Inside One of America’s Vaccine Deserts
Along a winding roadway festooned with lanky longleaf pines, a sign welcomes you to Meadville, Mississippi, population 519.
“Oh, we’re bigger than that,” says Cynthia Ann Wilkinson, a Mississippi State Extension agent, to the journalist who mentioned the sign in passing. Her co-worker and office associate, Suzanne Brown, intrigued and in disbelief, Googles the recent Census data. “It’s actually 604,” she says.
Meadville is the government seat of Franklin County, a 567-square-mile patch of rural America — one square mile for every 14 people. There are only two traffic lights here but more than two dozen churches. The 1,075-square-foot Okhissa Lake supplies residents with recreational pastimes — fishing and boating — and the dense Homochitto National Forest ensures the area is always awash in emerald green.
The county is astride both sides of the digital age: 70% of its residents have internet access, but only 9% have bandwidth enough to stream an ultra-high-definition video.
There is one hospital with 25 beds, but 14% of people don’t have health insurance to avail themselves of it. None have access to a brand-name pharmacy within the county’s borders.
But Franklin County is not an anomaly. There are, according to the U.S. Census Bureau, 704 rural counties in the United States; 19% of Americans call rural places home.
In Clark County, Idaho, residents drive 45 minutes to buy groceries or medicine. In Petroleum County, Montana, about 16% of people live in poverty. The only hospital in Fairfield County, South Carolina, shuttered years ago. Such statistics might have only resonated with rural planners and sociologists, if not for the events of the last year: Remote, sparsely populated areas are often devoid of the facilities or trained personnel needed to distribute Covid-19 vaccines.
In Franklin County, about 13% of its population had received at least one dose of a vaccine by March 30. For context, in Hinds County, home to the Mississippi state capitol and its largest city, Jackson, nearly 18% of people had been vaccinated by the same date; and in nearby Orleans Parish, Louisiana, which includes the city of New Orleans, 21% of people had been inoculated.
In the race to plunge as many shots into as many arms as quickly as possible, some experts worry that rural counties will be left behind, allowing an already recalcitrant virus to linger, fester, or surge in areas disadvantaged by decades of health care inequities, and undermining nationwide efforts to eradicate the pandemic.
Rural counties face a bevy of obstacles to vaccination: Those with hospitals are less likely to be equipped with cryogenic storage systems necessary to stock two of the three Covid-19 vaccines currently authorized for emergency use. These hospitals have fewer health care workers to dispense the shots. And reliable and fast internet service is often required to schedule a vaccine appointment.
Public opinion polls suggest that rural Americans are less likely to want a Covid-19 vaccine. For some, their hesitation stems from a deep-seated distrust of government or health care systems, thanks to feelings of neglect or being forgotten. Others reject the notion that the pandemic is a problem at all.
When a journalist called Meadville’s town hall to schedule an interview with one of the town’s aldermen, the woman who answered the phone said they had declined to talk. The aldermen wouldn’t have anything to add to the article, she said: “We don’t have a Covid problem here.”
In fact, Franklin County has reported more than 800 Covid-19 cases.
That’s more than 10% of its population, according to the 2019 Census estimate — or slightly less, if county gossip that conspiratorial citizens refuse to fill out their Census forms is true — which puts Franklin County ahead of the U.S. national average of reported Covid-19 infections.
According to the Centers for Disease Control and Prevention, long-standing systemic health and social inequities — paired with a higher likelihood of cigarette smoking, high blood pressure, and obesity — have increased rural residents’ risk of contracting serious cases of the coronavirus.
“I had the Covid,” Wilkinson says.
But to take a Covid-19 test, she bypassed the local hospital, Franklin County Memorial Hospital in Meadville, and drove 30 minutes to McComb, Mississippi. And when Wilkinson was so sick with the virus that she could barely stand, she again went to McComb, where she was put on oxygen and kept four days for observation. “I hate to say it,” she says, “but it’s one of the things I leave the county to do.” Outside their community, “I think they’re more experienced,” she says.
Wilkinson isn’t the only Franklin County resident to express concern about the hospital. When asked about the hospital’s vaccine distribution, one Roxie resident — who asked to remain anonymous and who’s been unable to secure a dose — said, “I know they’re giving it to friends.”
Standing in downtown Roxie, centered by an unmanicured lawn the length of a football field and framed only by a pint-sized post office, single-story city hall, and antique shop, he says, “They [local residents] want to act like we’re all as happy as pigs in a poke. If you say anything else, you’re cast out.”
(For its part, FCMH administrator Mike Boleware told Elemental that “we’re dealing with the distribution like every other hospital. We have vaccines.” He ended the call, but agreed to answer additional questions by email. Multiple subsequent emails and phone calls went unanswered.)
In rural communities that have hospitals, distrust is common, says Alison Davis, PhD, professor of agricultural economics at the University of Kentucky. It can lead to what experts call bypass behavior — bypassing the local hospital, even if it provides quality care, to visit a larger hospital.
