Mass vaccination against covid will be a challenge for Alabama and other poor, rural states
The lone doctor at his clinic in Marion, the county seat, Lee watched his two nurse practitioners leave during the pandemic in search of less grueling work. An X-ray technician also quit.
“I will take the first vaccine that hits the street,” he said.
Lee is among the Americans expected to have priority access to a coronavirus vaccine that could become available as soon as next month. But as for when the vaccine will reach Perry County — and whether the rest of the community will agree to take it — the doctor would not hazard a guess.
Under its Operation Warp Speed initiative, the Trump administration has promised simultaneous distribution of vaccines to “all of America.” The soaring ambition, however, is set to run headlong into the barriers to health care and mistrust of speedily developed vaccines that mark Perry County and other rural, impoverished parts of America. Residents of these places are especially vulnerable to the virus because of their poor health status and often precarious employment in low-wage service industries. Responsibility for their inoculation, meanwhile, will fall to a public health system maimed by budget cuts and riven by racial and other inequities. The day-to-day delivery of shots, without reinforcements, will play out at understaffed clinics, overwhelmed pharmacies and beleaguered long-term care facilities.
“Administering a vaccine in rural Alabama is not about pulling up to a Walmart parking lot,” said John McGuinness, a member of the committee advising the state on vaccine distribution and a former state surgeon for the Alabama National Guard. “This amounts to a military campaign, moving from town to town and gathering demographics, relying on local leaders and being comprehensive in that way.”
Some of the steepest obstacles involve doubt about scientific advances championed in Washington.
Distrust of the medical establishment permeates the state’s Black community, nearly a half-century after the revelation that syphilis patients in Tuskegee, Ala., were deceived and had treatment withheld to study the natural course of the disease. The so-called Tuskegee experiment casts a long shadow.
“That still haunts us today,” said Benard Simelton, president of the Alabama State Conference of the NAACP.
Also threatening participation is the “unprecedented head wind of disinformation about the virus itself,” said Jim Carnes, policy director for Alabama Arise, an advocacy group for low-income residents. The swirl of falsehoods, Cares said, has led many of President Trump’s backers to disregard medical guidance. “How are you going to get people to take a vaccine to fight a virus they don’t believe in?” he said.
Lee shares these worries. Herd immunity is a long way off in Perry County, he said, explaining, “I have to browbeat people just to take the flu vaccine.”
The logistical hurdles are just as concerning to the doctor. Shots that require ultracold storage, a specification of the Pfizer vaccine, are “not practical” in rural areas without big hospitals, he said. Drive-up vaccination sites are also not realistic, he noted, because more than 16 percent of households in his county have no vehicle.
“There are so many logistical issues that they, in total, are mind-blowing,” said Scott Harris, Alabama’s top health officer, who is overseeing the state’s immunization effort and who has won plaudits for his management of a crisis pitting political loyalties against adherence to health guidelines.
Many of Alabama’s obstacles, from rural access to racial disparities, are mirrored across the country, said David Kimberlin, a pediatric infectious-disease specialist at the University of Alabama at Birmingham. That makes the planning underway in Alabama a window into the problems also vexing other states.
“Our challenges are not unique to us — we are a relatively rural state, and we are in a part of the country where, generally speaking, people don’t like to be told what to do,” said Kimberlin, who is the American Academy of Pediatrics’s liaison to the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices, the body charged with making recommendations on who should get the vaccine first.
The first allotment is unlikely to be sufficient to cover all health-care workers in the highest priority group, said Burnestine P. Taylor, the state medical officer leading Alabama’s vaccine-related planning. Who should be included in that group is still being worked out. Even within a hospital, there may be different degrees of risk, officials said, a recognition that ICU nurses or respiratory therapists involved in intubating patients face more direct and extended exposure than do other staff, who may nonetheless be at risk in common settings. A CDC team was in Alabama this month helping the health department refine its criteria.
To make the most of the limited resources, the state is relying on software developed by a California company to map anticipated demand in each county and compare the location of health-care workers with the layout of facilities equipped to handle the shots. “Strike teams” set up by the health department may help with delivery in locations where medical infrastructure is limited, Taylor said.
Drawing up that battle plan has been difficult. Information technology challenges delayed the state’s efforts to enroll medical providers capable of receiving and storing the vaccine, Harris said. The federal government asked each state to identify five locations where shots will be propositioned, pending final go-ahead from authorities. These are mostly large hospitals, such as the University of Alabama at Birmingham’s flagship facility.
The primary locations put forward by Alabama officials are among a larger set of 68 facilities equipped to store ultracold vaccines, said Jamey Durham, the health department’s logistics lead for vaccine implementation. These are the facilities poised to become vaccination sites following the initial allotment, he said.
“In more rural areas, this means bringing the vials to a central location and having the public come to the vaccine as much as possible,” Durham said.
After the initial rollout, staff at smaller clinics will have their crack at the vaccine, said Ryan Kelly, executive director of the Alabama Rural Health Association. When distribution expands beyond health-care workers, the onus will shift from hospitals and other organizations largely inoculating their own staff to a wider range of sites, from sports arenas to school parking lots, for community immunization.
Minority groups are among the “critical populations” the CDC is directing states to consider in the planned allotment of vaccines when they’re still in short supply, later this year or in early 2021. The timing gives added salience to efforts aimed at addressing vaccine hesitancy among people of color.
Focus groups across Alabama, set to begin next month, will probe deeper into concerns about the vaccine, particularly among Black residents, who remain disproportionately affected by infections, said Mona Fouad, director of the University of Alabama at Birmingham’s Minority Health and Health Disparities Research Center. The results will inform promotional messaging and are likely to highlight the need to involve Black community leaders in the endorsement of the vaccine, in addition to White physicians like Lee.
The most important factor is that Trump stays away from the vaccine rollout, said the NAACP’s Simelton. “If he comes out and says, ‘It’s approved; it’s a good drug,’ no one’s going to take it,” Simelton said, noting that Black Alabamians are so distrustful of the president that many refused to believe he had actually contracted the coronavirus.
If the Food and Drug Administration, “without his interference,” gives the go-ahead, Simelton said, “they would be a lot less skeptical.”
For Lee’s patients, advice will come from a more local authority — what he refers to wryly as the “Perry County medical association” on which he is joined by the town’s pharmacist and veterinarian. Lee has questions about the monitoring of side effects, but such considerations are not delaying his preparations for the day he can begin inoculating his community.
“We can’t say for this or that reason that we don’t want to fool with it,” he said. “We’ve got to fool with it.”