After a sluggish start last March, Tunisia's vaccine efforts exploded in August with a series of open-call vaccine drives that saw about 10 per cent of the population receive their jabs in a few short weeks. The drives came amid a major wave of infections driven by the Delta variant and people crowded vaccine centres across the country, streaming in from cities, suburbs and the countryside to receive their shots.
But one demographic was conspicuously absent.
“When we launched the open-call days, we noticed right away that West Africans, especially our Ivorian residents, were absent,” said the Tunis Regional Health Director, Tarek Ben Naceur.
Their absence was puzzling for healthcare workers.
“We had invited anyone and everyone to come, regardless of whether they were a resident or registered in the country — you just needed to show your ID and there were no questions asked.”
Experts estimate there are between 20,000 to 40,000 West Africans living in Tunisia, most without legal status, and many on a months or years-long stopover to save money before attempting to cross the Mediterranean into Europe. Largely employed in the informal sector, they work as housekeepers, nannies, stone masons, construction workers, car repairmen and cooks.
They are also a part of the larger battle against Covid-19 in Tunisia, which has the second highest vaccination rate in Africa.
A combination of misinformation at home and a lack of outreach and education from Tunisian health authorities may mean this vulnerable population could be the country's Achilles heel in reaching herd immunity.
'A giant game of telephone'
“Everyone has his reason” for not being vaccinated, said Bakary, 37, an Ivorian who works as a cashier at a grocery store in Tunis. But for many, those reasons start with rumours and misinformation coming from friends and relatives back home in Ivory Coast.
“It's like a giant game of telephone,” said Coulibaly, 36, also from Ivory Coast. Information is passed through voice notes on WhatsApp or chats with friends and family at home, and spreads rapidly.
Ivory Coast struggled in the early days of 2021 with waves of vaccine misinformation that circulated on social media. Unfounded rumours that the AstraZeneca vaccine was a form of population control spread like wildfire, and kept Ivorians from coming to take their shots. The country's initial supply of vaccines, which its health ministry had fought to secure, risked expiring from lack of uptake.
Newly appointed Ivorian Minister of Health Pierre Dimba recognised the urgency of the situation and began an aggressive campaign to combat the misinformation, reaching out to clergymen, social media influencers and community leaders in working-class neighbourhoods where the rumours ran particularly deep.
“The survival of our population is at stake,” he said in April 2021. Within weeks of the campaign, the vaccination rate shot up tenfold.
Meriam, 23, went to visit her family in Ivory Coast in October and, despite some reservations, decided to be vaccinated while she was there to make travel back to Tunisia easier.
“There was information in my language — in all the local languages, actually — and that made it more clear what I needed to do and why. I'm still a little nervous, but it made it feel safer,” she said.
But little of that information trickled down to those in the diaspora. Initial fears about fertility or long-term side effects became entrenched in the minds of many who were out of reach of the public service announcements, TV programming and radio shows assuaging fears back home.
“African men are a bit hard-headed — it’s tough to convince them to change their minds on something,” said Richmond, 37, who has been working odd jobs in Tunis since he left Ivory Coast three years ago.
“So many people had a bad feeling about the vaccine from the beginning that now they’re staying with those ideas.”
For many those ideas have lingered, even as more information about the vaccine has emerged. Estelle, 27, who is pregnant with her first child, said she lied to her physician and her employer about her vaccination status on the advice of friends and relatives back home.
“I’m not alone in this,” she said after the end of her workday in Tunis. “It’s me and the baby and, you know, there could be complications.”
A confusing path to vaccination
While Ivory Coast was combating rumours last spring in the very working-class neighbourhoods many migrants come from, Tunisia was fighting its own battle with misinformation.
A wildly popular Ramadan hidden camera show with an Angelina Jolie look alike depicted local celebrities panicking after actors on the show received a shot of a "WHO-approved vaccine" and proceeded to have seizures. Distrust in the vaccine grew and few signed up to receive it.
Mr Ben Naceur, the health official, said much of the official focus was on combating disinformation in Arabic — not French, the country's second most spoken language and the lingua franca of most West Africans in the country.
“Really it was only the elite who were getting information in French” primarily from satellite stations, he said. Little clear information was available for those West Africans without such luxuries.
Even for those who wanted to sign up to receive the vaccine, information was scarce. Tunisia's digital Evax platform required personal information many were hesitant to provide; others struggled to register because they cannot read.
Jean Claude, 56, jumped at the opportunity to be vaccinated after losing a friend to Covid-19 early in the pandemic. An aid worker with UNHCR helped him sign up on Evax, and he waited for a text message telling him when he could have an appointment.
“I want to leave Tunisia, so the vaccine was a crucial step for me — you have to have a vaccine pass to travel — plus I was still really affected by my friend's death and wanted to be protected,” he said.
“I couldn't imagine what would happen if I were sick for three weeks or a month, or if I had to go to the hospital.”
Months went by before he realised a series of texts in Arabic, which he neither speaks or reads, were likely from Evax. He asked his boss at the car repair shop where he works to help him decipher the texts.
“He told me I'd already missed three appointments and needed to sign up for a new one!”
For others, even the basic requirement of showing identification to receive the vaccine has proved difficult. Seventeen-year-old Mory, who crossed the Sahara without a passport late last year, came to an open-call vaccination day but was turned away.
“I want to be protected,” he said. “But they won't let me.”
(Mr Ben Naceur insists that identification is necessary to keep accurate records and that they have no intention of changing the requirement.)
An advantage or an obligation
The turning point for many Ivorians in Tunisia came at the end of December, when the country instituted a vaccine requirement to gain access to many public buildings, shopping malls, large grocery stores and in some cases, public transit, though its enforcement has been lax.
“Without the vaccine, you can't take the train or go into a store,” said Richmond, who was vaccinated early last year after his mother, a midwife in Ivory Coast, told him to take the first appointment he could find.
“I’ve been trying for months to convince my friends that getting vaccinated is an advantage, but in end it was the law that persuaded them to do it.”
Despite lingering doubts and hesitations, Coulibaly said if his employer started requiring the vaccine pass, he would take the shot: “If I don’t do it, I won’t eat.”
Mr Ben Naceur sees stricter enforcement as the linchpin to finally reaching the elusive goal of herd immunity.
“After we instituted the vaccine pass, we noticed that at the next open-call vaccine day, so many more of our West African immigrants showed up — they showed up in big numbers.”
Those big numbers could tip the scales for Tunisia's virus outlook. With about 60 per cent of the population fully vaccinated and an estimated 30 per cent having contracted the virus, “it's that last 5 or 10 per cent that we're aiming for”, Mr Ben Naceur said.
“The virus doesn't respect nationality or borders, so we have to get everyone their shot.”
This report was supported by the International Women’s Media Foundation’s Global Health Reporting Initiative: Vaccines and Immunisation in Africa.
Reporting support provided by Armelle Marcelle Seambo, in Tunis.