People sometimes bypass their local hospital because of “something that happened to someone’s grandparents, two generations ago,” Davis says. She doesn’t say it mockingly. “In rural areas, information travels fast,” she says. “And it’s very personal because everyone knows everyone.”
But access is more often the problem: Of more than 6,000 hospitals in the U.S., 1,805 are located in rural areas, but in the last decade, at least 120 rural hospitals have closed, and nearly one in four — about 450 — of the remaining rural hospitals are considered to be vulnerable to closure.
Hospitals are businesses, after all. Vivian Riefberg, a professor of practice at the Darden School of Business at the University of Virginia and director emeritus with McKinsey, says that many rural hospitals have been challenged for years by lower patient volumes, aging infrastructure, and patients without the ability to pay. The pandemic has only exacerbated these issues, she says.
Rural hospitals’ facilities also may not be equipped for the first vaccines authorized for emergency use in the U.S. Made by Pfizer-BioNTech and Moderna, the doses need to be stored at -70 and -20 degrees Celsius respectively. (Once vials are opened, they must be used.)
At the end of February, the Federal Drug Administration authorized for emergency use Johnson & Johnson’s Covid-19 vaccine, which could be transformative for rural communities, some experts say. Its vaccine requires refrigeration at 35 degrees Fahrenheit — the same temperature required by the flu shot, meaning every hospital in the country will be able to store it safely.
This week, President Joe Biden announced that the federal government is working to more than double the number of pharmacies able to distribute Covid-19 vaccines, and will set up another dozen mass vaccination sites by mid-April — moves the administration says will help ensure more Americans have easier access to the vaccines, and that could also help rural communities.
In Franklin County, residents turn to the Franklin Advocate, the local weekly newspaper, for information. And the man in charge of the newspaper is Sean Dunlap.
Dunlap accepted the general manager’s job early last year, joining a staff of four that includes an advertising agent, office manager, and writer. He, too, writes many of the newspaper’s articles.
“I cover government. I cover health care. I cover just about anything you could imagine would be important, right down to the local chicken competition,” Dunlap says. He also covers the pandemic.
As news of the novel virus spread, “it was a curiosity for most people around here,” Dunlap says. Cases in Franklin County — like in many other rural areas — took off slowly, and it wasn’t until schools were ordered closed that people began to look at Covid-19 “with a wary eye,” he says.
Readers can buy the newspaper at gas stations or the local Family Dollar. Many will simply stop into the newspaper’s Meadville office, located in a one-story house, to pick up the weekly issue.
But not many read it online.
Only 9% of Franklin County residents have 25 megabits per second or more of internet speed at home. Wilkinson says service wasn’t even offered in her neighborhood until last fall.
A 2019 report from Purdue University revealed that the number of rural homes without internet access was 20 times higher than urban homes; 4.8 million people had no internet whatsoever.
Black and Hispanic adults are also less likely than whites to say they own a traditional computer or have high-speed internet at home, according to a 2019 report from the Pew Research Center.
Lack of internet access “is one of the most significant barriers for rural communities,” says Shawnda Schroeder, PhD, associate professor of population health and associate director of research and evaluation for the Center for Rural Health at the University of North Dakota.
Traditionally, those who live in what have been dubbed “broadband deserts” could go to a library or community center to get online — “which is a barrier in and of itself,” says Schroeder. “You shouldn’t have to travel to a nearby public library to access high-speed internet or even mediocre internet.” But “when you exacerbate that [barrier] with a pandemic,” people have even less access to the internet. “You might not feel safe sitting in that library, or that library may not be open,” she says. The Covid-19 vaccine rollout has been intimately tied to internet access: In many states, residents must register online to schedule a coronavirus vaccination appointment.
And while Congress recently appropriated $3.2 billion for a new program that would allow eligible people to get discounts on broadband service and devices, that’s only helpful in places that have broadband infrastructure in place. Many broadband service providers won’t enter rural communities. There are too few people — and too few people with the money to pay for the services, says Davis. “They don’t find places like a rural community very attractive,” she says.
Mark Thornton knows Covid-19 is real. Seated inside the Franklin County Board of Supervisors board room, the county emergency management director rolls his eyes toward the ceiling as he ticks off the list of recommendations he made to the county government, many of which were executed but ultimately ignored: People should wear masks inside, he advised, but compliance is willy-nilly at best. Desktop plastic partitions would shield employees from coronavirus-carrying droplets; but when two partitions were placed atop two desks inside the bedroom-sized county clerk’s office, one clerk promptly took hers down. “It’s in the hallway collecting dust,” he says.
When his wife, Millie, and his 19-year-old son caught the virus, the 60-year-old sequestered himself on the first floor of their two-story home in Bude and asked his family to stay on the second floor. When his wife sneaked down to the kitchen for a glass of water, he shooed her back upstairs, packed a cooler with Gatorade and apple juice, placed it at the top of the stairs, and said, “You get ready for something to drink, it’s right outside. Don’t come downstairs.”
Thornton does not want to get Covid-19.
But at the same time, he’s suspicious of the mask he wears. Taking it off, Thornton holds it up and says, “Almost all of the masks that the Mississippi government sent us came from China.”
