S1E70 / Country In-Roads: Building Vaccine Confidence in Rural America / Elizabeth Ellis, Dana Friend, Anna Loge, Chris Martin

I think in the very beginning they didn't believe it was real.

Almost everybody in our community, I would say, knows somebody who's had COVID.

When you look at vaccine hesitancy, a lot of the concerns that people have are fundamentally issues of trust.

You're listening to Epidemic, the podcast about the science, public health, and social impacts of the coronavirus pandemic. I'm your host, Dr. Celine Gounder. Anna Logie lives in the city of Dillon, Montana.

It's a ranching community, so think of wide open valleys, high mountain Rocky Mountain mountains. It's about as classic Montana as you possibly can get.

Anna grew up here. She left for medical school and even worked as far away as Australia, but she never forgot her hometown.

I'd always said I wanted to move back to a place like Dillon, and I looked at a lot of different places and realized there's really no place like Dillon. And so we chose to move back home and raise our kids where we grew up.

For the last 10 years, Anna's been a practicing general internist there. Dillon is a city of around 5,000 people, but there is a critical care hospital there where Anna works. She remembers their first COVID case in March of last year.

I distinctly remember getting the phone call that we had our first positive test within our patient panel. You know, over the course of several days, his condition declined very, very quickly and we We very much realized we were dealing with something we had never seen before. There was so little that we could do to help this individual. We elected not to escalate care to intubation, and he ended up dying with wonderful nurses at his bedside. But it was, it was really rattling to, for all of us to have gone through that.

Anna says they quickly figured out their COVID procedures. But there were other challenges. Some people just didn't think the pandemic was a serious threat, especially Dillon's political leadership.

So from a political leadership standpoint, there was a very strong anti-COVID, anti-mask, anti-public health component on that board.

Public meetings about masks and other public health measures got contentious.

I don't think there were ever any verified threats against public health officials, but I know that our public health officer became quite afraid at times for her family's safety.

But Anna says these tensions eased.

I've been proud of our community through this entire response, even despite some of the political difficulties. And the vaccine rollout, I think, has actually been going really well. Montana, when you look at the national numbers, is at least ahead of most states in terms of the rate of vaccination. And our rural communities actually are doing better than our more urban communities.

While some perceptions of rural America suggest vaccination rates would be lower, a recent survey from the Kaiser Family Foundation found the opposite. 4 in 10 rural Americans reported getting at least their first dose of vaccine. That's compared to 3 in 10 in urban and suburban areas. In this episode, we're going to hear more about what's working in Dillon and how other communities in rural America are handling the vaccine rollout. We'll hear about the challenges to convincing people to get the vaccine.

A large number of the elderly immediately wanted wanted to obtain the vaccine, but then there was a substantial amount that did not have confidence.

Hear what's working in rural communities.

There was a real consistency in being able to set up these Friday clinics, and the volunteers at the vaccine clinics were local community people that you knew.

And what it's like to volunteer in a rural vaccination clinic.

You're somewhat emotionally exhausted because you, you've given a lot at the end of the day, but you're, you're also on top top of the world. It's a mixture of feelings.

Today on Epidemic, rural America and vaccines. Anna says because Dillon is a small community, almost everyone knows someone who got COVID or even died from it.

So it really does touch people, but there is still this strong sense that it's not that big of a deal. All of these restrictions seem to be a bit overblown, and that's a hard narrative to work within, or maybe even sometimes work against, to try to do the best for our community and for our patients.

You know, it's interesting what you're saying about people having a personal connection to many of those who have died in the community because it is such a small community. You know, how does that square with this idea that it's not a big deal?

Yeah, so it's interesting. So when I talk to people about COVID and how serious it is, I more often hear them say, oh, well, so-and-so had it and they didn't get really sick and they should have gotten really sick. And so the focus really is more on all of these people who didn't actually get that sick. And that tends to be the stories that drive more of the narrative versus those that actually died.

Besides ambivalence about the virus, Anna says she encounters a lot of questions about the vaccine. The most common concerns are about safety, side effects, and how fast the vaccines were developed. Anna says earlier in the pandemic, they tried to get information out about the vaccines through their public health department, but the politicization limited their reach.

And so I really have gotten to a point where the best way to have the conversation is a one-on-one Generally in the office. So I can't tell you the number of hours I've spent on either talking about COVID and health precautions or now vaccinations. And that tends to be the most effective way to allow people to perhaps change their minds.

Anna says there are a few people whose minds she just can't change, but she's reaching a lot of other people. She says the key is to listen to their concerns and then talk through the science.

So even despite that hesitancy, with that conversation, 3 out of 4, I would say, are actually making the choice some few weeks later to get vaccinated.

Besides sharing the facts about vaccines and their safety, Anna finds other ways to convince people.

