By Natalie Eilbert
Medill Reports

From above, the roads in Walnut, Kansas, intersect into the green and gray geometry typical of so many rural towns in Middle America. Main Street, the major town artery, offers a bar, a bank, the fire department and a post office.

In January, the Crawford County Health Department announced on its Facebook page that a mobile COVID-19 testing unit would be parked in front of His and Hers Bar to administer testing between 9:30 a.m. and 11:30 a.m. the next day.

This was the last direct contact the County Health Department has made with Walnut, at least through Facebook — although a contact phone number exists on the page for health-related inquiries. With a population of just 186 people in Walnut and equally tiny populations in other small towns in the area, the county health department must triage the frequency of where their testing units go. For the people of Walnut and other poor, rural communities, this means that, when it comes to vaccine distribution, residents face more steps and many additional challenges to get vaccinated.

The sprawling farmlands of America hit several roadblocks in the race to the vaccine. Unprecedented winter storms halted vaccine delivery in even the bigger Midwestern cities such as Chicago and Minneapolis. But climate change-driven weather patterns only paint some of the picture in the story of vaccine distribution. A recent lack of vaccine supply and a dearth of vaccine education for the people living in poor and rural communities, compounded by bitter partisan sentiments, have emphasized the sense of being abandoned by the country at large.

A lack of coordination

Canese Jarboe, 30, returned to their hometown of Walnut, Kansas, to assist on their parents’ family farm and help with general upkeep in anticipation of their father’s upcoming back surgery. A year into pursuing a Ph.D. in English and creative writing at the University of Wisconsin–Milwaukee, they straddled polar opposite attitudes about the pandemic. In Milwaukee, a rich community spirit buoyed their sense of safety and protection. People, for the most part, wore masks and social distanced. They posted flyers about carpooling to COVID-19 testing centers.

“There was more of a community effort to keep people safe,” Jarboe said.

When they came back to Walnut, wearing a mask became an affront to other residents, even people who had known Jarboe since they were an infant. In Milwaukee, community members would request someone without a mask to don one in public. Such an ask is unthinkable in Walnut.

“I would not do that out of fear, and I’ve been harassed for wearing a mask,” they said.

Jarboe attributes the hostility they experience in their town to the consequences of divisive rhetoric surrounding COVID-19 and masks. But more than that is the sheer isolation within which a town such as Walnut exists. For the most part, people in Walnut haven’t stopped working, and there’s been no hazard pay since the start of the pandemic, Jarboe said.

“A lot of people don’t want the vaccine. They’re not saying they’ll never get it. They just want to wait and see what happens to other people because they distrust it,” Jarboe said. “The attitude is more like, ‘I’m not scared of it,’ which is kind of fatalistic in a way and I can understand to some extent. But it’s created a lot of harm.”

The primary means of public health communication for many residents in Walnut has been the Crawford County Health Department Facebook page, Jarboe said. For most of the year, people have relied on the Facebook page for mobile testing announcements, but vaccine rollouts make fraught an already tense waiting game.

Their parents are both essential workers and eligible for the vaccine. Jarboe’s mother, Vicki, is a postal worker, and their father, Kelly, delivers dairy as a truck driver in addition to his long hours as a rancher on his own property. But the paradox of vaccinating essential workers has been present since the early days of the pandemic. They have to work and expose themselves on a nearly daily basis, and they don’t have the luxury of time to prioritize their health. And certainly, they don’t have time to scroll Facebook for updates and endless websites for potential vaccine appointments, Jarboe said.

In their free time between university Zoom classes, Jarboe checks the Facebook page for vaccine updates in the hopes of signing their parents up. Jarboe acknowledged their position is unique: They’re one of the few nonessential workers in town.

Public health experts have emphasized a need for nuanced coordination efforts in streamlining vaccine allocation. Dr. Rupali Limaye, an associate scientist at the Johns Hopkins Bloomberg School of Public Health, thinks aligning outreach to reflect the community is imperative.

“The outreach has to match the target demographic, and if that target demographic is not really online, how do we communicate to people? How do we make sure that people know that, one, they’re eligible for it, that they can have access to it, and that it’s not going to be essentially punitive for them to try to get access to it, i.e. it’s not going to take them four hours to get to a place where they can have it,” Limaye said.

