicholls et al., 2021). However, in developing countries, other contexts and/or 14 community-specific factors should be explored (MacDonald, 2015). 15 Vaccination education and mandates can usefully address misconceptions, hesitancy, and 16 misbeliefs regarding influenza vaccines. However, deeper engagement with ethics is required 17 to tackle core questions concerning, (i) who is responsible for funding influenza vaccination 18 for the elderly (to ensure its availability and affordability) and why they are responsible, and 19 (ii) the responsibility of the elderly to vaccinate (to foster acceptability). Should institutions and 20 which institutions fund seasonal influenza vaccination for older adults? Equally, do the elderly 21 have a corresponding ethical duty to vaccinate against influenza and why? This project 22 interrogates these vaccine access questions by drawing on key values, particularly solidarity, 23 distributive justice, incompleteness and conviviality, grounded in African moral philosophy and 24 scholarships in the Global South. Although I provide a detailed description of the African moral 25 philosophy in the body of the work, it is worth emphasizing that a philosophy is said to be 26 African to the extent that it draws on thought patterns that are more common on the continent 27 4 and have not come to the continent from elsewhere (Metz, 2013). One way of thinking 1 common on the continent is that communal relationship is good in itself and should inform 2 morality (Gyekye, 2011). This differs from Western theories like Kantianism, which require 3 individuals to honour the rational capacity of human beings. Specifically, in African moral 4 philosophy, an action is moral to the extent that it fosters social cohesion (Wiredu, 1992). In 5 subsequent chapters, I will articulate the thinking about solidarity, distributive justice, 6 incompleteness and conviviality that can be grounded in this philosophy. 7 1.2 Literature Analysis & Critique 8 Ethical reflections on influenza vaccine access, particularly for older adults 65 years and 9 above, are scanty or almost non-existent. While many studies have explored questions around 10 attitudes, perceptions and other factors influencing older adults' behaviour surrounding 11 vaccines and the influenza vaccine for children, ethical reflections that focus explicitly on 12 fostering influenza vaccine access for older adults of 65 years and above are still absent in 13 these conversations. Equally missing are normative studies that support a focus on promoting 14 seasonal influenza vaccination uptake from unique, underexplored African perspectives. 15 Notably, existing ethical reflections on the seasonal influenza vaccines, more broadly, tend to 16 adopt dominant theories in the Global North like Principlism, Utilitarian and Kantian moral 17 approaches. One such position is the deontological argument that it is the government's 18 responsibility to fund necessary healthcare in correspondence to citizens' right to healthcare 19 (Reay, 1999). Furthermore, the elderly face specific age-related health challenges that other 20 population groups may not experience (Sibanda et al., 2021), such as increased influenza-21 related health risks. Miguel (Kottow, 2019) posits that older people's physical and health-22 related vulnerabilities would imply that older adults should be afforded special rights to realize 23 these specific health needs and achieve equality through simplifying accessibility to healthcare 24 services, especially in developing countries. 25 Some scholars (Ibom and Soni, 2015) deny that governments have this responsibility by 26 drawing on the principle of utility grounded in consequentialism. According to them, it would 27 5 benefit the greatest number of people if hospitals were operated as businesses so that 1 governments could allocate those health funds to other sectors. Although this research study 2 justifies that the government, particularly the South African government, has a responsibility 3 for maintaining these special rights of preventative health measures (namely, influenza 4 vaccine) for the elderly, it defends this view by drawing on an under-explored philosophy 5 salient in Africa. 6 Although I focus on South Africa, this project has implications for other governments. 7 Nonetheless, the focus on South Africa requires justification. The United Nations, Department 8 of Economic and Social Affairs, Population Division (2020) estimates that the global population 9 of those over 65 years will reach 1.5 billion by 2050. This population explosion will mostly 10 occur in developing nations like South Africa. To effectively mitigate future public health 11 challenges associated with population ageing in resource-limited nations like South Africa, the 12 government must prepare adequately for healthy ageing through the development of 13 comprehensive national policy in the promotion of a life-course approach (rather than only 14 focusing on infants) to vaccination (Sibanda et al., 2021). 15 It is worth stating here that the South African government currently provides influenza vaccines 16 for the elderly at no cost through the National Immunisation Program 2023. However, free 17 influenza vaccinations for the elderly are only available at the country’s public health facilities 18 rather than in private facilities (National Department of Health, 2020). According to a report 19 (Statistics South Africa, 2023), almost 68% of adults aged 60 and older accessed public 20 healthcare facilities and over 31% accessed private healthcare facilities in 2021. Furthermore, 21 the National Immunization Program 2023 does not have the force of law and is akin to a 22 guideline for influenza vaccine access for the elderly in South Africa (SAHPRA, 2020). 23 Notably, these guidelines are useful in informing healthcare professionals as to who should 24 be targeted for prioritized influenza vaccination through the outlined at-risk population groups, 25 the signs and symptoms to identify infection, recommended dosages for vaccination, 26 prevention and treatment of different age groups, amongst other useful information. However, 27 6 the implication is that there is a lack of willpower to enforce the guidelines. Equally, where 1 some efforts have been made to enforce the same, it is difficult to accurately measure the 2 success of the implementation of and adherence to such guidelines since a system for adult 3 vaccination records (other than that for Covid-19 and a paper register system for minors 4 recording the Expanded Programme on Immunisation) do not currently exist in South Africa 5 causing barriers to efficient influenza vaccination surveillance (Moonsamy and Singh, 2022), 6 especially for specified risk-groups like older adults (Duque, McMorrow and Cohen, 2014). 7 To address these gaps, I contend in this dissertation that the SA government has a prima facie 8 duty to make influenza vaccination available for adults 65 years and above. Although this 9 thesis has implications for two core components of vaccine access (affordability and 10 availability), it may not be sufficient to ensure acceptability. To promote acceptability, the study 11 defends the view that the elderly also have a moral obligation to vaccinate against influenza. 12 To justify these positions, the dissertation draws on previously mentioned values grounded in 13 African philosophy: solidarity, distributive justice, incompleteness and conviviality. 14 There are many reasons to inform influenza vaccine interventions designed for African 15 countries with these under-utilized African values. One reason is that it is important for 16 epistemic justice for policies and interventions in Africa to be shaped by African values so that 17 the communities wherein they are implemented can fully identify with them. Notice how this 18 dissertation defines epistemic justice. It is the capacity to be recognized as a valid contributor 19 to knowledge production that feeds into various policies, guidelines and measures that have 20 implications for oneself. Policies and interventions that guide people should reflect their values 21 and be cohesive with their beliefs for people to be able to identify with them. Importantly, 22 individuals are more likely to abide by or accept policies that align with their values. 23 Furthermore, this approach can increase the acceptability of these interventions in the 24 communities and contribute to the success of the interventions if they are guided by values 25 already ingrained in the communities. 26 7 Another significant reason is that informing vaccine interventions in an African context with 1 values that are dominant on the continent would contribute towards the decolonization of the 2 health system in Africa, ending scientific or health colonialism and demonstrating the exact 3 ways in which normative theories from the Global South are useful and relevant alternatives 4 to the dominant normative theories elsewhere. 