WORAWORA, Ghana — Covid-19 cases are virtually non-existent these days here in the dust-covered villages around Worawora in eastern Ghana. Many people in these small communities, where people line narrow, winding roads selling mangoes and vegetables, feel no urgency to get vaccinated — some even run away when health care workers approach with coolers filled with shots.
That wasn’t the case a year ago. Those living in the villages of this district — now a target of U.S. aid donations — wanted the shot when people in their communities were dying back in the spring of 2021. But the doses the world promised Africa didn’t come until months later, health officials here say. Now, a spirit of resistance has set in. Some believe rumors about health risks. Others don’t trust the Western countries sending the vaccine, with local religious leaders and gossips playing on cultural and racial mistrust.
But for the health care workers who have struggled to bring modern medicine to the eastern edge of the country, drawing back on their Covid vaccination campaign is not an option. They worry a new, even bigger wave of cases could eviscerate the health care system — one where hospitals and health centers across the country are lacking things like sterilization machines, surgical gowns, oxygen and ultrasound machines.
The system is already struggling to keep up with a slew of systemic health issues that permeate every corner of the country. If doctors and nurses here aren’t dealing with common road traffic trauma cases, they’re treating a myriad of different diseases, including HIV and tuberculosis — even anthrax. And in children, doctors are treating cases of malnutrition. At a nearby district hospital, health care workers treat up to 65 children at once for nutrition issues, giving them formula and fluids on a daily basis.
But those case numbers do not compare to the number of cases of malaria. The rainy season has begun here, bringing in unwelcome levels of humidity, swarms of mosquitoes and an uptick in cases. In nearby hospitals, patients line up for care, complaining of high fevers and excess vomiting. In this part of Ghana, the disease is treated almost like the common cold — there are so many of them that doctors here expect 75 percent of the cases they see in a given week to be malaria.
Covid is the last thing on doctors’ minds. But even though cases are at a low in Ghana, health officials, finally armed with enough doses from the international community, say they hope it is not too late. They are adamant that the country must continue to try and increase its vaccination rate over the next several months.
“We are pushing and pushing and pushing,” says Stephen Bordotsiah, the head of the health directorate in Bongo in northern Ghana.
Their determination is rooted in a mix of dread and wanting to prevent a nationwide health disaster and the feeling that they have to make up for lost time. The doses should have come sooner, health care workers here say. They should have been able to start vaccinating the general population long before they did in late August 2021. But now, they finally have the money and doses to make a dent — the government is relying on its longstanding relationship with Gavi, the vaccine alliance leading COVAX, and it just received $27 million from the U.S. Agency for International Development to put shots in arms.
There’s just one big hurdle to cross: Convincing people to get the shot.
Down a winding, narrow road, past huts filled with locals selling water and yogurt drinks, vaccine volunteers from the nearby hospital, carrying gray plastic carriers filled with Covid doses, are snaking their way in and out of homes. They are here in this roadside village in the Biakoye district for the second time today, trying to convince a few of the most resistant members of the village to get the shot.
The sun is bearing down its final rays here — a welcome sign after a nearly 100-degree weather day. Women pace in and out of open-air brick and mud structures preparing fires for supper. Their sleepy children are slung onto their backs, tied snuggly in colorful fabric.
One of the volunteers, Priscilla Oppong, who is from the Biakoye district area, checks a small notebook lined with pencil markings to see who in the village has received the shot. There’s the woman in the home at the center of the neighborhood, her mother and a few men down the path. There are a handful of others who have yet to get the jab. As the vaccinators approach, several men prance away, avoiding the conversation they know is coming.
“I guess we’ll have to try again,” Oppong says, sighing. “There are a few here who refuse.”
It’s a common problem across the nation. Since 2021, Ghana, which received the first shipment of vaccines in the world from COVAX, the global vaccine facility, has ordered or received more than 18 million Covid doses. So far, the country has administered more than 14 million shots — 9.6 million of which came from the U.S., according to government data shared with POLITICO. Over the past two years, the country has also received more than $11.4 million from the U.S. to help treat Covid in the country and to put shots in arms.
