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The coronavirus might not be the worst of it
The Washington PostDemocracy Dies in Darkness

Rural Maryland and Virginia counties were once ahead in vaccinations. Not anymore.

Signs in a shopping mall in Tysons Corner direct people to a vaccination site. (Bill O’Leary/The Washington Post)
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The early leaders in the vaccination race have stumbled. And those who were lagging behind are surging ahead — for now.

What started as a trickle of coronavirus vaccine doses in Maryland, Virginia and the District four months ago has grown into a steady stream of 150,000 shots daily, administered at pharmacies, doctor’s offices and mass vaccination sites. Stark racial gaps have narrowed, though not consistently. And rural counties that once led the region in vaccination rates are starting to run out of willing customers, while demand continues in some of their more densely populated neighbors.

At the end of January, rural counties in Maryland were administering a daily average of about 455 shots per 100,000 adults, compared with about 360 shots in Baltimore County, Montgomery County and other populous jurisdictions. The strong start appeared to defy early polling suggesting that Republicans in rural areas would be among the least likely to get vaccinated.

But it did not last.

By March, urban and suburban counties had started to overtake rural areas in both vaccination rates and percent of population vaccinated. As of mid-April, densely populated counties in Maryland were giving out 800 doses per 100,000 adults, compared with 615 in rural localities. Similarly, in Virginia, rural counties reported an early sprint in vaccinations but fell behind in March.

The rural-suburban shift has helped to bridge racial disparities in vaccinations, though the data is not complete and the changes are not consistent.

In Maryland, state data suggests that the gaps have closed more significantly between Black and White residents than between Latino and White residents. In Virginia, the reverse appears true, though there is a large share of vaccinations — 44 percent — for which no race information is reported.

Across the greater Washington region, majority-Black counties have started to report a higher daily rate of vaccinations, though Black residents are still underrepresented in overall vaccination numbers. In the District, which is nearly half Black, only 36 percent of fully or partially vaccinated individuals for whom race data has been reported are African American.

U.S. coronavirus cases drop as spring wave of infections ebbs

Collectively, experts say, these geographic and demographic trends illustrate how the greater Washington region will have to shift tactics in coming months to attain herd immunity — the point at which, with at least 70 percent of the population vaccinated, the number of coronavirus cases decreases so that it is no longer a significant threat.

Already, government officials are preparing for the waning demand emerging in rural areas to spread to more populated areas. The mass vaccination sites and preregistration lists being used to push out large volumes of the vaccine will soon be retired, health officers say, replaced with walk-up sites or mobile clinics.

“What’s happening in rural settings could very well be a bellwether,” said Lauren Hughes, an associate professor at the University of Colorado who studies rural health systems. How governments improve access, combat misinformation and shed hesitancy in the countryside — and how residents respond — could help shape the playbook for cities and suburbs.

In mountainous southwest Virginia, a remarkable early lead in vaccinations came to an abrupt stop when eligibility expanded to all residents above 16, said Karen Shelton, the health director for 16 counties in the region. “All of a sudden, when Phase 2 opened, boom — it was like no one wanted it anymore,” she said. “We’ve had to turn very quickly to looking at access.”

Bob Stephens, health officer for Garrett County, said the drop in demand also came earlier and more suddenly than expected in his rural community in Western Maryland. “The ground game now is to get it out to people who are hard to reach,” he said.

Even in populous, wealthy suburbs where people are still clamoring for shots, officials say they’re preparing for ways to reach the leery and the underserved. “We’re not just waiting around,” said Travis Gayles, health officer for Maryland’s Montgomery County. “We’re proactively preparing for that inflection point.”

Public health experts warn against reducing the outstanding challenges simply to hesitancy in particular demographic groups, such as White evangelicals, supporters of former president Donald Trump, or Black and Latino residents. In both rural and more urban settings, they say, access barriers and long-standing gaps in health infrastructure are major factors to consider in boosting turnout.

“It’s always a combination,” said Beth O’Connor, executive director for the Virginia Rural Health Association. “If you have any sort of hesitancy, the barriers you have are going to seem bigger. And if you have barriers, your hesitancy serves as a good excuse. You can’t separate these issues.”

Resources and politics

In mid-February, four of the top five Maryland counties ranked by percent of population vaccinated were rural. One was Garrett, spread across the Allegheny Mountains with a population of 29,000 that is 97 percent White. At the time, majority-Black, densely populated Prince George’s County trailed in last place, two spots behind Baltimore City.

Two months on, Garrett has since slipped to sixth-lowest among Maryland’s 24 jurisdictions, with about 35 percent of its population at least partially vaccinated, compared with 46 percent statewide. It sits behind both Prince George’s and Baltimore, which have climbed to eighth-lowest and 10th-lowest, respectively. Thirty-seven percent of Prince George’s and 38 percent of Baltimore have received at least one shot.

The change is in part because in the early months, the state set a floor of at least 300 doses per county, which gave places such as Garrett more doses per capita than more populous jurisdictions. As overall supply increased, allocations evened out.

But the dramatic slowdown in sparsely populated areas, local officials say, is also partly due to misinformation, income inequities and, in some cases, government missteps.

