When COVID-19 vaccines rolled out earlier this year, Alaska, West Virginia and several other rural states quickly jumped ahead of the pack, vaccinating residents at rates that outpaced other states.
Those less populous states outhustled bigger ones using innovative distribution schemes such as flying vaccines on small airplanes to remote areas, tapping into existing rural health systems and eschewing the county-by-county model that slowed larger states’ distribution.
During that period, Alaska’s rural doctors were hailed as heroes. In February, West Virginia Gov. Jim Justice, a Republican, crowed that his state had distributed 100% of its federal vaccine allocation. “This is a huge achievement, and I am certain that no other state can possibly be ahead of us,” he said.
That was then.
Now, Alaska, West Virginia and some other rural states, are near the bottom when it comes to the percentage of their population that’s vaccinated. And they are at the top for infection rates.
What happened? The plummet is a combination of the unsustainability of early distribution methods and less demand for vaccines among the remaining, largely rural population, experts say.
“It is certainly the case that some of the states that had early success at getting people vaccinated have … languished or plateaued. States that struggled out of the starting gate have, over time, achieved much greater success,” said Jennifer Tolbert, the Kaiser Family Foundation’s director of state health reform, in a phone interview.
“More recently, what you are coming up against are ideological issues in more conservative states,” she said. “Vaccines are available, but absent mandates and requirements for people to get vaccinated, if there is hesitation or reluctance in large sectors of the population, the vaccines are going to plateau.”
William Galston, a senior fellow in governance studies at the Brookings Institution, a nonpartisan think tank, pointed out West Virginia and Alaska solved the supply problem earlier than most other places. “But they have run up against the demand side,” he said in a phone interview.
He noted that White people without a college degree, who generally make up more of the vaccine-resistant U.S. population, are a higher share of the rural population. “I won’t say demography is destiny, but when you are looking at vaccines, it’s way up there,” he said.
In West Virginia, vaccine uptake has not just plateaued, it has plummeted.
On March 5, 12.3% of all West Virginians were fully vaccinated, making it the third-most vaccinated state and topping the U.S. average of 8.6%, a Stateline analysis of federal Centers for Disease Control and Prevention data shows.
But by mid-May, the state’s vaccination rate started slipping behind the U.S. rate and has gotten progressively worse since. Now, West Virginia has the lowest vaccination rate among the states, with 40.4% of residents fully vaccinated. The national rate is 55.8%.
The low rate frustrates Dr. Clay Marsh, vice president and executive dean for health sciences at West Virginia University, who has been designated by the governor as West Virginia’s COVID-19 czar.
Initially, he said, there was a huge demand, particularly among older adults. West Virginia has the third oldest population in the U.S., after Maine and Florida, and 90% of its over-65 population have gotten at least one shot. But younger state residents have proven more hesitant.
“As we continue to see the eligibility criteria expand, we start to see some of the hesitancy,” he said. “We are called Mountaineers for a reason: a sense of rugged individualism and an innate sense of distrust of government, medicine and science.
“The delta variant, with its high transmission capability, is feasting on people who are unvaccinated or whose vaccines have lost their potency,” he added.
Yet Justice has declined to issue statewide vaccine mandates, leaving those decisions to counties or localities.
The West Virginia Health Care Association, which represents nursing homes and assisted living facilities, he said, also has come out in favor of vaccines, and West Virginia’s large hospital systems all require staff vaccinations by Oct. 31.
But West Virginia hospitals are still struggling to care for COVID-19 cases amid more routine hospitalizations. Some of the state’s rural hospitals were at capacity early in September.
Marsh said mandates may not be what pushes the vaccine-resistant to get a jab; it’s more likely to be people getting sick and dying.
“With people dying in other people’s neighborhoods, with people getting sick, sick, sick, we’ve seen an uptick [in vaccinations],” he said.
In Alaska, where echoes of the origins of the Iditarod dog sled race—the historic “serum run” nearly 100 years ago that saved the town of Nome from a diphtheria epidemic—fueled early success in vaccinations, health officials are equally frustrated.
On March 5, Alaska topped the state rankings with a 14.6% vaccination rate among all residents, well above the U.S. average of 8.6%. But then uptake slowed significantly, despite state efforts to fly vaccines to remote villages and a notable willingness on the part of Native populations to take the shot.
Today, 50.4% of Alaskans are fully vaccinated, compared with a nationwide average of 55.8%.
“Those were good days,” recalled Dr. Anne Zink, Alaska’s chief medical officer, in a phone interview. “There were people who were very interested, and the demand was there early. It was like riding a bicycle downhill really fast trying to keep up with people who wanted it. Now, we’ve hit bottom and are climbing up very, very slowly.”
Ironically, she noted, the early vaccinations may have slowed the spread so much that people didn’t see many sick people in their towns and decided not to get a shot. But now with the delta variant, she said, that’s no longer the case.
Alaska still flies vaccines to remote locations, along with monoclonal antibodies for treating sick residents. And the state holds vaccination lotteries to try to entice the reticent to get shots. The “Give AK a Shot” lottery awards $49,000 weekly to winners. There are no statewide vaccine mandates.
Alaska’s hospitals are filling with COVID-19 patients, a trend seen across rural America. In a state where rural residents travel an average of 147 miles one way to get health care, the virus has strained the system. Rural residents often mistrust the health care system to begin with, Zink said, and misinformation on the internet and elsewhere adds to the problem.
People in rural areas, she said, don’t want to be sick, “but they have been consistently underserved by the health care system. They are smart and articulate and care about their friends and communities. But they have been susceptible to misinformation.”
The situation is the reverse in Maryland, which had significant trouble early in the vaccine rollout. The difficulties of making appointments to get a shot through cumbersome county websites led to the formation of the Maryland Senate Vaccine Oversight Workgroup, chaired by state Senate President Bill Ferguson, a Democrat.
Ferguson credits his group with pushing the state toward a better vaccine distribution system, but he wasn’t the only Marylander putting pressure on Republican Gov. Larry Hogan and state medical officials. Outraged citizens and professional medical personnel also expressed frustration. The state in March supplemented the county distribution system with a chain of mass vaccination sites.
Now, Maryland is among the top 10 states in the rate of vaccinated residents, with 64% of all residents having received at least one shot.
“For so long supply was not sufficient,” Ferguson said in a phone interview. “Then supply became sufficient, and the states that had delivery systems in place got ahead of the curve. If 60% have the vaccination, everyone you know has it, and they are asking ‘Hey, have you gotten it?’”
But there are still Marylanders who are hesitant or who flatly refuse the vaccine, he acknowledged.
Two of the three least vaccinated counties are in the far western part of the state, Garrett and Allegany counties. Both border West Virginia.
Stateline staff writer and assistant production editor Lindsey Van Ness contributed to this story.