I have a patient who wasn't going to get vaccinated, but I talked to him a little bit about kind of the role of ending the pandemic is going to require, you know, approximately two-thirds of people to choose to get vaccinated. And Is he going to be part of the solution or let everybody else solve this pandemic for him? And he saw me a week later. He said, you know, I heard what you said and I decided to be part of the solution, which I thought was just awesome.

So once people decide to get vaccinated, where do they go? Access and distance are some of the biggest challenges when it comes to getting vaccines into rural communities. Some people may have to drive for hours to reach a vaccination site.

We learned really quickly that you can't really give these somewhat sporadically in clinic. And so our county health nurses organized mass immunization clinics every Friday, and we've been doing this since the end of January.

When we spoke with Anna, almost 30% of her county had been vaccinated.

Over 70% of our patients over the age of 70 have received at least one immunization as of last week. And I think that's a pretty powerful number too. So I feel like we're doing well. By the state metrics, we're doing really well.

Having a single location where people know there will be vaccines available every Friday has been a big help when it comes to improving access. But some communities don't have the resources of a critical care hospital like Dillon. Sometimes there's just one provider in a small town, someone like Elizabeth Ellis.

My name is Elizabeth Ellis. I'm a doctor of nursing practice, family nurse practitioner. I am the clinic owner and operator of an accredited rural health clinic in Bee Dias, Texas.

Bee Dias, Texas is about halfway between Houston and College Station, where Texas A&M is located. Bee Dias is a small town, less than 400 people. The median age there is 50, and Elizabeth's clinic is the only one of its kind for miles. To help improve access to vaccines across the state, Texas officials set up vaccine centers called hubs.

Our hub that has been designated for our county is a whole nother county away, and given where we are located and where that hub is, that would take patients here in Bee Dies an hour to drive to, and people do not have reliable enough transportation to do that.

Setting up appointments was also a challenge.

You have to realize we are very rural, and most of these residents don't even have computers. And cell service is sketchy at best.

So Elizabeth looked at the situation and made up her mind.

I knew right away, given the limited availability and the travel time and/or the lack of internet access, that I would have to at least attempt to start to try and vaccinate.

Elizabeth's quest to help vaccinate her community is a good example of some of the challenges rural providers face. The first issue was if her clinic even had the resources to keep the vaccine. Remember, the Pfizer vaccine, the first to get emergency use authorization, has to be kept at very cold temperatures. Many rural clinics don't have the equipment to handle it.

I did not have a deep freeze, but I knew I could hold Moderna just fine.

So Elizabeth put in a request for 100 doses of the Moderna vaccine.

So we gave an initial 100 vaccines in January, beginning January 11th. And it took me a week to get all 100 administered.

Elizabeth's clinic is small, so she needed all the help she could get to administer those vaccines. Other healthcare workers volunteered to help, and a local Baptist church played an important role too.

Yes, without the churches and the faith leaders, you know, trying to talk with their congregations, I, I'm not so sure that we would have had the good turnout that we did.

But it wasn't a sure thing Elizabeth would even have second doses to give people. She reached out to a state representative to help secure the vaccines she needed. Soon, she was on the phone with state health officials.

By the end of the phone call, they promised not only to get me that second 100 for dosing administration, but they would send me— hearing that I was a solo provider, they sent me the National Guard to help administer those shots, which was a total godsend. Then suddenly Tuesday evening at 5 o'clock, FedEx shows up at my clinic door with 200 doses. So those were my original 100, then somehow another 100-dose allocation. So then we had to scramble.

Elizabeth went from worrying she didn't have enough to give out to too much.

We were up till all hours of the night on Friday and through the week trying to garner 200 people.

Remember, the town of Bidias' entire population is less than 400. Word of mouth spread through church organizations, community leaders, and local officials. Elizabeth and others were calling providers in neighboring counties to make sure nothing went to waste.

I had to run over to the post office and grab participants, and they were older. They were over 65. They met the qualifications because we still had some no-shows at the very end, and I didn't want to waste any vaccines, but we got it done.

It took her a week to administer the first 100 doses. It took her team one day to do another 200. But after all that work, it's still an uphill battle.

And so next Wednesday, we are giving the 200 second dose allocation. But it saddens me that already we have so many cancellations of people who've just decided No, I can't get there. And given we've had a site change, which is just about 20-25 minutes further from where we gave it at the Beadahs Church.

And it's just too far for them. Is that the issue?

I think they have a multitude of reasons. Either they don't want their second or it's location or it's during the work week. On the other end, we have a lot of elderly who driving just that little bit further instead of around the block. Makes a big difference.

But Elizabeth is hopeful that people will continue to get vaccinated.

The biggest benefit and assistance we got was from the first 100 people that we vaccinated. They have spread the word.