5 Although I will provide detailed descriptions in subsequent chapters, it is worth acknowledging 6 that the values in the African philosophy I draw on also exist in the Global North. Nonetheless, 7 the dissertation focuses primarily on the thinking about these values that are salient on the 8 African continent. For example, it is common to argue in African philosophy that solidarity 9 requires one to conduct oneself in a compassionate and considerate manner, that is, in a way 10 that might benefit others. The intention behind this behaviour in African thought is to care for 11 the well-being of others (Metz, 2019). Equally, the thinking about reciprocity in the Global 12 South entails an obligation of mutual aid and is typified by the common agricultural practice in 13 Southern Africa known as letsema. This is the Sesotho practice wherein members of a 14 community undertake to assist each other during each step in farming, including ploughing, 15 sowing, weeding and harvesting (Mohapi, 1956). Directly translated, the Setswana word 16 letsema means “a group of people coming together for a common purpose” (Setlhodi, 2019). 17 This practice encapsulates several norms implicit in the significance of reciprocity in 18 communal living. Letsema calls for mutual collaboration and cooperation underpinning 19 collective responsibility among community members (Mofuoa, 2015). Furthermore, it 20 predicates compassion in contributing towards an agricultural project that will benefit others in 21 the community. 22 In African normative literature specifically, although both are considered expressions of social 23 justice, distributive justice is sometimes differentiated from commutative justice. While 24 distributive justice describes the first-order duties of institutions and states to their citizens (to 25 protect their civil liberties, distribute goods equitably and create a conducive environment for 26 communal relationships), commutative justice describes the responsibilities of citizens to one 27 8 another and the State. Notably, their responsibility to be solidary to one another and to the 1 State (Ewuoso, Cordeiro-Rodrigues, et al., 2022). 2 Finally, the use of incompleteness as an established African normative theoretical principle in 3 texts is still relatively new, and the formation of a concrete definition and the parameters of 4 normative application is still in its infancy stages. However, one component of incompleteness 5 in African scholars' literature is that it tends to express the idea of a default mode of being. 6 Specifically, the shared West African Yoruba and Central African ontological belief is the 7 acknowledgement that everything – nature, humans, the supernatural and human 8 achievement exists in a state of incompleteness (Guma, 2020). This state of being is also true 9 of entities that appear to be complete or a finished product. This manner of being incomplete 10 is one of normalcy (Nyamnjoh, 2019b). Contrary to more Western or Eurocentric thinking, the 11 state of incompleteness does not denote a lack or an inadequacy. Instead, incompleteness 12 exists only because of the existence of a multiplicity of possibilities (Nyamnjoh, 2015). 13 Relationality is the natural consequence of incompleteness (Nyamnjoh, 2015). This is true of 14 all entities that experience incompleteness: humans, animals or supernatural beings. 15 Relationalism allows one to reach out, engage and extend the incomplete self into a multitude 16 of possibilities of being and becoming that would not otherwise be possible in isolation 17 (Nyamnjoh, 2019a). Incompleteness enjoins one to conviviality. According to Francis 18 (Nyamnjoh, 2015), “If incompleteness is the normal order of things, natural or otherwise, 19 conviviality invites us to celebrate and preserve incompleteness and mitigate the delusions of 20 grandeur that come with ambitions and claims of completeness.” Thus, conviviality calls us to 21 actively search for ways to extend, transform and complement our incomplete selves within 22 relationships by ensuring that the ways in which we relate are more effective and successful. 23 Conviviality then encourages conversations within relationships, the extension of more 24 compassion to others, the pursuit of collaborative choices that forgoes self-centred decision-25 making and the alignment towards collective interests (Nyamnjoh, 2015). 26 9 1.3 Research Question 1 The dissertation’s overarching question targets two groups who can play critical roles in 2 increasing influenza vaccine access in light of the definition I provided in the previous section: 3 the governments and older adults 65 years and above (the elderly). Precisely, the research 4 study interrogates the question, “Do governments have any prima facie duties to fund 5 influenza vaccination (for the elderly in South Africa) and adults 65 years and above to 6 vaccinate against influenza, respectively?” 7 1.4 Thesis Statement 8 Drawing on the moral norms that arise from key underexplored values – such as solidarity, 9 reciprocity, social justice, conviviality and incompleteness – dominant in Africa, some of which 10 have been articulated, defended and expounded upon by African philosophers, I contend that 11 the South African government has a prima facie duty to fund influenza vaccination of the 12 elderly in South Africa and adults 65 years and above have a moral duty to vaccinate against 13 influenza. 14 1.5 Research Aim 15 This project aims to defend the thesis, that is, to justify how the described underexplored 16 values dominant in Africa ground the respective prima facie and moral duties that the South 17 African government and the elderly have to increase accessibility of the influenza vaccine for 18 the elderly. 19 1.6 Rationale 20 This study is of both social and academic significance. One reason it is socially significant is 21 that vaccination access for older adult populations is important to reduce gaps in preventative 22 health equity between age groups, decrease the burden on the health system and prevent 23 unnecessary waste of health resources that could otherwise be used to treat more urgent 24 health cases. Influenza vaccine access is equally an important public health measure to limit 25 infections to particular population groups. In this case, vaccine access can prevent infection 26 10 in the elderly population, where complications of influenza and more significant associated 1 health risks are more prevalent. Increasing vaccine access for the elderly would contribute to 2 mitigation efforts against future public health challenges associated with population ageing in 3 resource-limited developing African nations, wherein the impact of population transition will be 4 felt most. Furthermore, guidelines and policies must be ethically informed so that influenza 5 vaccine policy not only holds willpower in that they provide actionable change, but also has a 6 value-based impact. 7 Regarding academic importance, normative explorations from a unique African perspective 8 that support a focus on influenza vaccination access are intrinsically valuable and can 9 increase African voices on issues that affect the continent. A failure to echo these voices on 10 health issues relevant to Africa contributes to the colonization of health on the continent. 11 Additionally, such failure is less likely to respond to the call to shape public health policies and 12 interventions for Africans in Africa by drawing on more prominent values and philosophies on 13 the continent (Mbali and Rucell, 2022). The methodological approach of this study should also 14 be of interest to academic scholars unfamiliar with dominant theories in the Global South. 15 1.7 Research Design & Methods 16 This dissertation is a mostly normative ethics research study (rather than an empirical one) 17 that draws on moral norms arising from values dominant in the Global South. This normative 18 approach is essential and is reckoned by others to be equally valid for research articles 19 because of their philosophical analytic method (Vogelstein and Colbert, 2019) (Molina Wills, 20 2022). Other scholars like Luis Cordeiro-Rodrigues and Kevin Behrens have also used the 21 philosophical method this dissertation adopts. As a philosophical analytic method, the 22 dissertation builds on relevant articles that have been retrieved from databases like PubMed, 23 PhilPapers, and Google Scholar, using key phrases like "solidarity and African moral 24 philosophy", “incompleteness, conviviality, Africa”, “vaccination, influenza and elderly”, 25 “elderly vaccination and South Africa”, to name a few. For example, for the discussion on 26 solidarity, the dissertation retrieved relevant articles from PhilPapers and Google Scholar by 27 11 using key phrases like “solidarity and Afro-communitarianism”, “formulations of solidarity in 1 African moral philosophy”, and “African philosophers and solidarity”. More than researching 2 various conceptions, common features and formulations of solidarity in African scholarship 3 and how the nuances might impact the research question, this dissertation will also juxtapose 4 the African conception with global conceptions of the same, especially those that might have 5 implications for the thesis this dissertation defends. These philosophical approaches are not 6 uncommon and have been used by others to push the boundaries of knowledge in normative 7 ethics papers (Atuire, 2022). 