Even as experts stress creative outreach strategies, those can all fall short if a public health department’s administration officers are in constant flux. That’s been the ongoing situation in Crawford County, where the positions within the Crawford County Health Department have changed in major ways since the pandemic began.

First, in June 2020, County Health Officer Rebecca Adamson resigned from her post following a coronavirus outbreak at the SugarCreek bacon plant in Frontenac. The county replaced her position with two positions. The Crawford County Health Commission appointed Dr. Timothy Stebbins as the county’s new public health officer and Dr. Linda Bean deputy public health officer. Then, in January, Teddi Van Kam was appointed the new Crawford County Health Department director, which reframed Bean’s role as a consultant to the department and puts an expiration date of June 2021 on Stebbins’ public health officer appointment.

What comes next? The Crawford County Health Department declined to comment.

For people like Jarboe, the county’s departmental scramble meant a continued lack of communication. Rumors about weekly dose amounts at the county level started to concern Jarboe, whose only real connection to the health department was through the Crawford County Facebook page. Meanwhile, their father continued to be exposed to COVID-19-positive truck drivers, which ratcheted up their anxieties.

Just how hard is it to distribute the different vaccines to rural America?

Dr. Glen Nowak, the director of Center for Health & Risk Communication at the Grady College of Journalism and Mass Communication at University of Georgia, said health departments need better vaccine coordination. While the Johnson & Johnson vaccine doesn’t need frigid temperatures maintained like the Pfizer and Moderna vaccines, that vaccine, only recently approved for emergency use, began shipments only at the end of February.

“In a rural area, if you get a cooler of 975 doses, you’re now on the clock to be able to use it. And then each of those vials is on a clock. And so, when you take out a vial, which has 10 doses, and you mix it, you now have six hours to use those 10 doses — because then, at that point, they expire. So shipping Pfizer vaccine to a rural health care provider who has, say, 45 patients in a long-term care facility and 25 workers — what do you do with the other 900 doses?” Nowak said.

While the Pfizer vaccine is less stable, the Moderna vaccine, a more forgiving and user-friendly vaccine, has delivered fewer doses in the Midwest as a result of winter storm Uri’s devastating aftermath in February. Unforeseen weather conditions play a critical and frightening role in vaccine allocation efforts, and this affects how the county responds to registering patients.

Such instability at the county level adds additional chaos to what is already an overburdened time for local health departments across the country. Limaye said the key trait of a successful health department is coordination. In rural areas, communication and coordination among several communities and even whole counties becomes essential.

“Coordination, coordination, coordination. States needs to determine this, and they need to make sure that they’re communicating with every other actor within their state that could be administering the vaccine, to ensure that we have as smooth of a rollout as possible. I mean, that’s really going to be critical. And it’s going to be hard because most public health departments I know at the state level are really already overwhelmed,” Limaye said.

“A different kind of rural”

Public health experts have been wringing their hands over how to gain the trust of various communities. Dr. Lawrence Gostin, a professor of global health law and faculty director of the O’Neill Institute for National & Global Law at Georgetown University, said he thinks that creating community trust requires information campaigns designed from the bottom up.

“Scientists are often remote and detached from the lived experiences of many people of color and the poor. These communities often look to local civic and religious leaders for information,” Gostin said in an email.

Establishing trust in poor, rural, and Black, Indigenous and other communities of color can be exceedingly challenging when towns feel abandoned even by neighboring cities. Dr. Harald Schmidt, assistant professor of Medical Ethics and Health Policy at University of Pennsylvania’s Perelman School of Medicine, said the metrics for establishing trust are not one-size-fits-all. “Non-traditional models” such as a mobile testing unit in front of one town’s barbershop will be less relevant for the next town over, he said.

For Walnut residents, even community leaders from nearby Pittsburg, home to 19,918 according to the 2020 U.S. census, are considered elite and untrustworthy by many. Much of this outsider mentality can be ascribed to Pittsburg’s industries, which tend to lack manual labor. Crawford County, Kansas, made up of 12 towns, has a population of 38,818, with Pittsburg representing the most populated city. Walnut, with a population of 186, makes up about 0.5% of the overall population.

From the vantage point of Walnut residents, Pittsburg is the hotshot city of Crawford County, teeming with elite infrastructure and resources such as a city government, multiple public safety departments and community services. Advice from outsiders in the big town — even if they were born and raised within Crawford County — can feel insulting in Walnut.