But Ghana has struggled to ramp up its vaccination rates, particularly in rural communities like this one in the eastern part of the country near Togo. Last summer, the country was struggling to reach a 10 percent vaccination rate. The situation has improved slightly since then. Now, 19.8 percent of the total population is fully vaccinated. About 25 percent of the 22.9 million of Ghana’s targeted eligible population, which includes pregnant women, is fully vaccinated.
The vaccination situation in Ghana is emblematic of the scene on the ground in many African countries which have struggled to reach the 10 percent mark in recent months. Ghana is one of 11 African countries receiving millions of dollars from USAID under its Global VAX program — a program launched last year to help countries improve, giving the governments money for training vaccinators and hiring drivers to transport doses from cold storage to health centers and hospitals.
The vaccination campaigns are moving slowly but, some say, steadily. For example, in Ghana, the Ministry of Health mandated districts across the country to try and give 13 percent of all people eligible for first, second and booster shots during the government’s second national vaccine campaign April 21 to 26. Multiple districts were unable to reach that target. But the numbers weren’t all bad — some missed the mark by just a few thousand shots.
Health care officials here say the government will not be able to continue pressing forward without outside funding. Ghana relies on Gavi and USAID support for accessing the shots and for transportation, including boat rentals to help communities that need to be reached by water and outreach activities such as radio messaging. A significant portion of the money has also gone to helping hire and train new vaccinators so district health offices can send teams out en masse.
“That is where the money that we’re providing in Ghana and other places is really important,” said Jeremy Konyndyk, executive director of USAID’s Covid task force. “The unit cost to vaccinate a person in an urban center is just inherently lower. When you’re talking about the logistics, and the outreach and the workforce requirements to get to some of those harder to reach more remote areas, it just costs more money.”
At the Biden administration’s second Global Covid Summit Thursday, U.S. and international officials announced $3.1 billion in new funding for worldwide Covid efforts. About $2 billion will go to helping fund various Covid programs, including getting shots into arms in low-income countries — far less than what is needed to help increase vaccination rates in countries across Africa. The rest of the money is being put aside for a new World Bank pandemic preparedness fund. Without sustained funding throughout 2022, Ghana’s vaccination rates could stall — leaving millions of people vulnerable.
That seems increasingly likely. The USAID Global VAX program is at risk of losing steam after Congress failed to approve $5 billion in additional global Covid funds last month. Without it, USAID will struggle to fund its Covid vaccine program in Ghana. The funding it is currently using to prop up vaccination campaigns across Africa is dwindling and set to run out by the summer. There was a chance that funding was going to be included in another Ukraine supplemental package. But this week, President Joe Biden said he believed a package that included Covid funding would slow down the approval process and that the two measures would have to be separated, with a Covid package potentially moving through at a later date.
Lack of U.S. Covid funding would set Ghana back and put a crack in the longstanding partnership between the two countries, said Janean Davis, acting mission director of USAID in Ghana.
“The impact goes beyond Covid,” Davis said. “There’s the glaring impact of what that means for our ability to respond to this global pandemic. [But] there’s significant impact for what it means for the broader health system because Ghana uses these resources to impact health. For example, our ability to get oxygen … addressed Covid patients and that same system is being used to help babies live longer and moms live longer.”
If U.S. monies — and other global Covid cash — were to run dry right at the time when Ghana has finally received enough doses to push forward with large national vaccine campaigns would only further sow distrust among Ghanaians, Davis said. It would also leave Ghanaians vulnerable to another wave of Covid should a new, more transmissible variant emerge that can evade prior protection.
Now, Ghana is relying on local volunteers to convince their family, friends and neighbors to get the jab.
Health care workers say many people are not simply hesitant to get the shot —they just downright reject it. Vaccinators don’t just have to lay out the science behind and benefits of the shot. They have to also dispel conspiracy theories.
“A lot of people don’t want it. They think the white people from America and Europe are here to get rid of them,” said one woman in the Worawora village who did receive her primary series vaccination. She asked to remain anonymous to shield her vaccination status from other community members.