8 This theoretical approach is vital for several reasons. Although I explained the reasons in the 9 previous section, it is worth repeating key points here. Firstly, it is crucial for epistemic justice 10 for policies and interventions in Africa to be shaped by African values so that the communities 11 wherein they are implemented can fully identify with such guidelines. Policies and 12 interventions that govern people should reflect their values and be cohesive with their beliefs 13 for people to identify with them. Secondly, it would lend to the acceptability of these 14 interventions in the communities and contribute to the success of the interventions if they are 15 guided by values already ingrained in the communities. Finally, informing vaccine 16 interventions in an African context with values that are dominant on the continent would 17 contribute towards the decolonization of the health system in Africa, ending scientific or health 18 colonialism and demonstrating the exact ways normative theories from the Global South are 19 useful and relevant alternatives to the dominant normative theories elsewhere. 20 The dissertation conceptualizes Afro-communitarianism in the same way it has been 21 described by Cornelius Ewuoso and Susan Hall (2019), as the moral philosophy informed by 22 values that are dominant on the African continent. These values are not only found in the 23 Global South. But the thinking about these values has not come to this continent from 24 elsewhere. 25 12 1.8 Research Objectives 1 1. To draw on the norms arising from the thinking about solidarity, reciprocity and 2 distributive justice grounded in African philosophy to assert that institutions, particularly 3 the South African government, have a prima facie duty to fund influenza vaccination 4 for adults 65 years and above in South Africa. 5 2. To draw on the moral rule of thumb arising from key values of incompleteness and 6 conviviality that can be grounded in the scholarship of the Global South to contend that 7 adults aged 65 years and above have a moral duty to vaccinate against influenza. 8 3. To defend the dissertation’s core thesis against potential objections. 9 1.9 Argumentative Strategy 10 To realize objective 1, first, I will provide broad descriptions of solidarity, distributive justice, 11 and reciprocity in the works of African philosophers, epistemologists, and anthropologists. 12 What key features of these values are dominant in these scholarships? In what ways are the 13 views of solidarity, distributive justice, and reciprocity different from ideas about the same in 14 philosophies dominant elsewhere? 15 Having provided a broad description of solidarity, distributive justice, and reciprocity in this 16 section, I will proceed to outline moral norms that can arise from these values. For example, 17 one moral norm that can arise from the thinking about solidarity in African philosophy is that 18 we ought to act for the group's well-being since we are implicated in one another’s lives (Metz, 19 2010). Subsequently, I draw on these norms to defend the position that institutions, particularly 20 governments, have a prima facie duty to make influenza vaccine freely accessible to the 21 elderly 65 years and above. 22 Against the above, the specific research question the project interrogates in the first chapter 23 is, “Do governments have a prima facie duty to fund the influenza vaccination of adults 65 24 years and above? I draw on the relevant values and answer in the affirmative. Herein, I briefly 25 re-introduce the three interrelated dimensions of access (Thiede, Akweongo and McIntyre, 26 13 2007) – availability, affordability, and acceptability – and limit my focus in this section to 1 affordability and availability. Suppose the dimensions of access are interrelated. In that case, 2 an improvement in availability can impact affordability. Availability and affordability may not 3 guarantee acceptability and thus foster an increase in influenza vaccine uptake (Thiede, 4 Akweongo and McIntyre, 2007). Evidentially, according to Ayako Honda and colleagues 5 (2015), if only the availability and affordability of healthcare services, for example, say in South 6 Africa, are improved, patients may not find the quality of the service acceptable, and access 7 to the services would still not be increased. To successfully develop effective influenza vaccine 8 access measures, I focus on questions around acceptability in the second section. 9 Furthermore, I address potential objections to the position I endorse in this first part of my 10 dissertation. For example, someone may contend that requiring governments to fund influenza 11 vaccination could spiral into forms of authoritarianism. Governments may begin to think that 12 they have the responsibility to dictate their citizens' health habits or choices. The Chinese one-13 child policy is one example of how the position this project endorses could encourage 14 governments to make arbitrary health, including reproductive decisions, for their citizens. 15 Individuals who exercise their freedom to refuse vaccination may be penalized or sanctioned. 16 Freedom may be curtailed in the world where governments believe that they have the 17 prerogative to make health decisions for their citizens. 18 Additionally, another critic may deny that the moral norms I draw on can arise from African 19 views about solidarity, distributive justice, and reciprocity or imply that institutions have a prima 20 facie duty to provide free influenza vaccines to the citizens. Still, another critic may indicate 21 that the prima facie duty I endorse may create unrealistic expectations for a government with 22 an overwhelming elderly population but limited resources. The dissertation addresses these 23 and other potential objections to its position that governments have a prima facie duty to fund 24 seasonal influenza vaccination for adults 65 years and older. 25 To realize objective 2, the project provides broad descriptions of incompleteness and 26 conviviality in the works of prominent African scholars. It describes the key features of these 27 14 values. Equally, the project identifies and analyses how the African thinking about 1 incompleteness and conviviality is similar and different from this conception in other 2 scholarships. Having provided these descriptions, the project outlines the moral norms that 3 emerge from these values. For example, one moral norm that can arise from the thinking about 4 conviviality in the scholarship of African anthropologists and philosophers is that one ought to 5 act in collaborative and compassionate ways since everything and everyone else in relation 6 to oneself is just an extension of oneself (Samuel and Fayemi, 2019). In other words, 7 conviviality suggests the interconnectedness of lives, implying that we are accountable for 8 each other’s lives and well-being. In African scholarship, individuals are not unimpacted by 9 the actions of others. This interdependency also typifies the pattern of thought evident in 10 African epistemology, wherein relationships and connectedness between humans (Metz, 11 2017) and even between animals and nature are valued (Ojomo, 2011). The project justifies 12 why conviviality implies that the elderly aged 65 years and above have individual and collective 13 responsibilities to vaccinate against influenza. 14 The project’s analysis in this section is not merely limited to justifying this duty. It also includes 15 defending the same against potential objections. For example, a critic could reason that 16 conviviality places too much burden on individuals since it assumes that these individuals who 17 are expected to endorse and encourage influenza vaccination uptake do, in fact, agree that 18 influenza vaccination ought to be endorsed. They may have a contrary view. Moreover, there 19 are many other ways to exhibit conviviality other than influenza vaccination, like promoting 20 sanitary practices to limit infection. Furthermore, a critic may point out that the call to act in 21 collaborative ways in the pursuit of collective interests violates one’s freedom of personal 22 pursuits, personal interests, individuality, creativity, and autonomy. The project addresses 23 these and other potential objections. 24 1.10 Research Outcomes and Outputs 25 The project aims to publish insights from the research in highly-rated journals like Vaccines. 26 Furthermore, the project aims to engage with policymakers and create awareness of the 27 15 responsibilities of entities like the government in ensuring and establishing influenza 1 vaccination programs that target adults 65 years and older. The project will promote this 2 awareness at important public and town hall meetings and health seminars. This population 3 group remains under-targeted in many influenza vaccination programs, particularly in Africa. 4 Equally, the specific ways home-groomed (African) approaches can inform influenza 5 vaccination programs deserve greater visibility in global influenza vaccination programs to 6 realize global health justice. This project will contribute towards this effort by presenting its key 7 findings regarding how Global South scholars use and apply important concepts like solidarity, 8 reciprocity, distributive justice, incompleteness or conviviality. Additionally, the insights from 9 this project will be shared at international conferences like the World Congress of Bioethics, 10 Oxford Global Health and Bioethics International Conference, and the International 11 Conference on Clinical Ethics Consultation. 12 1.11 Limitations 13 This project is largely a normative and conceptual research study. Some of the limitations of 14 conceptual analyses in research are that it is complex and time-consuming to investigate a 15 concept. Furthermore, this can be a challenging process that can be overwhelming since the 16 analysis requires large amounts of data and literature to be processed. Since this project 17 focuses on a framework that could be applied in a multitude of African countries, a limitation 18 is that this framework analysis cannot be made highly specific since high specificity would limit 19 the variability and flexibility of the framework’s application capacity and interpretations of 20 analyses in differing contexts can be error-prone. 