Coronavirus in rural America (Part CXVIII): The difficulties of vaccine rollout

It’s a common sentiment amongst many news articles I’ve read this week that getting rural Americans vaccinated is much harder than getting those individuals in suburban or urban areas vaccinated. Bennett Doughty and Pamela Stewart Fahs explored this difficult issue in their piece, Why Getting Covid-19 Vaccines to Rural Americans Is Harder Than It Looks, and How to Lift the Barriers. Among the key obstacles in vaccinating rural Americans are storage, distribution, and misinformation.

The first issue has to do with storage. The first two authorized vaccines – one made by Pfizer and BioNTech and the other by Moderna – are mRNA vaccines that require storage in very cold temperatures. The Pfizer vaccine must be stored at minus 94 degrees Fahrenheit and Moderna’s at minus 4 Fahrenheit. Once thawed and prepared, the Pfizer vaccine must be used within five days and Moderna’s within 30 days. 

Unfortunately, small hospitals, which are more prevalent in rural areas, are less likely to have expensive freezers that can accommodate storing these vaccines. An article by Thomas C Ricketts, III and Paige E Heaphy puts forth a number of figures demonstrating the numbers and distributions of hospitals in rural America. I found the most telling statistic to be the following: 

Nonmetropolitan hospitals are smaller: 72% have fewer than 100 beds, and 42% have fewer than 50 beds. Twenty percent of all hospital beds are in rural hospitals. The median number of staffed beds for nonmetropolitan hospitals is 59 compared with 156 for urban hospitals, while the average number of beds per hospital is 82 and 245, respectively. Rural hospital inpatient days account for 20% of all hospital inpatient days in the United States. Medicare and Medicaid are important sources of payment for hospital patients.

Having always lived in a city or suburbia, I found it to be astounding that hospitals with fewer than 50 beds even existed. Moreover, with the influx of coronavirus patients, I can easily see how rural hospitals with these small numbers of beds would be overwhelmed with the number of patients they need to treat. 

On another note, this got me thinking: the time limit to use the vaccines, within 5 and 30 days respectively, proves to be a larger issue because rural populations are much smaller compared to their urban or suburban counterparts. I decided to do some research and came across the following Census data, where Census Bureau Director John H. Thompson noted, “Rural areas cover 97 percent of the nation’s land area but contain 19.3 percent of the population (about 60 million people).” As a result, rural areas may not have enough individuals to vaccinate within the time limit set by the FDA, thus leading to wastage of unused vaccine doses. 

This is a great 3-minute listen provided by NPR that discusses the significant challenges faced by rural hospitals to rollout mass vaccinations. 

The second issue has to do with big batches. The vaccine doses are currently being shipped in special containers with dry ice, and for now, vaccines are being delivered only in large batches. While urban areas will be able to quickly distribute these large batch doses, finding enough patients to vaccinate quickly in rural areas may be more difficult. As a result, the vaccine distribution efforts will favor hubs that cater to more populated areas to avoid wasting any vaccine or leaving patients unable to get their second dose. 

The article notes: 

The current vaccines’ cold storage requirements and shipping rules mean many rural hospitals can't serve as vaccination distribution hubs. That can leave rural residents – about 20% of the U.S. population in all – traveling long distances, if they’re able to travel at all.

The third issue has to do with difficult barriers to healthcare access. This is not a new problem in rural America. As Haider Warraich, Robert Califf and Sarah Cross discuss in their article, Beyond covid-19, rural areas face growing threat from chronic heart and lung diseases:

Rural hospital closures grab all the headlines and perhaps rightfully so. From 2010 until today, some 134 rural hospitals have closed, and a report released last spring, before the pandemic had hit many rural areas, showed a quarter of surviving rural hospitals in dire financial straits. Cancellation of routine medical care necessitated by the novel coronavirus, which causes covid-19, has pushed more hospitals off the cliff.

 The Rural Health Information Hub has also noted that:

Recent years, however, have presented challenges for rural hospitals. Factors such as low reimbursement rates, increased regulation, reduced patient volumes, and uncompensated care have caused many rural hospitals to struggle financially.” 

Rural areas have fewer health care providers that serve a more geographically diverse population than in urban or suburban communities. Moreover, in many of these areas, the closure of rural hospitals has forced individuals to travel farther for care. This got me thinking about more vulnerable populations such as the elderly and poor, which, I would imagine, have an even more difficult time traveling for care. Not only do these vulnerable populations lack access to public transportation to help them reach hospitals, at least in comparison to their urban or suburban counterparts, but at the same time, the “distance and geography, such as mountain roads, can mean driving to those sites takes time."

At a more local level, Hailey Branson-Potts notes in her article for the LA Times:

In the battle against COVID-19, health officials in Northern California face the daunting task of vaccinating more than 683,300 people spread across a mountainous, heavily forested region where calamity — either from illness or physical trauma — can mean hours-long drives to the nearest medical facility.

This further demonstrates the difficulty that rural areas across our nation face in regards to vaccinating a population that is much more spread out amongst various geographic areas. 

The fourth and last issue involves widespread suspicion and defiance. Aside from growing skepticism that the virus is a serious threat only in major towns, there is also a common fear amongst the rural community that the new vaccine is unsafe. Moreover, there has been a constant and continuous open rebellion against health orders.

As Hailey Branson-Potts discusses, “the pushback in rural parts of California is emblematic of the challenge in many parts of the United States, particularly outside more liberal urban centers.” 

"We’re getting very frustrated here in Northern California,” said Dr. Richard Wickenheiser, the Tehama County health officer. “We have a lot of anti-vaxxers and a lot of independent people who just feel that COVID was a hoax, that it was going to go away when the election was over. And that didn’t happen. ... The excuses just go on and on.” 

In Shasta County, some speakers at supervisors’ meetings have compared mask mandates to Nazis forcing Jewish people to wear a yellow Star of David and spouted conspiracy theories about vaccines containing tracking devices. The county health officer has been threatened repeatedly.

In Tehama County, where indoor dining is banned by the state, restaurants were still seating maskless customers in recent days. In downtown Red Bluff, signs in store windows read: “Please respect everyone’s personal space. ... Masks are welcome, but not required” and “Due to pre-existing health conditions, some of the staff are not wearing a face mask” and “MASKS OK."

The widespread suspicion and defiance exhibited by rural communities across Northern California are a telltale sign of the difficulties of vaccine rollout, not simply due to logistical issues, but rather of a more deeper belief system. 

This is a great podcast on the vaccine rollout in rural areas. 

Other posts on this topic are here, here, and here.