WASHINGTON — Each Friday afternoon for more than two months, the staff at the Heart of Texas Healthcare System in the rural town of Brady, Texas, have rehearsed what they will do when their first doses of Covid-19 vaccine arrive.
They have the space at the town civic center ready to go, a plan for how they will let the public know when they can sign up for an appointment and staff trained to dole out the shots. Yet each week they put in their request for 500 doses from the state — and each week, just as with other rural hospitals across West Texas, the doses never arrive.
“We have been ready for two months. The only missing piece in the equation is the vaccine,” Tim Jones, CEO of Heart of Texas Healthcare System — the only hospital serving a four-county region two hours west of Austin — said last week. “This story is ubiquitous with every little town of 2,500 to 5,000 people. From Amarillo to Brownsville, it is a carbon copy.”
President Joe Biden has emphasized getting the Covid-19 vaccine to those most affected by the pandemic, with a focus on racial and ethnic minority groups, such as Blacks and Latinos, who have been dying at higher rates than whites and have thus far been less likely to receive the vaccination. But in that push, some rural health care providers say they are being left behind, with many of the steps the White House has taken so far disproportionally benefiting urban areas and not the unique challenges rural areas have been struggling with.
“There needs to be some initiative to get vaccines out to those communities and an acknowledgement that we need to not forget about those rural underserved areas,” said Bill Finerfrock, executive director of the National Association of Rural Health Clinics. “Our concern is that it doesn’t seem to be part of the conversation.”
Rural states have been some of the hardest-hit by the pandemic: The death rate for rural areas was 48 percent higher in December than that of urban areas, according to a study by the Agriculture Department. In North Dakota, about 1 in 500 residents have died from the virus.
Rural areas have borne a greater brunt from the virus in part because they tend to have older populations and a high prevalence of underlying medical conditions, the Agriculture Department report found. People in rural areas may also be more vulnerable because of a lack of nearby medical care or health insurance.
With demand for the vaccine far outstripping the supply, health care providers across the country have complained about a lack of shots for their patients. Biden has said the federal government is working as fast as it can to get the vaccine to all Americans and has pledged to have enough vaccines for every American by the end of May.
“I don’t think their concerns are unique to only rural communities. Everyone feels like we could be doing more,” an administration official said. “The federal government is trying to do as much as we can with the capacity we have.”
But with several months to go until there are enough vaccines to go around, the administration has decided to focus on getting the shots to populations they have identified as most at risk of getting severely ill and dying of the virus.
To make the determination about where to set up mass vaccination centers and which retail pharmacies should get the vaccine, the White House has been using the Centers for Disease Control and Prevention’s social vulnerability index, which measures how susceptible a community is by looking at metrics like poverty, lack of vehicle access and crowded housing. Rural health providers, though, say those metrics often overlook the unique needs of rural areas.
Along with the mass vaccination centers and the retail pharmacies, the Biden administration has also been shipping doses directly to federally funded community clinics, which serve 1 in 5 rural residents. For now, though, it is focused on getting the doses to clinics primarily serving homeless people, public housing residents, migrant agricultural workers and people with limited English language skills, an administration official said. About a third of vaccine doses that have been sent through that federal program have gone to rural clinics.
“The goal of the federal program was to ensure that underserved communities and those affected are equitably vaccinated,” the official said.
The official also pointed to efforts made to vaccinate tribal groups in rural areas: The Indian Health Service, they said, has distributed more than 1.1 million doses of the vaccine to some of the most remote regions of the U.S., including 189,000 doses to the Navajo Nation, which covers 27,000 square miles of rural Utah, Arizona and New Mexico.
The Biden administration has talked about deploying mobile vaccination units to rural areas, but so far the effort hasn’t been fully rolled out. Rural providers said they were hoping they would get a large share of the single-dose Johnson & Johnson vaccine, which doesn’t require the special refrigeration capacity many rural clinics lack. But White House officials said last week it will be distributing that vaccine evenly across the country and not targeting it at any specific areas.
“This vaccine distribution isn’t equitable when it comes to urban and rural, that is the perception,” said Alan Morgan, chief executive officer for the National Rural Health Association. “These communities are also most at risk. There are hundreds of these small towns with a greater percentage of elderly, people with multiple chronic health issues and chronic workforce shortages. Some of these communities aren’t adhering to public health measures like wearing masks, and now you have an unequal distribution of vaccines. What more could possibly go wrong here? It is the worst possible public health setup.”
Morgan said he and other officials representing rural organizations met with the White House Covid-19 response team earlier this month to discuss their concerns. They would like to see action by the federal government to increase the number of doses sent to rural areas, along with help to address both the shortage of health care workers to administer the vaccination and the needs of older populations who lack the ability to travel far distances and have limited access to the internet.
In most rural areas, the demand for the vaccine is outstripping the supply — though there are signs of early vaccine hesitancy affecting the stock as well. Dozens of appointments at CVS stores in rural parts of Alabama and Louisiana went unfilled on Tuesday, while the appointments in other states were quickly booked.
At mass vaccination clinics in rural parts of Missouri last month, thousands of doses went unused, causing city dwellers to accuse the governor of prioritizing rural areas over urban ones, according to local media reports. State officials blamed the issue on allocating doses based on total population rather than the number of people eligible in that area.
Only about 31 percent of rural residents said they would definitely be getting the vaccination, compared with 43 percent of suburban and 42 percent of urban residents, according to a survey by the Kaiser Family Foundation.
While hospitals like the one in Brady, Texas, are struggling to get their first doses of the vaccine for their patients, some in other parts of the country are struggling with the demands of administering the shots.
At Allen Parish Hospital in Kinder, Louisiana, which serves a population of around 25,000 people, they have been giving 400 shots a week, but it’s a pace that is straining its staff and its budget, said CEO Jackie Reviel.
With a shortage of health care workers in rural areas prior to the pandemic, the hospital hasn’t been able to bring on additional personnel to administer the shots and finding volunteers, like retired nurses, has been difficult, Reviel said. As a result, the hospital has had to take employees away from providing other patient care to give out the vaccinations three days a week and is using money it received from the last Covid-19 relief bill to pay for overtime.
“It's becoming a stretch. We just don’t have enough people to give out vaccine for all the people who want to get the vaccine,” Reviel said, who said the hospital has a running waitlist of around 200 people.
The federal government has deployed 2,225 employees and 1,200 National Guard troops to vaccination sites to help administer shots. But neither Morgan nor Finerfrock were aware of any rural clinics that had welcomed federal personnel. All of the 730 U.S. Army soldiers deployed across the U.S. to help with vaccinations have gone to urban areas, including Dallas, Miami and Orlando, Florida, according to a breakdown by the Pentagon.
When Reviel asked the state for National Guard help, she was told the troops were tied up transporting vaccines around the state.
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Her hospital has also had to grapple with the logistical challenges posed by the storage of the Pfizer vaccine. By the time the hospital receives its weekly shipment on Wednesday, it has already started to thaw — so they have until Saturday to get the shots into arms.
When about 100 people didn’t show up for their appointment for a second dose recently, the hospital put out an urgent message on Facebook telling anyone who wanted a vaccination to come and get one.
These are problems Jones says he wishes he had in Brady. He said there is easily enough demand in his community to give out as many as 1,500 shots immediately, and his hospital feels it has the manpower to do so.
For the time being, if his patients want the vaccination, they need to make a 150-mile round trip drive to the nearest mass vaccination center for their first and second doses. That’s too far a distance for many of his older patients to travel on their own.
"We want to be able to help that farmer out in Menard," Jones said. "We are there to help, and we aren’t helping. We feel guilty."