21 Equally, this study is mostly applicable to countries in the Global South and would not be of 22 great use in application to Euro-centric and Western countries. A limitation of most normative 23 projects is that it is mostly explorative studies relying on existing empirical studies so that no 24 new data is produced. 25 16 1.12 Ethical Approval 1 The project is mostly a normative and evaluative project that draws on norms arising from key 2 concepts in Global South scholarship to think critically about issues regarding influenza 3 vaccine access for older persons 65 years and above. Hence, the study does not involve 4 research with humans/animals. In light of this, the project did not apply for ethical approval. 5 6 17 CHAPTER 2 1 AVAILABILITY AND AFFORDABILITY OF THE INFLUENZA VACCINE 2 3 2.1 Introduction 4 In this chapter, I draw on the norms arising from the thinking about solidarity, distributive justice 5 and personhood grounded in the African Ubuntu philosophy and African philosophy more 6 broadly to argue that institutions, particularly the South African (SA) government, have a prima 7 facie duty to fund seasonal influenza vaccination of the elderly aged 65 years and above in 8 South Africa. This will likely contribute to vaccination uptake by fostering influenza vaccine 9 access by this population group. From the outset of this dissertation, it is essential to note that 10 although my focus in this chapter is on influenza vaccine access by the elderly in South Africa 11 specifically, the arguments I articulate can be contextually adjusted to ground the dissertation's 12 thesis within other African countries. Subsequently, I believe that my argument extends to all 13 governments. To this end, I draw on African norms that arise from values dominant in African 14 regions. 15 This project has become necessary since ethical reflections on whether governments have a 16 duty to fund seasonal influenza vaccination for the elderly from the unique, underexplored 17 African perspectives are mostly missing. As previously stated, existing ethical reflections on 18 the government's responsibility to fund the vaccination of older adults tend to adopt dominant 19 theories from the Global North. One such position is the deontological argument that it is the 20 government's responsibility to fund necessary healthcare in correspondence to citizens' right 21 to healthcare (Reay, 1999). Furthermore, the elderly face specific age-related health 22 challenges that other population groups may not experience (Sibanda et al., 2021). One of 23 these age-specific health needs is prevention from influenza infection since 50%-70% of 24 influenza hospitalizations and roughly 90% of influenza-related deaths are adults aged 65 25 years and older (Centers for Disease Control and Prevention, 2019). However vaccination 26 18 programmes (the most effective preventative public health measure against influenza) have 1 been mostly aimed at infants, and global vaccination coverage in the elderly is low. Miguel 2 Kottow (2019) posits that older people's physical and health-related vulnerabilities would imply 3 that older adults should be afforded special rights to realize these specific health needs and 4 achieve equality through simplifying accessibility to healthcare services, especially in 5 developing countries. 6 Some scholars like David Ibom and Piyush Soni (2015) deny that governments have this 7 responsibility by drawing on the principle of utility grounded in consequentialism. According to 8 them, it would benefit the greatest number of people if hospitals were operated as businesses 9 enabling governments to allocate those health funds to other sectors. This argument justifies 10 that the government is responsible for maintaining these special rights of health prevention for 11 the elderly by ensuring that they have equitable access to age-specific preventative healthcare 12 such as influenza vaccines. 13 Furthermore, this project has social significance in light of the United Nations, the Department 14 of Economic and Social Affairs, Population Division's (2020) estimate that the global 15 population of those over 65 years will reach 1.5 billion by 2050. This population explosion will 16 mostly occur in developing nations like South Africa. To effectively mitigate future public health 17 challenges associated with population ageing in resource-limited nations like South Africa, the 18 government must prepare adequately for healthy ageing through the development of 19 comprehensive national policy in the promotion of a life-course approach (rather than only 20 focusing on infants) to vaccination (Sibanda et al., 2021). This dissertation will be important in 21 addressing the ethical considerations of influenza vaccine access for the elderly in South 22 Africa and should contribute to more comprehensive policy formation. 23 In consideration of the elderly population group's vulnerabilities to influenza as well as the 24 impact of the burden on the healthcare system, the South African government does currently 25 provide influenza vaccines for the elderly at no cost through the National Immunisation 26 Program 2023. This is only available at the country’s public health facilities rather than in the 27 19 private facilities (National Department of Health, 2020). According to (Statistics South Africa, 1 2023), almost 68% of adults aged 60 and older accessed public healthcare facilities and over 2 31% accessed private healthcare facilities in 2021. 3 There are also limiting factors that undermine access to influenza vaccines, even at public 4 health facilities. These are particularly challenging for the elderly such as prolonged waiting 5 times, costs incurred by transport, and overburdened and understaffed health professionals 6 (Solanki et al., 2019). In fact, in 2019 (the most recently captured available data) only 67.4% 7 of the elderly in South Africa that were surveyed were willing to consult a healthcare 8 professional in a public health facility when ill and more concerning, 27.4% chose to self-9 medicate instead due to some of the barriers mentioned above to accessing public healthcare 10 facilities (Statistics South Africa, 2021). 31.2% of adults 60 years and older responded that 11 they usually access private healthcare as opposed to the 36,2% that accessed public health 12 care when ill (Statistics South Africa, 2023). If influenza vaccines were made freely available 13 to all elderly persons at private healthcare facilities (regardless of whether they can afford 14 private health insurance), these challenges and barriers to accessing healthcare would be 15 significantly alleviated. Currently, at private facilities and pharmacies (such as Clicks, Dischem 16 and Medirite) that are widely accessible by adults 65 years and above, the influenza vaccine 17 comes at a cost, often between R109 and R250 (Thukwana, 2021). 18 What is more, as stated in the previous chapter, in South Africa, the National Immunization 19 Program 2023 does not have the force of law and is akin to a guideline for influenza vaccine 20 access for the elderly in South Africa (SAHPRA, 2020). The implication is that there is a lack 21 of willpower to enforce the guidelines. Equally, where some efforts have been made to enforce 22 the same, it is difficult to accurately measure the success of the implementation and 23 adherence to such guidelines since a system for adult vaccination records (other than that for 24 Covid-19 and a paper register system for minors recording the Expanded Programme on 25 Immunisation) do not currently exist in South Africa causing barriers to efficient influenza 26 vaccination surveillance (Moonsamy and Singh, 2022), especially for specified risk-groups like 27 20 older adults (Duque, McMorrow and Cohen 2014). The most recent report presenting data on 1 vaccine coverage by age group reported a vaccine coverage of 53% for adults 65 years and 2 older (Wolter et al., 2022). While this coverage rate may seem adequate, the accuracy and 3 reliability of this data estimate may be greatly skewed and subject to bias due to the small 4 sample size of 34 older adults. My thesis that the SA government has a prima facie duty to 5 make influenza vaccination available for adults 65 years and above also includes the 6 responsibility of implementation. Additionally, I will provide clear guidelines on what concretely 7 needs to happen to realize these duties in SA. 8 2.2 Afro-communitarianism in African Scholarship 9 The value of community is salient among Africans in their practices and perceptions (Metz, 10 2013). This is not to say it is necessarily representative of all Africans or that communalist 11 thinking is not common elsewhere in the Global North. Still, this thinking pattern on the African 12 continent specifically (although globally shared) has not originated elsewhere. An Afro-13 communitarian ethic is very generally described as prizing harmonious communal 14 relationships (Cordeiro-Rodrigues and Metz, 2021) and denotes a way in which individuals in 15 a group ought to relate with one another (Metz, 2013). However, there is some contestation 16 in African scholarship regarding whether communalist ideals are of intrinsic normative value 17 with an end in and of itself (Metz, 2007) or whether it is a means to an end, such as the 18 improvement of vitality, flourishing or well-being (Gyekye, 2011). Although the reason behind 19 the pursuit of communalist ideals may differ, the main motivation remains the same – to 20 become more human. The late Desmond Tutu (1999, p. 35), South African Archbishop and 21 Chairman of the Truth and Reconciliation Commission, befittingly remarked, 22 We say a person is a person through other people. It is not I think therefore, I am. It 23 says rather: I am human because I belong. I participate I share… Harmony, 24 friendliness, community are great goods. Social harmony is for us the summum 25 bonum — the greatest good. Anything that subverts or undermines this sought-after 26 good is to be avoided like the plague. 