Politico

Vaccine-skeptical Trump country poses challenge to immunization push


The Biden administration can finally ship large quantities of coronavirus shots into the American heartland, where health officials are encountering a reservoir of vaccine skepticism among rural Americans who’ve adopted former President Donald Trump’s denial of a virus battering their communities.

If a critical mass of people don’t accept Covid-19 vaccines, the country won’t achieve “herd immunity.” When there was just a trickle of vaccines, hesitancy didn’t matter as much because plenty of people were clamoring for the scarce shots. Now that the supply is ramping up, the challenge is to overcome fear, distrust and outright antagonism to the new vaccines shared by some groups in large numbers. That’s the path to save lives, slow the emergence of new virus variants, end the stress on the health care system and restore the economy.

“We’ve got fairly good trust — but there’s a block of the community, or the population, who thinks that this is a hoax, that it’s to exert control to limit people’s freedom,” said Mike Holmes, who for over 40 years has been CEO of Scenic Rivers Health Services in one of the most rural regions of Minnesota. “That’s a hard group to convince.”

Because the pandemic hit Black and brown communities so hard — at the same time as a broad and disruptive American awakening over race — much of the focus has been on getting the shots to minority communities and addressing their long distrust of a health care system that at times has ignored and abused them. But polls have found that some of the deepest opposition to vaccines is among rural whites and Republicans, including some who say the risk of Covid-19 has been exaggerated. One coalition of health groups and nonprofits has even engaged a prominent GOP pollster and wordsmith to help them break through with pro-vaccine messages.

But the damage from months of mixed messaging about the virus’s severity, whether from Trump world or social media, has been done, say public health experts and health care workers administering shots in rural America.

“There’s been a lot of politicization about the response, a lot of misinformation,” said Adriane Casalotti, chief of government and public affairs at the National Association of County and City Health Officials.

One thing President Joe Biden and his coronavirus team have going for them: The nation’s governors, some of whom have politicized masks and defied public health guidance on reopening businesses, have been solidly united on vaccines as the single most important way to get the country back to normal. White House senior coronavirus adviser Andy Slavitt recently praised governors of both parties who have been “very public” about their own vaccinations — though he deflected a question about whether the Biden administration would ask for Trump’s help to address vaccine hesitancy among his supporters.

Of course, rural America isn’t monolithic — it isn’t all white, Republican and poor. It’s found in pockets of the bluest states, as well as vast stretches of the red ones. But reaching the most vaccine skeptical in those communities — which polls regularly find are white, Republican and under 50 — will be a messaging challenge that helps determine the pandemic’s trajectory in the coming weeks and months.

Rural hospital closures and higher uninsurance rates, particularly in the dozen conservative states that did not expand Medicaid under Obamacare, leaves more low-income people without a regular place for medical care, without a doctor or nurse that knows them, who they trust. That trusted voice is often the one most able to cut through the noise around vaccines.

“They have less reliable access to health care, and they tend to be under vaccinated,” even for routine illnesses like flu, said Nancy Berlinger, a bioethicist at the Hastings Center.

Not all vaccine fears are identical. People who are worried about side effects for instance — a common theme — can be reassured, and there are already signs that such apprehension is dissipating as they watch friends and family get vaccinated without injury. But people who just don’t believe that the virus is a threat, or who viscerally oppose all vaccines, are a lot tougher. Others may be inclined to get vaccinated but aren’t willing to travel long distances for it.

“Vaccine hesitancy comes in a whole lot of different flavors,” said Alabama’s top health official, Scott Harris. His team is currently focused on the historically underserved rural “Black Belt” counties in southern Alabama but is planning a broader multi-media campaign aimed at building confidence in all demographic groups.

Other conservative states are also targeting their outreach. North Dakota, which got off to a strong start vaccinating nursing homes, in addition to the usual public service announcements is sending letters to the 62,000 residents age 65 and over who haven’t already received their first dose, said a spokesperson for Gov. Doug Burgum.