It’s not that the people here don’t want to protect themselves from Covid. In the spring of 2021, Ghanaians scrambled to find shots. Cases began to rise all over the country, including in the rural communities. At the University of Ghana Medical Center in Accra, the intensive care unit filled up. But shots were slow to arrive for the general population — the majority of Western donations didn’t get to the country until August 2021, nearly six months after people in the U.S. began receiving their first dose.
“The vaccinations here did not take off at the same time as the West,” said Eric Quaye-Appiah, who helps lead the Covid vaccination response in the Biakoye district, where Worawora is located. “In March 2021 we had some vaccine for health care workers. But it was August before the general population could get the vaccine. Meanwhile, all the other richer countries were vaccinating.”
In that time, people here watched on CNN as people in the U.S. and across Europe lined up to receive their jab. Western leaders promised the shots were on their way. But nothing came. In the time that Ghanaians had to wait, misinformation about the vaccine spread and frustration grew, people here say. Religious leaders told their followers that Covid shots would send them to hell. Others heard the vaccine would hurt pregnant women and their babies.
Quaye-Appiah, who is in charge of the entire district vaccination response, is sitting in a building at the Worawora Government Hospital — a structure normally dedicated as a clinic for pregnant women and other individuals with chronic illnesses. The building is one floor, with wooden benches aligned as if they are church pews. On the walls hang anatomy charts and informational flyers about childhood nutrition and breastfeeding.
He slouches back in a wooden chair at a long wooden table and his staff sits on the benches behind him. He’s wearing a gray t-shirt, glasses and tan shorts. He’s tired — frequently wiping his eyes from behind his frames. He and his team are taking a break for a few hours before finishing up vaccinations for the day. In the distance, clouds roll in from the nearby mountains. It begins to rain.
Quaye-Appiah, who has been involved in vaccination campaigns in Ghana for more than 14 years, begins to describe the effort it takes to reach people in this region and the hours upon hours his vaccinators spend with people here, trying to convince them to get their primary series vaccination and boosters. He says his staff — who are paid about $6.50 a day during national vaccination campaigns —have to walk for miles, crossing rivers, carrying coolers of vaccine, lined with ice packs to keep the doses cool.
The staff in Worawora has expanded in the last few weeks in preparation for the country’s second vaccination campaign — propped up in large part by international funding, including funding from USAID. In normal times, his staff is minimal — the team sets up underneath a tree in the center of the Oti district, in hyper-local health centers or in local schools, hoping people will come to sign up for the shot. In those times, the door-to-door knocking is significantly reduced and vaccine uptake tends to slow.
“In all vaccination campaigns, we struggle with adults,” he says. “For Covid, we tell them about the benefits of the vaccine and why it is important to take as far as herd immunity is concerned. Some will accept. We have people who do not take anything at all — they have spiritual and religious reasons. For those, we cannot do anything.”
One of his volunteer staff, a young woman from the community, is sitting in one of the wooden pew-like benches, chiming in from the side.
“Some of the men in the region think the shot is going to give them erectile dysfunction,” she says, her room of peers, including Quaye-Appiah, erupting in laughter.
“Yea, and for some we have people who say it gives them too much function!” another male volunteer staff member says, joking. It’s a conspiracy theory not dissimilar to the ones currently held by large portions of the American population.
As the rain begins to fall from a tap-tap to a shhh, a drone flies through the dewy sky above the front of the hospital complex, dropping a medium-sized red box. Zipline, a California-based company, supported by Gavi, set up a hub in Ghana in 2019 to help deliver blood, vaccines and other kinds of medicines. It’s been crucial for helping deliver Covid shots in hard-to-reach areas in Ghana.
The red box slowly falls to the ground, suspended from a paper hood. It includes more Johnson & Johnson shots — a favorite in this area because it does not require the ultra-cold storage of some other vaccines. Unused J&J doses simply go into the normal containers in the front of the hospital alongside AstraZeneca doses. They sit in a small room off the main entrance. They’ve come from a large storage center in Accra where the government keeps giant freezers full of vaccines.