Next, we'll go to West Virginia, a rural state that made headlines when it had some of the best vaccination rates in the country. We'll hear the secret to their success and hear what it's like to volunteer in a vaccination center. That's after the break. West Virginia was the last state in the union to report its first COVID case.

We were very happy about that, but we knew with a sense of inevitability that with cases arising throughout the rest of the country, that it was only a matter of time before it would affect us as well.

This is Chris Martin.

I'm a professor in the West Virginia University School of Public Health and director of our Health Sciences Center Global Engagement Office.

Chris says West Virginia had a lot to worry about when it came to COVID. The state has an older population and high rates of chronic conditions and obesity.

When we finally got the vaccines, I think we surprised a lot of people.

West Virginia is known for its beautiful natural resources and coal mining pride, but the Mountain State could soon be about to add a new title to their list of accolades: best vaccine rollout. West Virginia has been a leader from the outset. In fact, it has outpaced nearly every other state when it comes to vaccinations. There are states in this country that aren't even close to getting the first doses. What does it What does it feel like to have West Virginia basically blow everybody away?

Feels great.

The messaging that we've done in West Virginia is let's keep this up. Let's continue to raise those eyebrows and have people ask themselves, why West Virginia? And prove those stereotypes wrong and that we really can succeed when it matters.

Part of that success is due to a decision the state made early in the vaccine rollout. They opted out of a federal program that relied on big retail pharmacy chains to distribute vaccines. Instead, West Virginia looked to local independent pharmacies that were more evenly distributed across the state.

This was obviously a, a logical choice for logistical considerations, but I think we hit on something much more profound in choosing to work with our community providers.

Everyone we spoke with for this episode agreed that the participation of local community health providers was key to success.

My wife has been heavily involved in volunteering to give these vaccines.

There was always so much gratitude, so much thankfulness and appreciation, and just, "Thank you for what you're doing. We really appreciate it." This is Dana Friend.

She's a nurse at the West Virginia School of Nursing, and she's married to Chris. Dana hadn't given out a vaccine in years, but she volunteered to help. The first day she volunteered was at a National Guard vaccination site for people 85 and older.

I was a little anxious because I hadn't given a vaccine in a while, and I watched the nursing instructor beside me give her first vaccine, and I was like, okay, I remember I can do this. And so then I got my first patient, gave the vaccine.

What did it feel like for you to have that in your hands?

I mean, you feel like it's, you know, a piece of gold almost. It's— you have this beautiful vaccine that can help us move forward.

Dana was surprised by how intimate the experience of giving out vaccines was. There was one man in particular she remembers. He told her about how when he was a child, before the polio vaccine was available, he had to spend his summers indoors. His parents were afraid he'd be crippled by the virus.

And just the relief that was felt once that polio vaccine came for the families. Of these children who lived in fear. And so he was so happy to get his vaccine that day that it felt to him very much like that polio time when the vaccines were available and no longer living in fear.

Afterwards, the man sat down with his wife to wait 15 minutes to make sure he didn't have an allergic reaction.

And I could see him watching me, and I wondered, what is he thinking? You know, is he remembering those days back when he was, you know, could have been crippled from polio, but he had these beautiful blue eyes and they were very powerful. And they just watched me going around and I would check on him. And, you know, before he left, he said, "Thank you." And I don't know if I'll ever see him again, but it was just a really intimate, powerful moment with him.

Dana said people wanted to share why they were getting vaccinated. Many, especially that first day, said they were getting vaccinated so they could safely see their family and friends in person again. Were you surprised by the number of people who showed up in those early days?

I was actually. I mean, again, it's a rural state. Transportation is challenging, it's difficult, and these are elderly patients. But you know what I realized were that the people that came very early on, they were strong, they were determined. They've seen a lot, right? They're 85 and older, so they've seen the horrors of life and they've seen the beauty. Of life and they know that this time too shall pass and they want to be able to help.

Dana had her own personal moment too. She got to vaccinate one of her close friends.

And to me, that was just such a moment of pure joy to be able to share that moment with her. We had somebody standing there to take our photo and you can see, you know, that she's all smiles as I'm giving her her vaccine. Vaccine. So it's truly something to remember.

These are still early days for vaccine distribution. Chris Martin and Anna Loghi both said that vaccinations so far have been focused on high-risk populations like frontline healthcare workers and the elderly. These are groups where the demand is very high. Time will tell if younger people in rural America will line up to get vaccinated in the same numbers. But in the meantime, being part of the solution gives people like Dana a sense of empowerment.

At the end of the day, you're just, you're somewhat emotionally exhausted because you've given a lot at the end of the day, but you're also on top of the world. It's a mixture of feelings, but it is, it's just a beautiful thing to be able to do and to provide.

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