27 21 This excerpt denotes the paramount importance of social relations in Afro-communitarian 1 ethics. It is the utmost moral pursuit in which one becomes more human – an increase in moral 2 value in developing humanness. 3 Of equal ongoing dispute is the primacy of the community and its interests compared to 4 individual interests and rights – specifically, the debate between which takes precedence if 5 either (Molefe, 2017). Regardless of existing contestations in African scholarship, there remain 6 presupposed normative values common in Afro-communitarianism ethics. 7 Kwame Gyekye (1992, p. 103), a most prominent Ghanaian philosopher, asserts that “A 8 communitarian socio-ethical philosophy [puts] emphasis on communal values, collective good 9 and shared ends…” Similarly, Cornelius Ewuoso (2023) refers to some principal communal 10 values, including interdependence, fellowship, solidarity, communal relationship and harmony. 11 Segun Gbadegesin (1991, p. 65), a Yoruba Nigerian philosopher contends, “Every member is 12 expected to consider themselves an integral part of the whole and to play an appropriate role 13 towards achieving the good of all.” 14 All of these abovementioned communitarian values can be summed up into two overarching 15 principles to facilitate harmonious relationships from a framework of Ubuntu philosophy 16 formulated by philosopher Thaddeus Metz (2007) – identifying with others and exhibiting 17 solidarity with one another. Briefly described, identifying with others entails sharing a way of 18 life with them by perceiving oneself as part of a group. Exhibiting solidarity involves acting with 19 goodwill in promoting the well-being of others and acting for the common good (Metz, 2017). 20 Since in the next section, I provide a substantial overview of African conceptions of solidarity,in 21 this section I provide a brief overview of the conception of identification only. 22 Identifying with others is essentially to fully devote oneself – mentally/intellectually, emotionally 23 and actionably – to sharing life in an interdependent manner with others (Cordeiro-Rodrigues 24 and Metz, 2021). Not only is one cognisant of existing in as part of a group, but one also 25 experiences a sense of togetherness in a place of belonging (Metz, 2007). With a deep 26 emotional investment in the group, she/he would feel embarrassed or proud of the actions of 27 22 her/his group (Metz, 2019). Furthermore, identification garners a longing to engage in a 1 common way of life with group members which culminates in an inclination to collaborate in 2 communal projects and coordinate one's actions to be in line with common goals (Metz, 2013). 3 Another way to conceive of Afro-communitarian ideals is to consider the virtues one should 4 exhibit. If the goal is to become more of a moral human, then it follows that there are certain 5 moral characteristics one ought to exhibit. These other-regarding moral virtues include 6 “generosity, kindness, compassion, benevolence, respect and concern for others” (Gyekye, 7 1992, p. 109). Similarly, when one exhibits humanness (Ubuntu), they would be considered 8 to be “generous, hospitable, friendly, caring and compassionate” (Tutu, 1999, p. 35). Most of 9 these above-mentioned virtues are encompassed in Ubuntu philosophy as solidarity – 10 specifically compassion, caring, sympathy and friendliness (Metz, 2007). 11 A few African scholars hold the conception of Afro-communitarianism as not merely a type of 12 Virtue Ethic but as upholding altruistic ideals (Masolo, 2010; Metz, 2012; Ewuoso and Hall, 13 2019). For example, Thaddeus Metz (2013) contends that acting in aid of others, out of 14 sympathy and compassion, is purely motivated by altruistic service. This line of thinking is also 15 typical of the Philosophy of Care, and Afro-communitarianism is often understood as a kind of 16 Care Ethic of which Metz subsequently provides a brief comparative analysis. 17 Particularly, common in both ethics is the expression of empathy. In care ethics, one is not 18 only called to exhibit empathy but also to try to understand others’ unconscious motives. In 19 practising empathy for the other, one naturally becomes sympathetic so that the other’s 20 emotional condition would affect his/her emotional state as well (emotions are bound up with 21 one another). Thus, one would strive for an improved condition of the other in the expression 22 of compassion for the other, hoping that he/she has a good life with less suffering. Being 23 emotionally invested, one would desire to aid the other him/herself and not just hope for an 24 improved condition without necessarily implicating oneself by being actively involved in that 25 improvement. Lastly, these kind actions in aid of the other are motivated by successfully 26 helping the other for their sake (altruistic service). 27 23 I have provided a brief overview of Afro-communitarianism, some of the norms and values 1 derived from it and various conceptions of the same. I have also discussed some similarities 2 with other common ethical frameworks of which Afro-communitarianism is sometimes 3 understood to be a sub-categorical philosophy. I will now provide a brief global comparison of 4 Afro-communitarianism with some other philosophies dominant in the Global North to highlight 5 some major differences thereof and to showcase how Afro-communitarianism can be uniquely 6 useful. 7 One of the most dominant theories often utilized in health ethics is Kantian Deontology. 8 Immanuel Kant believed humans are rational agents and have a duty to act in certain ways 9 (Dhai and McQuoid-Mason, 2020,p. 11). He asserted that this rational ability is what grounds 10 personal dignity. These duties were formulated in the structure of moral laws/rules (Kant, 11 1993, p. 32-36). Contrastingly, in Afro-communitarianism, a person becomes more human the 12 more one successfully and harmoniously relates with others and the more one upholds others’ 13 capacity to relate (Shutte, 2001). That is, a person attains more moral value the more one 14 prizes harmonious relationships. Unlike Kantian Deontology, one does not need to be a 15 rational human being to be considered a person (of moral value) as long as one is capable of 16 entering into and maintaining relationships. Similar to Afro-communitarianism, Kant (1993, p. 17 30) contends that people are not merely a means to an end, but are valuable as ends in 18 themselves and should befittingly be treated with dignity and respect that moral value 19 commands. 20 This is in direct contrast to another dominant ethical theory in the Global North – Utilitarianism 21 otherwise known as Consequentialism. Herein, the ‘ends justify the means’ (Dhai & McQuoid-22 Mason, 2020, p. 13). Consequentialism entails locating the morally wrong or right action by 23 first evaluating the outcome of the actions to determine which one would be favourable. This 24 type of analysis requires unbiased or impartiality in decision-making (Kainz, 1988, p. 78). 25 Unlike Afro-communitarianism, which values interpersonal relationships, Utilitarianism rejects 26 considering the nature of a relationship with an individual when one must make a decision 27 24 regarding this individual. Utilitarianism is often useful for public health dilemmas (Act 1 Utilitarianism) and policy formation (Rule Utilitarianism) but, according to Afro-2 communitarianism, it fails to account for what makes us truly human – empathy and 3 compassion, or more comprehensively referred to as solidarity. Particularly, if one were to 4 make a difficult and cold/unbiased decision void of empathy with the primary goal to increase 5 the overall ‘good’, it could be said that the individuals implicated by this decision (the minority 6 who may have to deal with the unintended negative consequences of the decision) have been 7 treated inhumanely. This is not to say that this is always the case, but rather that Utilitarianism 8 as an ethic is lacking in this aspect as it fails to look after minorities and account for their 9 vulnerabilities. 