Right now, this district, like almost all of the others in Ghana, has too many vaccines — more than meets demand. And vaccination teams like Quaye-Appiah’s are struggling to move them out before they expire. A significant number of their current AstraZeneca doses — thousands in some districts — continue to arrive in the country with short shelf lives and will likely expire soon. Meanwhile, 2 million additional U.S. doses arrived in the country in late April.
Quaye-Appiah says at the beginning of vaccination distribution in August 2021, his staff was encouraged by the number of people they reached — sometimes over 100 a day. Now, though, his staff are at times only convincing 30 people a day to get vaccinated. That number has fallen to as low as seven.
“We are hearing in our consultations with African health counterparts, that there’s just not the same sense of urgency about it that there was last year,” Konyndyk says of vaccination campaigns in countries like Ghana. “It’s not to say those people can’t be convinced or won’t eventually be convinced. But this is one of the reasons why there is this need to really do a significant push on expanding that community engagement and combating misinformation. Because it is, it is going to be a barrier.”
Those barriers are also being met by community health workers in the Okere district, a four-hour drive southwest of Worawora on the way to Accra. The Okere district is the youngest and smallest district in the country, according to Augustine Ankuvie, the director of health services. This week, the second to last in April, community leaders across the district are desperately trying to ramp up their vaccination numbers before the national campaign comes to a close.
Ankuvie is sitting in one of the main rooms off the entrance of the district’s health office, just a few minutes drive from the senior high school. In this room, health care workers plot out how to ramp up vaccinations among both children and adults and track disease outbreaks. Binders line the bookshelf on the side of the room — just one of them is titled Covid. There are several for malaria, some for tuberculosis and HIV.
Ankuvie sits at a desk at the front of the room with his assistant who is pouring over the day’s vaccine numbers. Vaccinating people in this district is expensive, he says.
Okere launched its own district-wide vaccination campaign April 10 — a little less than two weeks before the national one started. During that push, Ankuvie said, the district spent about 44,000 cedis, or approximately $5,800 to pay vaccinators to knock on doors. USAID, in collaboration with the Ministry of Health, helped sponsor the campaign. But the money didn’t come in time and the district had to use money out of its own budget, which goes to help treat other illnesses, Ankuvie says. The district is still waiting for reimbursement. USAID officials say the money was transferred to the Ghanaian government April 21 — a few days after the campaign ended. Ankuvie suspects it has yet to trickle down to the regional government and on to the district for repayment.
The lack of quick reimbursement worries Ankuvie. In recent weeks, the rainy season has brought on a sharp uptick in malaria cases. The doctor at the local health center down the road says she treated several patients for malaria today, including a four-year-old girl. Before seeing the doctor, the young girl wearing a light pink dress squats next to a drainage ditch on the side of the health center building, vomiting excessively, crying out to her mother. She’s not the first child to seek treatment this week, the doctor says.
“For us, we aren’t seeing or focusing on Covid,” she says. “We are seeing a lot of malaria. We test to make sure and then give them tablets to take home. We will see how this girl feels after 24 hours of treatment. She may have to come back.”
The fact that Covid isn’t causing local hospital rooms to fill up has drained energy from the vaccination campaign, Ankuvie said.
With his assistant by his side crunching the numbers, he explains that the district is aiming to vaccinate about 49,200 people for Covid total. There are about 78,000 people who live here. This week, during the national campaign, Okere’s goal is to get 5,680 people vaccinated. So far, on the second to last day of the campaign, they’ve vaccinated just over 3,000 — only 544 doses were first doses, he said. Doses are expiring here, too. Ankuvie’s assistant, who tallies the vaccinations in a small notebook, estimates that the district has had 3,076 doses expire — almost all of them AstraZeneca.
“The shelf life is so short for those ones,” she says.
While the work of getting people vaccinated in northern Ghana is equally as difficult, one district near the border of Ghana — a 12-hour drive from Accra — is doing exceedingly well.
