LA GUAJIRA, Colombia – The vaccination team had spent an hour bouncing and bucking down a dirt road and over train tracks when the van driver issued a warning.

The toughest part of the drive was still to come.

The two women gripped their seat cushions as the van jolted, climbed a mound of dirt and fishtailed in the slick mud. Driver Toto Girnu honked at passing goats as he followed a path blazed only by tire tracks. In the distance, he spotted dark, menacing clouds.

If the group was lucky, the drive through this remote desert would take four or five hours. If it rained, as it did when Girnu made this trip a few days earlier, it could take more than 10.

But this was the only way to reach the Indigenous families who live in this arid swath of land in the northern department of La Guajira, where there are no paved roads, no electricity, no running water and no other access to the vaccines that would protect their communities.

Travel is only part of the challenge confronting the team, one of many contracted by the Colombian government to deliver vaccines to some of the country's remotest peoples. There is also a lack of information about the coronavirus, hesitation around vaccines and a general mistrust of authorities.

The van, "Route of Hope" written across the windshield, came upon a roadblock. Adults and children here string ropes across the road, to be lifted only in exchange for water, food or cash.

"Are you vaccinated?" vaccine team coordinator Katherin Gamez shouted to a young man. Girnu gave the man a fist bump, tossed him a small bag of water and translated the question into Wayuunaiki, the language of the local Wayuu Indigenous people.

"For what?" he asked.

Long-neglected areas

Across the Andes, a region that has reported some of the world's highest COVID-19 death rates, teams are traversing deserts, mountains, rainforests and rivers to vaccinate isolated communities.

Such teams are particularly active in Colombia, a country of more than 48 million people, where about 16% of the population lives in rural areas that were often neglected by the government during more than five decades of armed conflict.

In the northern department of Magdalena, a vaccinator on horseback rides up a muddy mountain, then dismounts to complete her trip on foot. In Amazonas, a team spends days traveling by boat. In Chocó, criminal groups add another challenge.

About 35% of Colombia's population has been fully vaccinated, according to the health ministry. More than half of residents in major cities – 62% in the capital of Bogotá – has received at least one dose.

But in La Guajira, home to the country's largest Indigenous population, only 38% has received at least one dose. In other departments, the rate is as low as 20%.

In La Guajira, years of government abandonment and mismanagement have caused many Wayuu residents to mistrust the health system. Only 4% of people here have access to clean water, Human Rights Watch reported last year; 77% of households are food insecure. In Alta Guajira, where the largest number of Wayuu people live, there is only one hospital, and it offers only basic care. People who need specialized treatment travel six hours or more to the departmental capital of Riohacha.

"By the time a lot of them get to care, they're so near death ... there's this perception that maybe the care didn't help," said Shannon Doocy, an associate professor of international health at Johns Hopkins who co-authored the Human Rights Watch report.

A lack of testing in rural La Guajira makes it difficult to know the full impact of the pandemic on these communities. But one thing is clear: If a community member falls ill with COVID-19 in Alta Guajira, it is nearly impossible to quickly access the care they would need.

Which is why the van was headed to the northernmost tip of the department.

"We're getting close," Girnu told Gamez and Eliana Andrioly, the team's Indigenous leader. They sped down a salt flat, their view miles of sand and the distant bay.

Modest goal, massive effort

It was late afternoon when the group arrived at a medical center in Bahía Honda. A team of nursing assistants and a doctor were waiting. The providers spend 15 days at a time living in a dormitory next door, sleeping in hammocks and showering with buckets of water, to stage daily medical missions to the surrounding communities.

The organization, IPSI Palaima – "land of the sea" in Wayuunaiki – was founded in 2007 by an Indigenous woman who grew up in the area. It is one of the only providers in Alta Guajira with a permanent vaccine refrigerator, in a medical center powered by solar panels.

The team member in charge of shots this week was Daniela Vergara, a 21-year-old nursing assistant who had never been to Alta Guajira before she applied for the job.

Each day, Vergara aims to vaccinate at least 10 people – a modest goal that often requires a massive effort.

On this Monday, she had not yet reached her target. She packed her cooler – a blue backpack filled with vials of the single-dose Johnson & Johnson shot that has been a godsend to rural vaccine teams – and set out for a community across the bay.