10 There are two main forms – Rule and Act Utilitarianism. Act Utilitarianism is essentially what 11 has been described above wherein a specific act/decision is only morally right if it increases 12 goodness, pleasure, happiness or flourishing (Shaw, 1993, p. 54). However, Rule 13 Utilitarianism, similar to deontology, relies on a set of rules or laws to govern actions and these 14 norms or rules should have an impact of maximising utility when universally followed. Similarly, 15 Afro-communitarianism considers the impact of actions on everyone in the community, but 16 this does not necessarily mean that everyone ought to follow the exact same rules. What is of 17 importance in Afro-communitarianism is the common good and requires everyone in the 18 community taking collective responsibility. However, this does not necessarily entail everyone 19 following the same rules or actions to collaborate in a certain communal project that will have 20 some common good for the community. Different individuals in the community might be able 21 to collaborate on the same project but with different contributions according to their unique 22 strengths to achieve the same goal. However, Rule Utilitarianism may not take differences in 23 ability between individuals into account. The same general rules and norms would apply to 24 everyone in the same way and may end up disadvantaging certain people or overlooking 25 specific abilities or ways in which others could contribute more efficiently. One of the most 26 drawn-upon ethical frameworks in healthcare is known as Principlism or the ‘Four Principles’ 27 25 (Dhai and McQuoid-Mason, 2020, p. 17). An ethical analysis is done by considering the 1 principles of beneficence, non-maleficence, autonomy and justice from which certain prima 2 facie duties can be drawn (Beauchamp and Childress, 2013). Afro-communitarianism often 3 has a strong underlying value system of justice in restorative aid and reconciliation. 4 Furthermore, it advocates for the common good of the community and in this way seeks to 5 minimise harm. However, it does not necessarily rule harm as morally wrong if it is in response 6 to a greater harm (but only in an attempt to prevent or stop that harm on someone else). Lastly, 7 Afro-communitarianism does not put an emphasis on autonomy and individual freedoms. This 8 is not to say that the individual is not valued, but rather, if an individual’s interests are in direct 9 contrast with communal interests, it is regarded as selfish or ego-centric and would be 10 discouraged if acting upon this individual freedom might harm the community or decrease 11 social ability . 12 Lastly, it is worth noting that communitarianism is not unique to the Global South and various 13 Communitarian ethical frameworks exist in the Global North as well (Dhai and McQuoid-14 Mason, 2020, p. 13-15). 15 In this section, I have provided a brief overview of conceptions of Afro-communitarianism. This 16 does not exhaust all possible conceptions of Afro-communitarianism from the continent, and 17 some conceptions have been precluded from this discussion (such as feminist ethics). Still, I 18 have briefly mentioned ones relevant to this dissertation's argument. In the next section, I will 19 briefly outline key components of solidarity that are dominant in the philosophy I described in 20 this section. 21 2.3 Solidarity in Ubuntu Philosophy and Afro-communitarianism 22 The term, Ubuntu, is a Nguni expression meaning humanness (Metz, 2007). To exhibit Ubuntu 23 is to live a human way of life sincerely or display human excellence; to lack Ubuntu is to be 24 deficient in human excellence (Metz, 2016). Thus, to exhibit Ubuntu, it is necessary to develop 25 humanness wherein moral status, personhood and dignity are found, and to lack Ubuntu is to 26 26 no longer be considered a person. This begs the question, ‘How should one develop 1 humanness?’ 2 A foundational maxim of Ubuntu philosophy, “A person is a person through other persons” 3 (Ewuoso and Hall, 2019), roughly infers that one develops humanness through forming 4 positive communal relationships and valuing harmony with others (Metz, 2010a). Augustine 5 Shutte (2001, p. 30) states, "Our deepest [ethical imperative] is to become more fully human 6 by entering more... deeply into community [or harmony] with others and forgoing selfishness." 7 The thinking about solidarity grounded in Ubuntu requires that we conduct ourselves in a 8 compassionate and considerate manner, that is, in a way that might benefit others. The 9 intention behind this behaviour in African thought is to care for the well-being of others (Metz, 10 2019). But to be able to show true solidarity requires acknowledging our interdependence. If 11 we can do this, we will not feel obligated to just show compassion or try to benefit friends and 12 family with whom we have close relations; we will equally try to benefit all other members of 13 the community to whom we may not have personal ties but are aware that we are nevertheless 14 connected to as a fellow functioning member within our society. 15 The knowledge that the well-being of others in our community is inextricably linked to our own 16 well-being enables us to consider ourselves as a group and to act for the common good of our 17 community and society. This way of thinking implies that we value other individuals the same 18 as we value ourselves without needing to have direct personal ties to them because their value 19 is found through their ability to contribute to society by their capacity to enter into relationships 20 with others in society. Any act of aid for the greater good benefits both others around us and 21 ourselves simultaneously. As such, there is no specific distinction between oneself and others 22 around oneself because one regards themselves as a part of the greater community. 23 Contrastingly, other global conceptions of solidarity, such as that defined by Barbara 24 Prainsack and Alena Buyx (2012), which a Nuffield Council on Bioethics report has used, still 25 lean towards a nuanced individualistic perspective with a delineation of the individuals that 26 comprise the basis of groups and they posit that these individuals should also be regarded on 27 27 an individual level, not just on a group level. This conception of solidarity does distinguish 1 between oneself and the larger group. This conception subtlety rejects the thinking of others 2 as an extension of oneself and may present a barrier to valuing others in the community as 3 equal to oneself. Barbara Prainsack and Alena Buyx's (2012) conception of solidarity can be 4 useful to ground both individual and collective interests, and so it tends to be more inclusive. 5 However, it does not account for the location of individuals’ place in communal relationships. 6 A conception of solidarity wherein the individual and communal interest is not necessarily a 7 dichotomy but could be considered compatible interests or distinguishing between the two is 8 actually irrelevant. This is also alluded to by Innocent Asouzu (2011), an African philosopher 9 who has produced numerous works on the metaphysics and ontology of studying 10 Ibuanyidanda (complementary reflection). He interestingly questions whether it is entirely 11 necessary to categorize individualism as quintessentially Western because, in reality, both 12 individual and communal interests inevitably exist simultaneously regardless of cultural 13 association. 14 Notice that there are other ways in which the thinking about solidarity differs from the 15 conception of the same in the Global North. For example, although this conception of solidarity 16 from the Global North similarly prizes acting compassionately in aid of others, it sometimes 17 evaluates actions in solidarity by their costs incurred. An action for the benefit of others 18 incurring a cost implies that these beneficial deeds may become a burden or come at a 19 disadvantage to oneself, further highlighting the individualistic perception that benefiting 20 others does not necessarily entail concurrently benefiting oneself. Based on the preceding 21 thinking about solidarity, solidary actions are primarily individual-regarding. By contrast, the 22 African view of solidarity is other-regarding and often entails the moral duty to act for the well-23 being of others. 24 It is important to outline some conceptions of solidarity derived from common maxims and 25 motifs in various African regions to underscore Global South's tautology of the principle of 26 solidarity and how it can be understood in the African context and the norms deriving from it. 27 28 One foundational maxim by John Mbiti (1969), a Kenyan Christian philosopher often referred 1 to as the ‘father of modern African theology’ is, “I am because we are; and since we are 2 therefore I am”. This maxim denotes the utmost importance of relationships with others in 3 realizing one’s moral duties and values and developing one’s humanity or personhood. He 4 also aptly highlights the necessity of interdependence, that one cannot exist as a human 5 without being connected with others, and that others’ states of being are intricately bound up 6 with our own. West African traditional Igbo philosophers (of Nigeria) often use a set of 7 allegorical statements to draw on the principle of complementarity or mutual dependence 8 (Asouzu, 2005, p. 142-148). “Ibu anyi danda” translates to ‘no task is insurmountable for danda 9 (a species of ants)’ (Asouzu, 2007, p. 11). Danda can move hauls much heavier than 10 themselves when working in mutual dependence on one another (Asouzu, 2011). 