One can reach the Bongo district, a community of 120,000 people, by flying into Tamale from Accra. Tamale is the biggest city in the northern part of the country and home to some of the biggest health and humanitarian hubs in the country. To get to Bongo, you have to drive down a red-sand and dirt road about two hours from the Tamale airport. The land in this part of the country is significantly less developed. And there is so much of it — peppered with rows and rows of trees, often with large ant mounds underneath. Cattle graze the grass around it.
The communities on this road are further apart than those near Worawora and in Okere — and the houses lack reliable electricity. The roadside structures, where men and women sell food products and local goods, have just one light bulb for when the sun goes down — providing only enough light for someone standing in the doorway.
In Bongo, Bordotsiah, the head of the health directorate, sits with his team inside an air-conditioned building in the middle of town. In front of him is a laptop computer and sheets of scrap paper marking the district’s progress on Covid. Each of his staff members live in the area and have worked on vaccinations for years. The group has just come back for the day after vaccinating people who attended church.
Bordotsiah says even on non-national campaign weeks, his staff are “chasing people down” trying to convince them to get the jab.
“I think we equally have the same challenges the other districts have. Vaccine hesitancy has been very high in the region. And our team hasn’t had it easy at all,” he says. “But we also have a good strategy in place.”
The Bongo district is also attempting to meet the national campaign goal of vaccinating 13 percent of the population for all dose categories. So far, two days before the campaign ends, the district has reached 82 percent of that goal — and Bordotsiah believes it will get to 100 percent.
The health care workers here use the local radio station to educate the community about the vaccine. They also share stats on how many people have had adverse reactions to the shots and why, and they share details of scientific studies backing up the effectiveness of the vaccine. They also work with faith leaders in the community — both Christian and Muslim — to speak to their followers about getting the shot. That outreach effort is spread out across six subdistricts and leans on health care workers at the regional and district hospital, the seven health centers and the 58 community-based health planning centers.
Despite the success of the campaign, the health workers in Bongo have faced significant pushback. In one instance, an individual who was fully vaccinated died. The man had other chronic conditions, including liver failure, says Bordotsiah, but he also had Covid. He stayed at home, coughing, before seeking care at the district hospital. He was detained there for a week before dying from a confirmed case of tuberculosis. Everyone in the neighborhood became convinced that he died because he had received the jab — two doses of AstraZeneca.
In another situation, a local religious leader who received his primary series vaccination went around to his parishioners, telling them they would go to hell if they received the shot. The disinformation campaign got so bad the police had to intervene. “He had to go to the police station and he was warned that if he continued to spread those lies he would be in trouble,” says Bordotsiah.
For the health care workers in Bongo obtaining one of the highest vaccination rates is an honor — and a sign that their life’s work is paying off. Still, they are anxious to reach 100 percent of the people in their communities — and they wonder if they will ever reach it.
“I think when we had Covid, if we had gotten more doses, we would have probably been able to reach more people because now the perception is that Covid is gone,” Bordotsiah says. “If we had gotten some doses around that time in the spring of 2021, or even around the peak towards the end of the year in 2021, we could have reached so many more people.”
Back in the small roadside community in Worawora, Oppong and her team stop at a compound of homes which share a fire pit and cooking area. An older woman lights the end of a long wooden stick and places it in a stack of others below a cast iron pot. The sun has almost set completely, and the children living in these homes sit on the steps nearby, waiting patiently for food.
To the side, an 18-year-old mother of two, child strapped to her back, stands in the doorway to her home, staring at the ground. She’s kicking rocks around as Oppong, perched on a nearby ledge, asks her why she is still holding out on getting vaccinated when others in the village have signed up. She’s told vaccinators in the past that she did not want the shot — that she’d heard it would hurt her and make her sick. The woman does not answer. She shrugs her shoulders, eyes still facing downward.
After a few minutes of speaking with Oppong, she finally walks to a rickety wooden stool and sits down, rubbing her left shoulder and winces. The vaccinator gives her a first shot and a card showing she still needs to get a second dose in a few months. Her mother, who has also refused to get a shot, shuffles up to the group of houses. She takes her daughter’s newly minted vaccination card out of her hands, reads the print and then quickly shoots a look of bewilderment at the group.
Then, she too, squats down on the same wooden stool and rolls up her sleeve.