Given the high degree of hesitancy among Republicans and rural Americans, a coalition of health groups and foundations turned to Frank Luntz, a prominent GOP pollster and message crafter. He found that lecturing, shaming or even appealing to abstract notions of doing what’s right doesn’t change minds. What resonated is emphasizing how vaccines can make people and their loved ones safe — and how it can help life return to normal.

“Family is by far the most powerful motivator for vaccine acceptance,” Luntz reported. “Significantly more Americans said they’d be most willing to take the vaccine for their family as opposed to ‘your country,’ ‘the economy,’ ‘your community,’ or ‘your friends.’” (He also found a very pronounced preference for the word “vaccine” over “jab.”)

Military veterans provide one glimpse into the challenge. The Department of Veterans Affairs has been delivering shots almost as fast as it can get them but has struggled to connect with rural vets.

As of mid-February, the department had vaccinated some 29 percent of white veterans, but only 4.8 percent of those in rural areas. The low take-up can partly be explained by logistical issues around transporting and storing the first two authorized vaccines, which must be kept extremely cold, but the department is also trying to change attitudes toward the shot. The VA plans to convene focus groups and partner with veterans service organizations to get the word out.

“We’re trying to deliberately message around that,” VA Secretary Denis McDonough told reporters recently.

Vaccine opinion doesn’t fall squarely into two camps — “hell yes” or “hell no.” There’s a large group in the middle either nervous or unsure about vaccinations, but not irrevocably opposed. That’s who public health messengers believe they can reach – and need to reach in larger numbers for the immunization drive to succeed, said Mollyann Brodie, an executive vice president of the Kaiser Family Foundation who oversees its polling.

Kaiser’s most recent survey last month detected an encouraging shift out of the “wait and see” group. Those reporting they were “eager” to get vaccinated had risen to 55 percent, up from 34 percent from December.

But there was scant movement among the hard-line “no” groups. For instance, the share of Republicans who said they would not get a shot under any circumstances, or only if forced to for work, dipped ever so slightly, from 24 percent to 22.

That represents a challenge to reaching herd immunity, which experts project will happen when 70 to 85 percent of the population is vaccinated.

Rural clinics have also had practical barriers. Shots from Pfizer and Moderna are harder to ship and store than most traditional vaccines, and they aren’t well-suited to small rural communities. The newest shot, from Johnson & Johnson, is easier to handle and is the first to require just one dose, so it may be a boon to rural areas and places where people must travel long distances to get inoculated. The downside is that the J&J shot may be perceived as less desirable than Pfizer and Moderna, which had higher overall efficacy rates in clinical trials. However, health officials have tried to emphasize that J&J gives excellent protection against hospitalization and death from Covid-19.

No matter what kind of outreach government and health departments conduct on vaccines, health care providers said they recognized the personal relationships they forge with patients is one of the best ways to ease people’s vaccination fears. However, that’s not always easy for many of the uninsured or underinsured.

“We do a lot of talking,” said Beth Ann Wilmore, director of nursing at Mercy Community Healthcare, which runs clinics south of Nashville, Tenn., serving diverse populations of low-income patients. “I educated myself and the team and our providers and nurses on what the vaccine is, and why we’re giving it, and what it does,” added Wilmore, who said she was initially nervous about taking a brand new vaccine. But she now uses the experience to calm patients, who recently included a frightened young woman who came in for the vaccine she needed to work safely in her education job.

At the Scenic Rivers in rural Minnesota, it’s all proactive. Holmes, the longtime CEO, said staff is calling all eligible patients to make appointments, reinforcing efforts to build trust — and avoiding the pitfalls of spotty internet on the state’s Iron Range.

Melody Weaver, president of the Idaho Rural Health Association and a family nurse practitioner, has also had to calmly correct misinformation about supposed hazards of the vaccines.

“We see vaccination hesitancy with the flu vaccine every year — every year,” she said. “And with the virus — because of the enormity of this pandemic, and the mixed messaging and the politicization… you end up with trust issues.”

Despite that, more people turned out for the flu vaccine this year. That, she said, is a promising sign.

Darius Tahir contributed reporting

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