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SARE GIBEL, Gambia — The health outreach workers who drove past Lama Mballow's village with a megaphone handed out T-shirts emblazoned with the words: "I GOT MY COVID-19 VACCINE!"
By then, the women in Sare Gibel already had heard the rumors on social media: The vaccines could make your blood stop or cause you to miscarry. Women who took it wouldn't get pregnant again.
Lama Mballow and her sister-in-law, Fatoumata Mballow, never made the 3.4-mile trip (5.5 kilometers) to town for their vaccines, but the family kept the free shirt. Its lettering is now well-worn from washing, but the women's resolve has not softened. They share much — meal preparation duties, child care, trips to the well with plastic jugs, and their outlook on the vaccine.
"I definitely need a lot of children," said Lama Mballow, 24, who has a 4-year-old son, another child on the way and no plans to get vaccinated after giving birth. And Fatoumata Mballow, 29, struggling to get pregnant for a third time in a village where some women have as many as 10 children, quietly insists: "I don't want to make it worse and destroy my womb."
As health officials in Gambia and across Africa urge women to be vaccinated, they've confronted unwillingness among those of childbearing age. Many women worry that current or future pregnancies will be threatened, and in Africa, the success of a woman's marriage often depends on the number of children she bears. Other women say they're simply more afraid of the vaccine than the virus: As breadwinners, they can't miss a day of work if side effects such as fatigue and fever briefly sideline them.
Their fears are hardly exceptional, with rumors proliferating across Africa, where fewer than 4% of the population is immunized. Although data on the gender breakdown of vaccine distribution are lacking globally, experts see a growing number of women in Africa's poorest countries consistently missing out on vaccines. Officials who already bemoan the inequity of vaccine distribution between rich and poor nations now fear that the stark gender disparity means African women are the least vaccinated population in the world.
"We do see, unfortunately, that even as COVID vaccines arrive in Africa after a long delay, women are being left behind," said Dr. Abdahalah Ziraba, an epidemiologist at the African Population and Health Research Center. "This could mean they will suffer a heavier toll during the pandemic."
The spread of vaccine misinformation is in large part to blame for the gender gap, officials say. Delays in getting vaccines to impoverished countries allowed misinformation to flourish, even in outlying villages where few people own smartphones. And with female literacy a challenge across Africa, women have long relied on word of mouth for information.
Despite the rampant concerns about pregnancy and fertility, there is no evidence that vaccines affect a woman's chances of getting pregnant. The U.S. Centers for Disease Control and Prevention tracked tens of thousands of immunized women and found no difference in their pregnancy outcomes. The CDC, World Health Organization, and other agencies recommend pregnant women get vaccinated because they're at higher risk of severe disease and death.
In Gambia, like many African countries, AstraZeneca was the only vaccine available initially. Widespread publicity of the links between that shot and rare blood clots in women during a fumbled rollout in Europe set back vaccination efforts. Many Gambians believed the shot would stop their blood from flowing altogether, thanks to poor translation of news into local languages.
Officials also confronted a deep mistrust of government and a belief that Africans were getting shots no one else wanted. Rumors swirled that the vaccine was designed to control the continent's birth rate.
Health officials have since made strides getting Gambian women vaccinated; they now make up about 53% of those who've had the jabs, up several percentage points from just a few months ago. But there's been a lag among those of child-bearing age, despite how frequently they're in contact with maternity clinic workers.
Across Africa, officials report similar trends despite lacking wider data. In South Sudan, Gabon and Somalia, fewer than 30% of those who received at least one dose in the early stages of COVID-19 immunization campaigns were women.
In those countries — as elsewhere in the world, especially impoverished nations in parts of the Middle East and Asia — women face other obstacles accessing vaccines. Some need their husbands' permission, or they lack the technology to make appointments, or vaccine prioritization lists simply didn't include them.
Dr. Roopa Dhatt, assistant professor at Georgetown University Medical Center, said it's not surprising African women have been left behind, but addressing the problem is urgent. "If they do not get vaccinated at the same rate as men, they will become this pocket for COVID-19, and it will make it more difficult for all of us to get out of the pandemic," she said.
In Gambia, many women begin their day at dawn by starting a fire to cook breakfast, so Lucy Jarju rises and makes her way to the river after morning chores. She and other women spend hours paddling small boats on the open water in search of dinner. The oysters, crab or small fish that are left uneaten will be sold, making up the bulk of their household income.
Jarju, 53, isn't willing to be vaccinated against COVID-19 if it means missing even a day's work. Her husband died a decade ago, leaving her alone to provide for her seven children and three grandchildren.
"Every day I am running up and down to make ends meet. If I go and take the vaccine, it will be a problem for me," said Jarju, who often doesn't make it home until dark, washing dishes before finally heading to bed, ready to repeat her routine the next day. "If my arm gets heavy and I can't go to the water, who will feed my children?"
If they do not get vaccinated at the same rate as men, they will become this pocket for COVID-19, and it will make it more difficult for all of us to get out of the pandemic.
–Dr. Roopa Dhatt, Georgetown University Medical Center
Jarju said she's gotten other vaccines, but has yet to make the 25-minute trek on foot to the nearest clinic for her COVID-19 shot.
"Maybe later," she demurred, heading off to prepare dinner with her share of the day's catch.
