In April, a vaccination site in Trousdale County, Tennessee, administered just a handful of shots throughout the entire day. Since then, the daily pace of vaccinations has slowed even further. Rural areas across the South still have some of the lowest vaccination rates in the country. Blake Farmer/WPLN
July 4th was not the celebration President Biden had hoped for, when it comes to protecting more Americans with the coronavirus vaccine. The nation as a whole fell just short of the White House's goal, which was to give at least a first dose to 70% of adults by Independence Day.
Currently, 67% of adult Americans have gotten either the first shot of the Moderna or Pfizer vaccine, or the one-shot Johnson & Johnson vaccine. If you include teenagers age 12-17, who are now eligible for Pfizer-BioNTech, the national percentage of those who have gotten at least one shot is 64%.
But drilling down from national rates, the picture varies widely at the regional level, and from state to state.
For example, Massachusetts and most states in the Northeast reached or exceeded 70% (for adults 18 and older) in June. Tennessee and most southern states have vaccination rates between 50% and 60%, and administration rates are slowing down.
Variations in local desire for the vaccine, and in state strategies for marketing and distributing the shots, help explain the range.
In Massachusetts, for example, residents overwhelmed phone lines and appointment websites as soon as vaccines were available. The state began opening mass vaccination sites in January to meet demand. At Gillette Stadium in Foxborough, home of the New England Patriots, jumbotron screens flashed updates and speakers blasted instructions to people arriving for a shot.
When demand peaked in March, as many as 8,000 residents a day snaked through lines to a waiting syringe. Francesca Trombino delivered jab after jab at Fenway Park and then at the Hynes Convention Center in Boston for five months.
"I still hold a lot of interactions very dear to my heart," she said, reflecting on those months in late June. "I had so many people cry, just out of pure shock, just being able to feel free."
At this point, more than 82% of Massachusetts adults have received at least one shot. That number doesn't surprise many public health experts because residents generally have embraced vaccination recommendations in the past, and Massachusetts regularly registers some of the highest rates for pediatric and influenza inoculations in the country.
In Tennessee, where only 42% of adults are at least partially vaccinated against COVID-19, nurses sit waiting. In some of the state's rural counties, only 30% of residents are unvaccinated.
Although she coordinates COVID vaccinations at the federally-subsidized clinic in Linden, Tenn., nurse Kirstie Allen has not yet gotten the vaccine herself. She wants to wait a while and see more research first. In Tennessee, only 42% of adults have received at least one dose of the COVID-19 vaccine. Blake Farmer/WPLN
"Our first couple weeks we had people booked, then after that we had people start no-showing," says Kirstie Allen, who coordinates COVID vaccinations at the federally-subsidized clinic in Linden, Tenn. "We had a waiting list, the people on the waiting list didn't want to come. It's gradually just gotten worse."
Allen's down to offering doses one day a week, usually less than 10 to minimize waste of opening a new 10-dose Moderna vial.
Allen says there's still plenty of vague skepticism in her town of 1,200 people. And she, herself, can sympathize. The mother and licensed practical nurse says she's waiting for more research results to be released, and to see how everyone does over time, even though she's the one administering the shots in her community.
"I'm one of those people who are unsure at the moment about getting it," she says, adding that she wouldn't get her kids vaccinated yet either.
This wait-and-see attitude is especially common among white, rural conservatives in the South, according to many surveys in recent months. After an initial surge of interest, demand for vaccinations began waning, and states like Tennessee couldn't justify holding many mass vaccination events except in the most densely populated cities.
Having reached the 70% goal, Massachusetts adopts targeted strategy
In Massachusetts, with fewer than 20% of adults still unvaccinated, the state is closing its high-volume vaccine clinics and focusing on specific demographic groups and local communities where rates are lower.
"As these [big] sites come to their mission complete, we need to keep pushing harder into the neighborhoods," said Rodrigo Martinez, "into those locations that really need it."
Martinez is with CIC-Health, a company that moved from managing mass vaccination sites to running small outdoor clinics at supermarkets where shoppers who got a shot received a $25 gift card. That project is part of a growing effort in Massachusetts to bring vaccines to residents, especially those in low income and minority communities where the virus spread quickly and vaccination rates are still low.
Massachusetts has targeted 20 such cities including Brockton, south of Boston. It's a diverse city of essential workers who suffered during the pandemic. First-dose vaccination rates are especially low for Latinos at 39% and Blacks, 41% (although this is for all ages, not just adults).