When the state decided to establish a mass vaccination site for Western Maryland, for example, it picked the Hagerstown Premium Outlets, which is about a 90-minute drive from D.C. but a two-hour drive from Garrett. In the site’s first week, state officials set aside 250 doses for Garrett residents, but only seven people from the county came. As of Wednesday, less than 1 percent of all doses administered at the Hagerstown site have gone to Garrett residents. Nearly 40 percent have been administered to residents of Montgomery, the state’s largest jurisdiction and one of its wealthiest, with 1 million residents who share a median household income of $108,000.

Garrett, where the median household income is $52,000, has many residents who lack the broadband to make online appointments or cannot afford the time or the gas to travel far for their shots, said Stephens, the health officer. In contrast, tens of thousands of Montgomery residents have been both eager and able to drive across the state for their vaccinations. Of the 322,926 Marylanders who have been fully vaccinated at the state’s mass sites, 27 percent come from Montgomery, which accounts for about 17 percent of the state’s population.

“It’s not so much that the person is in a rural setting,” Stephens said. “It’s that they are in a rural setting and don’t have resources.”

As of April, more than half of Montgomery residents are fully or partially vaccinated — one of the best rates in the region. Gayles, the county’s health officer, said the county was able to scale up vaccination efforts while closing racial gaps by setting up an equity framework in January, two months before Maryland’s statewide vaccine equity task force unveiled its operation plan. Local, state and federal lawmakers from the powerful suburb successfully lobbied for more doses and a mass site, while nine county agencies worked to provide targeted outreach to minority communities, including specialized clinics and multilingual town halls.

“Certainly, we do have a high amount of resources that we’ve been able to utilize,” Gayles said.

Montgomery also has a highly educated, science-literate and liberal population where demand remains strong, said Earl Stoddard, the head of emergency management. Even with most residents vaccinated, there are about 40,000 people on the county’s preregistration list waiting to be invited for appointments.

In Garrett, where residents voted overwhelmingly for Trump in November, vaccine resistance is more widespread, officials say. Some people are worried about safety, others cite religious reasons or a fear of needles. Many are swayed by misinformation they see online.

“We’re a very conservative, very religious county, and that has something to do with it,” said Paul Edwards, the Republican chair of the Garrett County Board of Commissioners. He has been vaccinated and hopes more residents will get the shot but said ultimately it’s a “personal choice.”

“I’m not in the business of telling people how to think,” Edwards said.

Misinformation and reluctance

Some counties, such as Somerset County on Maryland’s Eastern Shore, have struggled with the vaccine rollout from the start.

With 25,000 residents spread across an area nine times the size of D.C., including a significant Black population, challenges have been multifold, said Craig Mathies Sr. (D), the president of the Board of County Commissioners. Since late March, the county has had the smallest percentage of its population vaccinated in Maryland.

Mathies, who is Black, said it has been hard to engage both the “hardheaded skeptics” from minority communities and the “know-it-alls” influenced by conservative media despite specific state interventions.

“It’s sad in a way because the motto of the county is ‘semper eadem,’ which means always the same,” he said. “People and their mind-sets here can really be reluctant to change.”

Dimitri Cavathas, chief executive of the Lower Shore Clinic, said he is also on a mission to change the “hearts and minds” of locals, starting with his own employees. The clinic, which serves Wicomico, Somerset and Dorchester counties, has offered vaccines to its 155 staff members on three separate occasions; 40 percent have declined.

The hesitancy “is much higher than I thought it would be,” Cavathas said, noting that his staff saw the impact of covid-19 firsthand. Misinformation and conspiracy theories on Facebook and YouTube have taken a heavy toll, he added.

Lori H. Deel (R), vice chair of the Board of Supervisors in conservative Smyth County, Va., told a similar story.

Located near the border with North Carolina, Smyth in February had nearly twice as much of its population vaccinated than the crowded suburbs in Northern Virginia. People lined up to get their shots, and a local paper touted the success of its rollout. Two months later, 34 percent of Smyth’s 30,000 residents have gotten at least one dose, compared with 38 percent statewide and 43 percent in populous Fairfax County.

“There’s so much information out there right now, people aren’t sure who to trust,” Deel said. “Do they listen to the CDC or to their neighbor who they know and trust? Our political climate doesn’t make it easy.”

Shelton, the rural Virginia health director, said officials knew the early surge in vaccine-takers would eventually abate, but “how quickly it happened was a surprise.” Mobile clinics, targeted ad campaigns and more doses for primary care physicians should help, she said. Still, a lot also hinges on individual community leaders getting the shot and telling others to do the same.

Tara Kirk Sell, an assistant professor at Johns Hopkins University who studies health misinformation, said governments have been effective in communicating with residents who have taken the pandemic seriously, but less so with those who doubt the severity of the crisis.

“The reason why a piece of misinformation sticks with people is because it really resonates with their worldview,” she said, citing the idea in some rural communities that urban elites are against them. To change minds, Sell said, officials have to craft messages that tap into the “shared values” of each community.

But some experts, like O’Connor from the Virginia Rural Health Association, say the government should work to improve access to doses before fretting too much over hesitancy.

“We tend to make a lot of assumptions about what rural people will or won’t do,” she said, echoing what advocates said about Black residents earlier in the vaccine rollout. “But really, when you take down the barriers, the differences won’t be that big.”

Dan Keating contributed to this report.

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