Only about half of the world's 200 countries and regions have reported COVID-19 vaccine data by gender, according to a global tracker at University College London. But since similar scenes play out across this country of 2.2 million people and its neighboring nations, experts fear the worst for women in these impoverished countries.
"In most countries in the world, we just don't have the data to tell us if there is a COVID-19 gender divide," said Sarah Hawkes, director of the Centre for Gender and Global Health at UCL. "But the few numbers that we do have suggest that it's a problem."
Gambia's fate has been intertwined with that of its much larger West African neighbor Senegal, which completely envelops the tiny enclave of a nation except for the coast. Most foreigners arrive by land at checkpoints where no proof of negative COVID-19 results are needed, which allowed the virus to intensify as Senegal faced a crushing third wave.
And the pandemic has devastated the Gambian economy, which is sustained by tourists from Europe and money sent home from Gambians abroad. Gambians now depend more than ever on fishing and farming. Increasing numbers are taking to rickety boats to flee Gambia — which emerged from more than two decades of dictatorship in 2017 — risking death for a chance to reach European countries.
Hawkes said some hope exists that any initial imbalances in COVID-19 immunization rates between men and women continue to even out in Gambia and other countries once they have steady vaccine supplies. In most rich countries where vaccines have been freely available — including Britain, Canada, Germany and the U.S. — there is a nearly even split between the numbers of men and women getting inoculated.
But it's particularly difficult to push vaccines in areas that haven't had explosive outbreaks of the virus, such as parts of Gambia and South Sudan.
"Women here are worried their children will get pneumonia or malaria," said nurse Anger Ater, who works on immunization campaigns in South Sudan. "They are not worried about COVID-19."
Reluctance to the coronavirus vaccine isn't limited to remote villages. At the Bundung hospital in Serrekunda, on the outskirts of Gambia's capital, the situation confounds chief executive officer Kebba Manneh, who has worked there for more than 20 years.
On a recent morning in the hospital's maternity clinic, Manneh asked a group of dozens of expectant mothers how many had been vaccinated against COVID-19. Just one raised her hand.
Footsteps away, other women brought in their babies and toddlers for routine immunizations — measles, diphtheria and tetanus.
"You take your child to get vaccinations. What is so special about this one?" Manneh asked. A pregnant woman pulled out her phone to show him a video claiming a person's body became magnetic after the COVID-19 shot, with a spoon stuck to the arm.
Initially, confusion stemmed from advice against vaccination for many women, said Marielle Bouyou Akotet, who leads the COVID-19 immunization plan in the central African nation of Gabon.
"As we did not know the effect of the vaccine on pregnant women, breastfeeding women and women who want to have a baby in the next six months, we recommended not to vaccinate this category," said Bouyou Akotet, a professor at the University of Health Sciences in Libreville.
That recommendation was updated after several months, but many women in Gabon and elsewhere have still decided to skip vaccination altogether.
"If I take this vaccine, can I still conceive?" patients ask Mariama Sonko, an infection control specialist at the Bundung hospital. "We tell them the research says it has nothing to do with that."
But many women listen to stories instead of research. They hear about a woman who miscarried after her vaccination, at 11 weeks, and the fear spreads, even though pregnancy losses are common in the first trimester.
"What makes me afraid is what I heard on social media," said Binta Balde, 29, who has been married for two years and has struggled to conceive. "That if you take the shot, you will not get pregnant."
She's visited the local health clinic and a traditional spiritual healer, who counseled her to swallow pieces of paper with Quranic verses and to drink tea made from herbs to boost fertility.
"When you get married and go to your husband's house, you have to have a child," she said. "If not, he could divorce you or leave you at any time. He may say, 'She cannot give me a child, so I should look for another.'"
The rumors about COVID-19 and fertility have been especially troublesome in predominantly Muslim countries such as Gambia and Somalia, where polygamy is common.
"For Somali women, it means a lot to them," said Abdikadir Ore Ahmed, a health specialist with CARE. "For you to stay in a family and a marriage, it's expected you should be able to give birth to more children. The more children you have, the more acceptance you get."
In Gambia, husbands must give permission for their wives' medical procedures. Most women tell health care workers they won't get the COVID-19 vaccine unless their spouse consents. But few husbands come to prenatal visits — only about half even attend their children's birth at the Bundung hospital.
The hospital recently held an information session for fathers, where Manneh tried to explain the vaccine's proven effectiveness.
"All the pregnant women coming here are not getting the vaccine because the husbands haven't given their authorization," he told the men. "Two of them have died. We are not forcing anybody, but lots of vaccine will expire soon."
Fatoumata Nyabally's job as a security officer puts her at heightened risk of contracting COVID-19, and she hasn't been vaccinated. She's seven months pregnant, but her husband did not attend Manneh's presentation. He's already refused to consent for his wife's vaccination.
So Nyabally declined the Johnson & Johnson vaccine, telling workers: "He's the head of the family, so I have to obey him in anything we do."
Of the 100 women approached that day at the hospital, only nine agreed to be vaccinated.
This story is part of a yearlong series on how the pandemic is impacting women in Africa, most acutely in the least developed countries. AP's series is funded by the European Journalism Centre's European Development Journalism Grants program, which is supported by the Bill & Melinda Gates Foundation. AP is responsible for all content.
Contributors: Yves Laurent Goma, Cara Anna and Mohamed Sheikh Nor