This hyperlocal approach was on display in Brockton on a Sunday in late June, where the city, with assistance from the state, hosted a mobile vaccine clinic at a popular park. A big yellow touring bus, retrofitted to hold vaccination stations, idled near tents offering free food, music, legal advice for immigrants and health insurance enrollment assistance.
"Bienvenue! Welcome!" shouted Isabel Lopez, a state funded vaccine ambassador, as she moved from one cluster of families to another, urging them to go grab a free hamburger, hot dog — and a vaccine.
"We are here, bringing the communities together, to make this a fun day and also a creative way to get people vaccinated," Lopez said.
Near the soccer field, Lopez scored a big win. She persuaded five hesitant members of one household to go to the bus, and at least talk with a nurse there. A half hour later, all five had received their first shot.
Lenin Gomez said afterwards that he had doubts about the vaccine, but was persuaded when the nurse stressed the need to protect the children living in Gomez's home.
"If I'm not fully protected, who will take care of the little ones?" Gomez said. "That's what opened my mind to getting vaccinated."
When Gomez gets his second dose in a few weeks, he can enter himself in a statewide lottery that will give away five $1 million dollar prizes for anyone who's vaccinated. Massachusetts Governor Charlie Baker says he hopes these jackpots will entice hesitant residents to roll up their sleeves.
No lottory-like incentives where needed most
In the states that need boosts like that the most, there's little interest in creative financial incentives. Tennessee has no plans. In Alabama, the NAACP funded a recent drawing for $1,000 prizes aimed at young people.
Overall, the daily vaccination rate across the south has slowed down, worrying health officials who are watching the explosive growth and spread of the delta variant in several parts of the U.S. But some southern residents continue to come around to the idea. In Lobelville, Tenn., 57-year-old Laurel Grant was initially hesitant to get the shot, because she was worried about possible side effects.
In Lobelville, Tenn., Laurel Grant was initially hesitant to get the shot. But after seeing friends and relatives get vaccinated, with minimal or no side effects, she got her own shot in June. It also helped that Grant's employer, a Pilot Flying J truck stop, offered $75 to employees who got fully vaccinated. Blake Farmer/WPLN
"But everybody I know has done real good, just maybe a little fever or a little tiredness," she says.
So Grant finally got her own shot in June, at a local pharmacy. It helped that the Pilot Flying J truck stop where she works offered a $75 bonus to employees who got fully vaccinated.
"There's a few down there at work who are like, 'I'm not going to get it,'" Grant says, "I'm like, 'Yes, you are. You gotta go, like it or not.'"
Converts like Grant are being seen as the best kind of evangelist for this next phase of vaccinating latecomers. Tennessee's health department has started taping video testimonials to release online.
But the marketing efforts are also beginning to annoy some Republican state lawmakers convinced the state is actually trying too hard. They're especially concerned about kids.
A recent hearing in the Tennessee state legislature included threats of disbanding Tennessee's health department. State Rep. Iris Rudder, along with some other GOP lawmakers, brandished printouts of social media ads produced by state health officials. They featured smiling kids with bandaids on their shoulders.
"It's not your business to target children. It's your business to inform the parent that their child is eligible for the vaccination," she told health department officials at the hearing in June. "So I would encourage you, before our next meeting, to get things like this off your website."
This criticism was mostly directed at the state's health commissioner, Dr. Lisa Piercey, who responded at the hearing by saying the state is not "whispering to kids" or trying to get them vaccinated behind the backs of their parents. She says she's not going to back off when it comes to vaccination outreach.
But Piercy also doesn't think the risk level in Tennessee is as dire as the low vaccination rates suggest. Tennessee had a huge surge of COVID illness during the winter. That meant there are at least 850,000 people — based on positive test results — who are walking around with some level of natural immunity. Piercey says those residents are partially compensating for low vaccination rates.
"Yes, I want everybody who wants a vaccine to get it," she says. "But what I really want at the end of the day is for this pandemic to go away. I want to minimize cases and eliminate hospitalizations and deaths, and we're pretty close to getting there."
But the outlook is less rosy in neighboring Arkansas. The state escaped the worst of the winter outbreaks. Now it's trying to stop flare ups of illness caused by the more contagious delta variant. Governor Asa Hutchinson told CBS's Face the Nation that if nothing else will inspire southerners to get vaccinated, "reality will."
This story comes from NPR's health reporting partnership with WBUR, Nashville Public Radio, and Kaiser Health News (KHN).
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