11 From this allegory, other African philosophers derive values of togetherness and a sense of 12 belonging (Ikechukwu, 2016). In a similar vein, consider the East African Luo proverb, “Alone 13 a youth runs fast, with an elder, slow, but together they go far” which underpins the value of 14 togetherness, that we can accomplish much more together than we could on our own in the 15 communal project. In this proverb, the elders provide wisdom, knowledge and guidance while, 16 amongst other things, the young can offer strength and put this guidance into action. There is 17 a mutually complementary relationship that exists with this sense of togetherness, where all 18 parties contribute towards the communal project in their capacity, but their contributions are 19 of equal value since they collaboratively bolster the common good of those in the community. 20 This depicts a sort of horizontal solidarity between community members (Ruch and Anyanwu, 21 1981). 22 Equally, to justify how we are implicated in each other’s lives, some scholars use the motif of 23 the Siamese Crocodile, with two heads but one stomach. This is a common motif in West 24 Africa and depicts how deeply connected and impacted African lives are (Cordeiro-Rodrigues, 25 2020). 26 29 While the conceptions of solidarity grounded in Afro-communitarianism depicted above 1 represent various nuanced understandings of solidarity from different African regions, it does 2 not exhaust all possible conceptions of African solidarity. I acknowledge that within these 3 conceptions of solidarity of the Global South remains a “missing link” of where the place of the 4 individual can be located within the community (Asouzu, 2011). As such, the African principle 5 of solidarity – like everything else in existence – exists in a state of incompleteness (Nyamnjoh, 6 2015), wherein the space for many possibilities of enhancing and extending this principle 7 arises, possibly even to a conception of solidarity wherein a complementary relationship of 8 mutual dependence between the individual, their interests and community interests can be 9 found (Asouzu, 2011). Nonetheless, the analysis indicates that the moral imperative arising 10 from solidarity in Afro-communitarianism often requires individuals to prize togetherness, 11 fellowship, docility, and acting for the well-being of others. 12 2.4 Reciprocity and Afro-communitarianism 13 Reciprocity refers to the notion that one is morally obligated to help those in their community 14 who need aid in whichever capacity one can, since others are morally required to do the same 15 (Metz, 2007). A common maxim used to express this idea is that “the right-hand washes the 16 left-hand and the left-hand washes the right-hand.” The moral norm that arises from this is 17 that the relationship of mutual aid is moral, and ought to be promoted since this is who we are. 18 It is essential to state here that this act of mutual aid is not necessarily done with the 19 expectation of exchange. Instead, it is a mindset which Julius Nyerere (1962) expresses aptly, 20 “we took care of the community, and the community took care of us. We neither needed nor 21 wished to exploit our fellow men.” Again, the African thinking of interdependence, wherein 22 others around us are merely an extension of oneself, encapsulates this motive to act in 23 reciprocity. 24 The thinking about reciprocity in the Global South is typified by the common agricultural 25 practice in Southern Africa known as letsema. This is the Sesotho practice wherein members 26 of a community undertake to assist each other during each step in farming, including 27 30 ploughing, sowing, weeding and harvesting (Mohapi, 1956). Directly translated, the Setswana 1 word letsema means “a group of people coming together for a common purpose” (Setlhodi, 2 2019). This practice encapsulates several norms implicit in the significance of reciprocity in 3 communal living. 4 Letsema calls for mutual collaboration and cooperation underpinning collective responsibility 5 among community members (Mofuoa, 2015). Furthermore, it predicates compassion in 6 contributing towards an agricultural project that will benefit others in the community. 7 Reciprocity is highlighted by those undertaking this practice in their recognition of the African 8 maxims that “a single finger cannot remove fluff” and “two heads are better than one” (Modipa, 9 2014). The value of collective efforts towards a communal project that brings about a common 10 good (for those contributing as well as for others in the community) is also aptly exemplified 11 by the Setswana phrase “kgetsi ya tsie e kgonwa ka go tshwaraganelwa” which means “it 12 takes a collective effort to overcome a swarm of locusts” (Setlhodi, 2019). 13 Reciprocity has also been derived from motifs from other regions in Africa. The previous 14 section explains how the motif of the Siamese Crocodile explains the interconnectedness of 15 lives. This Ghanian motif, Funtumfunafu-Denkyemfunafu, about the ‘Siamese Crocodiles’ 16 originating from the Akan tribe, is also a typology of reciprocity. The translated motif states, 17 “Siamese crocodiles with a common stomach but struggle for food when eating” (Sium, 2014). 18 This Adinkra symbol (Error! Reference source not found.) depicts two individual crocodiles 19 with separate heads and tails, but their torso is conjoined with one shared stomach 20 (Sladojević, 2009). Although the food 21 entering either crocodile’s mouth will 22 come to be in the same stomach, they 23 wrestle and compete to relish the 24 flavour of the food on their own 25 tongues and harm their survival as a 26 Figures Figure 1: Adinkra Symbol of Funtumfunafu-Denkyemfunafu - ‘Siamese Crocodiles’ 31 whole in doing so, as they eventually realize (Kyiileyang, Ama Debrah and Williams, 2017). 1 In realizing that the good that individuals in the community acquire becomes a shared good of 2 the community or a common good, competing for that good is no longer necessary (Müller, 3 Dorvlo and Muijen, 2021). Furthermore, preventing one from acquiring goods out of 4 competition only harms the community. This reflects back to the needlessness of exploiting 5 fellow community members and that aiding others in the community will help oneself in the 6 process. 7 This thinking about reciprocity is not unique to the Global South and can be found elsewhere 8 in the Global North. For example, Care Ethics also conceptualizes reciprocity as mutual aid. 9 However, the mutual freedom to enter a reciprocal exchange is necessary and requires a 10 mutual agreement to this exchange. A response to reciprocal action by one party (which may 11 be unequal) is then demanded by the other party to the agreement (Andrew, 1998). This is 12 not necessarily true in African thinking,for the reason that we are already in existing potential 13 reciprocal relationships with everyone else with whom we are in the community. In other 14 words, there is no specific agreement between parties to enter into a reciprocal relationship 15 as such. Moreover, acts of goodwill to others in the community are done neither with the 16 expectation of receiving anything in exchange nor to require an immediate reciprocal response 17 of equal measure from others (Nyerere, 1962), as it tends to be the case with Care Ethics. 18 2.5 Distributive Justice and African Moral Philosophy 19 Justice alone entails relating to others in a right manner wherein each person is given their 20 due (Ewuoso, Berkman, et al., 2022). Distributive justice in the scholarship on Ubuntu requires 21 one in a state of authority to equitably distribute advantages and disadvantages accordingly, 22 to reach as close to a state of equality among disparity groups as possible (Chroust and 23 Osborn, 1942). 24 Although distributive justice is not uniquely an African principle, there are unique features of 25 this principle emanating from the literature on African philosophy that are worth highlighting. 26 32 First, distributive justice is sometimes differentiated from commutative justice. Both distributive 1 justice and commutative justice are considered as expressions of social justice in the literature 2 on African (moral) philosophy. While distributive justice describes the first-order duties of 3 institutions and states to their citizens (to protect their civil liberties, distribute goods equitably 4 and create a conducive environment for communal relationships), commutative justice 5 describes the responsibilities of citizens to one another and the State. Notably, their 6 responsibility to be solidary to one another and to the State (Ewuoso, Cordeiro-Rodrigues, et 7 al., 2022). 8 Evidently, commutative justice also involves the distribution of some sort, but this is a second-9 order duty that explores issues around equity and relations on the horizontal (amongst citizens 10 or equal parties) and vertical (towards the State). For example, this conception of justice can 11 enhance our thinking about citizens’ duty to pay taxes or vote in elections. In contrast, 12 distributive justice describes the State’s responsibility to its citizens. 13 Second, although social justice and distributive justice are conceptually distinct, nonetheless, 14 it is not uncommon to find that the discussion on distributive justice is sometimes framed as 15 social justice. Specifically, matters of social restorative justice in Africa, such as land 16 redistribution to rectify unjust colonial land distributions, have been reframed and understood 17 as distributive justice in some publications (Masitera, 2020). For example, Thaddeus Metz 18 (2011), one of Ubuntu's most prominent African philosophers, does not distinguish between 19 social justice and distributive justice. He contends that Ubuntu philosophy bears many values 20 reminiscent of social justice, such as respect for all, communal participation and societal 21 inclusion. Ubuntu philosophy, he adds, is also representative of distributive justice wherein 22 values of equity, through a culmination of collective responsibility and promoted 23 interdependence and respect for others, through caring about the wellbeing of others in the 24 community (solidarity) as a motive to restore equality are located. In other words, the values 25 found in Ubuntu are positioned as expressing core concerns about social or distributive justice. 