The fastest way to arrive would be by boat, so Vergara and the other members of the IPSI Palaima team packed into Girnu's van and drove the 20 minutes to a dock. A boat carried them to a rocky cliff overlooking pristine turquoise waters.

From there, a member of the community offered the team a ride on the wooden back of his truck.

They drove to a gathering place where they hoped to meet people interested in the vaccine.

"There's no one here," Vergara said. "We got here too late."

A local leader suggested they go house to house. As darkness fell, the team members asked anyone who looked 18 or older if they wanted the vaccine.

Soon a woman recounted a rumor they had heard many times: Outsiders were pushing a vaccine that was sickening members of the Wayuu community.

The woman, a teacher who spoke some Spanish, knew what was at stake. She had contracted the virus a few months earlier, after a trip to the town of Uribia. For a month, she suffered chest pains, headaches, an intense cough and the loss of taste and smell. She was treated only with traditional Wayuu remedies. She worried about a 66-year-old neighbor who had no interest in getting a shot.

"Many people are dying from this disease," Juan Larrada, a Wayuu doctor in the group, said in Wayuunaiki. He said the vaccine could have side effects, but it would protect them from serious illness. He asked Amaita Uriana why she did not want it.

"Because I was afraid of getting sicker," she said. "I really feel very sick. I carry pains in my body. That's why I refused when a girl came here for the same reason. Besides, she was very pretentious. And we had already heard about the experiences of other Wayuu who had been vaccinated and become ill."

"The vaccine can have those effects," Larrada agreed. "Fever, muscular pains, that's normal."

Understanding the doctor as he spoke to her in her own language, Uriana assented. She closed her eyes; Vergara emptied the syringe into her arm.

Mistrust and missed opportunities

The next morning, Vergara collected her hair into a ponytail, chugged a plastic bag of water and hopped onto the back of a motorbike.

She held on with one hand and managed a cooler with the other as the driver sped across desert and along shoreline. As always, Vergara asked the driver to blast vallenato – the Colombian folk music popular along the Caribbean – so she could sing along. Trailing her, on the back of another motorbike, was Micaela Epieyu, the team nurse in charge of children's vaccines.

As the women approached their first family, a group of women in floral dresses on a front stoop, Vergara worried they would not trust an outsider who did not speak Wayuunaiki. She asked Epieyu, who speaks the language fluently, to help translate.

The soft-spoken 29-year-old was shy. But as she began talking to the women, most of them mothers, the family felt much like her own. Epieyu had three children under the age of 12, staying with her mother in the city of Maicao. Vergara is also a single mother, with a 1-year-old son back home with his grandmother. Both were counting down the days until they could return to their families.

Within minutes, Vergara had vaccinated five people.

A short motorbike ride away they found a family of more than 10 living in a home made of wood and sticks.

"Vaccines deceive," Cristina Pushaina told Epieyu. "A month ago, our uncle died from being vaccinated."

She said a girl from the community went to a hospital far away and died. Her relatives had to pay to bring her body back for a traditional Wayuu funeral.

Pushaina used a fish bone to scrape a fruit peel known as a taza de mono – a monkey's cup – to extract a juice used in traditional medicine to treat stomach aches and child malnutrition.

"We trust the medicine made by our own hands," she said. Not the medicine of an "alijuna" – an outsider. "This liquid that you want to inject in us, we don't know who prepares it or how."

"With any type of injection," she said, "the Wayuu always die."

Their fears were like those of others around the world who have rejected vaccines – fears based on misinformation, disinformation or lack of trust. Even here, in a place with no electricity and little cellphone reception, where locals rarely interact with people outside their families, the rumors still spread.

But the roots of the mistrust in Alta Guajira are much deeper. It's a community that has for generations suffered from malnutrition and food insecurity made worse by corruption and mismanagement in both local and departmental governments and publicly funded health care providers.

Families here have survived almost entirely on their own, relying on fishing and goat herding for food – and on medicinal treatments passed down by their ancestors.

"If our grandmothers had been alijunas," Pushaina said. "We wouldn't exist."

Vergara and Epieyu did not try to push the family any further. Their decision was made.

It was a missed opportunity, but the nurses understood there was only so much they could do. Even if they traveled house by house across the desert, even if they explained the vaccine to community members in their own language, it would not be enough to convince some.

The women hopped back on their motorbikes and drove to the next home.

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