As a journalist looks at him inquisitively, he adds, “It’s very possible they sprayed them with the virus. Where does the virus come from? China. A lot of us emergency managers, we’ve talked about it.”
Misinformation has spread widely throughout the country amid the pandemic, causing confusion over Covid-19 and vaccinations against SARS-CoV-2, the virus that causes it. For example, false rumors that the virus is no more deadly than the flu or that vaccines against it change your DNA may have fueled concern over inoculation. Recent polls have shown that people are warming to the idea of inoculation, but rural residents are among the most hesitant.
That hesitation is unrelated to partisanship, says Schroeder. Recent polls, however, suggest 41% of Republicans say they don’t plan to get a vaccine when it becomes available to them.
Though their hesitancy is decreasing steadily, Black Americans have had lower than average confidence in the vaccine. “We know that minority communities have a well-earned discomfort with the government because of decades and decades of racism,” says Samuel Scarpino, PhD, assistant professor of network science and director of the Emergent Epidemics Lab at Northeastern University. Access to available Covid-19 vaccines also remains a substantial barrier for many Black Americans.
In most rural areas, white Americans make up the majority of the population, recent data shows. In Franklin County, however, nearly 35% of the population is Black, according to 2019 Census estimates. And data has shown Black and Hispanic Americans are receiving fewer doses of the vaccines compared to their share of the population — and their share of Covid-19 deaths.
Because Covid-19 was slow to reach rural areas, many residents had difficulty accepting the novel virus was as dangerous as it had been portrayed. According to Jennifer Reich, PhD, a professor of sociology at the University of Colorado, Denver, people make vaccine decisions by comparing their “perception of the benefit of getting a vaccine against what they perceive to be the risk of the disease, and the risk of the vaccine itself.” In the case of Covid-19, some people may not think the risk is great enough to take a new vaccine, Reich explains.
“We can’t afford to leave parts of America vulnerable.”
“There’s vaccine hesitancy because it’s a new vaccine that’s not fully licensed,” she says. When you combine that with a lack of access to the vaccine itself and information about it, “we have two seemingly contradictory problems that I think are actually feeding off of each other.” She adds, “When there’s a perception that a scarce resource is being allocated unequally or unfairly, it diminishes trust in not just the vaccine but in the system that is responsible for distribution.”
As for Brown, after waiting more than a month to get the vaccine for which she was eligible at the Franklin County hospital, she drove 45 minutes away to receive her first shot on February 24. She was nervous. “I don’t know much about it,” she explains. “And I know they say the side effects are limited. But what about in 10 years? There is so much that isn’t known about this vaccine.”
If rural areas don’t widely embrace Covid-19 mitigation measures, including vaccination, some experts worry the virus could remain or reappear in these remote, vulnerable communities.
“If we have rural areas that continue to persist with low levels of vaccination,” says Scarpino, whose research shows Covid-19 sweeps through close-knit, rural populations faster than in urban areas, often with more devastating effects, “then they will continue to be at risk.”
And while widely unvaccinated rural communities may face higher rates of hospitalizations and death, “There is also the larger issue, which is that the entire country is not going to be safe until every state is safe,” says Jennifer Nuzzo, PhD, associate professor of environmental health and engineering and epidemiology at the Johns Hopkins Bloomberg School of Public Health.
“We can’t afford to leave parts of America vulnerable,” she says.
Another concern, Nuzzo says, is “if we leave pockets of infections happening, the more people continue to get infected, the more opportunities there are for this virus to mutate and possibly acquire a feature we don’t want it to have, such as not responding to vaccines and therapeutics.”
To get more shots into more arms, the U.S. recently announced it will partner with national and independent pharmacies to distribute vaccines, increasing overall access across the country. But more than 100 nonmetropolitan counties have no pharmacy at all — and an even greater number don’t have a retail pharmacy that is affiliated with the 21 retail chains targeted in the partnership.
In some rural places, access to pharmacies hasn’t mattered. In Alaska, about 22% of the population has received their first doses, the highest rate of vaccination in the country. The state’s success comes from its ability to procure more doses — its Indian Health Service department gets its own allocation of vaccine doses to serve the state’s tribal population — paired with its willingness to empower communities to distribute the vaccine in ways consistent with local cultures and utilized in previous vaccine rollouts.
West Virginia is another vaccine success story. There, state officials did not rely on the federal partnership with chain retail pharmacies — which are largely absent in the rural state — and instead worked with independent drugstores to deliver more than 85% of its vaccines.
Experts say courting local leaders, such as business owners and religious figures, to endorse the vaccine will be key in getting more rural residents to consider the vaccine. “It’s challenging to see and accept information coming from people who don’t fully understand the local culture,” Reich says. (What ultimately compelled Brown to get her vaccine, despite her hesitations, was knowing people who had come down with Covid-19, “and seeing how bad it really was,” she says.)
Public health information about Covid-19 vaccines also has to expand beyond the boundless confines of an often inaccessible internet. Schroeder suggests pinning information to the walls of local gas stations and launching direct mail campaigns. “That’s where you might reach your audience,” she says.