26 33 Furthermore, in the scholarship of African authors who contend that a distinction ought to be 1 made between distributive justice and social justice, it is not uncommon for one to read the 2 following to be the core of distributive justice from that positionality; i) it entails the 3 responsibility of States and established organizations to honour the rights of individuals, 4 including their health rights. ii) to create opportunities for individuals to enjoy a deep communal 5 relationship, which may include funding their health care since illness can undermine their 6 capacity to enjoy communal relationships, and finally, to regulate interactions amongst 7 individuals (Ewuoso, Cordeiro-Rodrigues, et al., 2022). 8 Although the main aim of this section is evaluative rather than descriptive, it is worth outlining 9 how distributive justice in the African philosophy literature broadly, has been described. 10 Distributive justice requires governments and institutions to showcase humanity to their 11 citizens by ensuring that they have a decent minimum to flourish, viz, they can access the 12 basic conditions necessary for participating in communal relationships or share a way of life 13 with others (Ewuoso, Berkman, et al., 2022). 14 In the subsequent section, I demonstrate why this description will require governments to fund 15 the vaccination of their elderly population, particularly in private healthcare facilities. Notably, 16 suppose communal relationships (and/or the capacity for the same) are the basis of morality 17 and moral status in the African Ubuntu philosophy. In that case, an essential way of fulfilling 18 the duty of distributive justice is for governments and established institutions to remove 19 conditions that undermine participation in communal relationships, especially when they can. 20 Illness undermines participation in communal relationships. To understand how, notice that 21 one needs to be a subject and object of a relationship to have full moral status in Afro-22 communitarianism. To be a subject is to be able to commune with others, exhibit caring or 23 other-regarding behaviours towards others. Objects of communal relationships are those with 24 whom one communes. Illness undermines one’s capacity to be the subject of this relationship 25 since it reduces one to an object of others' care, love and compassion. 26 34 Notice that I have not claimed in this section that all sick people cannot exhibit caring relations 1 towards others at all. Sicknesses and illnesses have a spectrum, and individuals may still be 2 able to exhibit other-regarding behaviours to others, even in that state. Instead, I focus on the 3 more intense forms of sickness, which are often lethal, like seasonal influenza in the elderly. I 4 contend that these often undermine adults 65 years and above’s capacity to enjoy deep 5 communal relationships as both a subject and an object of these relationships. As I 6 demonstrate, governments have a responsibility to alleviate conditions that undermine 7 citizens’ capacity. In that case, they ought to fund the influenza vaccination of this population 8 group. The preceding is, in fact, a moral response to the rights adults 65 years and above 9 enjoy as a party in communal relationships with the government. In other words, communal 10 relationships encumber what Thaddeus Metz aptly expresses when he remarks that, “if one 11 has been party to a communal relationship with others [such as the government]…. then one 12 can have some strong moral reason to aid these intimates as opposed to strangers, even if 13 the latter are worse off and if one did not promise to aid the former.” (Metz, 2018) The basis 14 of a State or government’s duty of distributive justice to others is communal relationship. I will 15 provide further justification in the subsequent section. 16 2.6 Government's Responsibility to Fund Influenza Vaccination 17 In the previous section, I provided an overview of – and described the moral norms that can 18 arise from – the principles of solidarity, reciprocity and distributive justice grounded in Afro-19 communitarianism broadly. Furthermore, I differentiated these conceptions from the thinking 20 about the same in the Global North and compared various other conceptions of the same in 21 the Global South. It is important to note that solidarity, reciprocity and distributive justice do 22 not exhaust all the principles in the African (Ubuntu) philosophy. There are others like 23 identifying with others. Nonetheless, these outlined principles are relevant to this section’s 24 evaluative goal. Equally, many other conceptions of solidarity, distributive justice and 25 reciprocity globally are not represented in this chapter, but are no less critical in their 26 applications in ethics broadly. 27 35 This section draws on the moral norms articulated in the previous section to justify why 1 governments broadly, but the SA government in particular, have a prima facie responsibility 2 to fund seasonal influenza vaccination of the elderly in private and public health care facilities. 3 To enhance the public health importance of this project, I also describe what efforts are 4 required to ensure that such vaccines are available and affordable. Notice that I do not contend 5 that accessibility issues only concern availability and affordability since such issues will also 6 include concerns around acceptability. Nonetheless, I focus on availability and affordability in 7 this chapter and defer the discussion on acceptability to the next chapter. 8 To justify my position, notice that most elderly Africans are unemployed, and few receive a 9 small pension fund or government grant, which is just enough to cover their living expenses. 10 The situation is worse for older people in South Africa. A 2022 study shows that less than 15% 11 of adults aged 60 years and older in South Africa are employed (Kopylova, Greyling and 12 Rossouw, 2022). In South Africa in 2020, BankServAfrica (2020) estimated under 19% of 13 adults over 60 years old receive private pensions (some of which receive less than R6510 per 14 month and, thus, fall under the qualifying threshold for social grants as well) and under 70% 15 receive Old Age Grants (OAG). This is consistent with the abovementioned study that shows 16 69% of the elderly receive an OAG of only R1780 (Kopylova, Greyling and Rossouw, 2022). 17 BankServAfrica (2020) also found that under 8% of adults over 60 years old were business 18 owners or still employed in 2017. This leaves an estimate of over 6% of adults over 60 years 19 old with no income, pension fund or government grant (including those with no income from 20 partners or spouses) in South Africa (BankServAfrica, 2020). In the current climate in South 21 Africa, where unemployment has increased to about 32%, these individuals are vulnerable 22 financially and physically, given their advanced years. Notably, many of them cannot work or 23 procure income for themselves or easily attain free quality and adequate basic healthcare 24 without aid. Physical and mental declines in this age group present further barriers to 25 accessing healthcare services. 26 36 Moreover, 69% of older adults receiving only the OAG would fall far short of a “decent standard 1 of living” according to SASPRI, the Studies in Poverty and Inequalities Institute, and the 2 Labour Research Service (2020). SASPRI contends that R7541 per person per month 3 equates to a “decent standard of living” in South Africa in 2020. For argument’s sake, say that 4 19% of adults receive private pensions of R6510, and all private pension owners also receive 5 OAGs of R1780. In that case, about 50% of elderly citizens would receive only R1780 per 6 month (not considering the number of elderly individuals who do not own their housing and 7 have to pay rent or individuals who live with other families). This means that over 56% of the 8 elderly (including those with no income) would have a low standard of living and experience 9 barriers to a good quality of life, including accessibility to basic healthcare services. 10 Indicatively, low economic levels can significantly impact other quality-of-life factors such as 11 household services and health. With 36,4% of the elderly living in households of three or more 12 generations (Kopylova, Greyling and Rossouw, 2022), overcrowding can become a 13 devastating health factor during seasonal influenza outbreaks. A low economic status can also 14 affect accessibility to quality healthcare services through barriers of transport costs and long 15 waiting times at public facilities (Solanki et al., 2019). 16 Although this chapter focuses on adults 65 years and older, given that i) this is the retirement 17 age in South Africa, and ii) adults 65 years and older tend to be more vulnerable than adults 18 younger than 65 years. Nonetheless, it is worth stating that influenza vaccination for adults 60 19 years and older falls under basic healthcare and is a core requirement of what could foster the 20 flouris