“It sounds silly, but [some] people here see someone from a town of, say, 30,000 as a city slicker who doesn’t understand what it’s like to be working and living here. You know, someone who doesn’t have to risk their lives every day working. People here work dangerous jobs,” Jarboe said. “It’s just a different kind of rural.”

According to Data USA, the largest industries in Walnut are construction, transportation and warehousing, and health care and social assistance. But, as a farming area, nearly every household undertakes the physical labor of farm upkeep in addition to full-time jobs. The median household income is $23,542, not quite one-third of the national average.

The disconnect doesn’t end with recent public health communications, either. Some households aren’t on Pittsburg’s water system, which only adds to the isolation mentality and distrust at the county level. And installing water lines to be on rural water can cost upward of $4,000 per household. Just 15 years ago, Jarboe’s family had to drive to an abandoned fire station with a quarter in hand to fill their water tank, an activity they’ll still do for their cattle in the summer when droughts dry out drinking ponds. And it remains this way for certain families just a mile away. It still costs a quarter.

“The county hasn’t made a real effort here anyway to help people out,” Jarboe said. “There isn’t a safety net.”

Health at a distance

Of the resources from which Walnut is out of reach — Jarboe said it takes 30 miles to get to the nearest Walmart for access to fruits and vegetables — a decent health care provider can be as far as a two-and-half-hour ambulance ride away.

Growing up, Jarboe saw a physician’s assistant in a neighboring town only when they needed a physical to play a sport. A more comprehensive doctor’s appointment, which for Jarboe meant a colonoscopy and endoscopy at 15, meant a ride to Kansas City.

Because Jarboe and their parents prefer not to rely on local hospitals and medical centers, they will travel either to Kansas City, Kansas, or Tulsa, Oklahoma, both of which are over 100 miles away for the major medical facilities there. Determining what constitutes a serious medical need, however, only adds to the sense of anxiety and isolation.

Bitter divides

A drive down Northrup Road in Union, Illinois, reveals banners and flags that staunchly contest the 2020 presidential election. A flag waves on the back of a pickup truck parked outside of Clasen’s Tavern with the words “F*ck Biden” in big white letters, with a caption beneath that says “And f*ck you if you voted for him.” The windows of businesses carry similar vitriol aimed at Gov. J.B. Pritzker.

Many people in these more impoverished towns blame the decline in small and independent community businesses on democratic leadership, and they are reluctant constituents. While the goal of stay-at-home orders imposed by counties and states has always been about health and safety protocols to contain the spread of the virus, safety is a hard argument when lockdowns lead to joblessness and joblessness leads to home and food insecurity.

Union, with a population of 509 people, has a 16.9% poverty rate, more than 50% higher than the U.S. poverty rate of 10.5%, according to the 2019 Income and Poverty in the U.S. Census Bureau report.

On the topic of vaccines, nobody approached in town for this story agreed to be interviewed. The bitter taste left from a highly contested election and baseless election fraud conspiracies spilled into resentment over any type of government mandate issued — and, apparently, toward journalists invading the town.

Elsewhere, in Stella, Nebraska, Kathy Jacobitz, 42, said there’s a reason you keep your peace if you live in a small town.

“I really try not to alienate the people that I know and care about here, even if it’s to correct information. Because if people don’t want to have that dialogue, it makes them feel threatened,” Jacobitz said.

Jacobitz, a mother of six children ranging in ages from 5 to 16, said that in her small town of 148 people, community has become so much more important than partisan arguments even about illness and even if COVID-19 had no business being politicized in the first place.

The case for not opening the can of COVID-19 worms became more complicated for Jacobitz, whose children were at risk of being exposed to her asymptomatic COVID-19-positive in-laws. They continued to go out without masks and host family events. In those situations, she did put her foot down about gathering for Thanksgiving, which has strained already fraught relations.

Educating the masses requires a willingness to be educated in the first place, and many experts cite former President Donald Trump’s lax stance on health protocol and his pandering to anti-vaxxers as one reason so many feel so empowered to remain maskless and unvaccinated.

Schmidt observed that when Trump announced Operation Warp Speed, he told people that those who want the vaccine would be able to get it quickly and efficiently, but followed this up by saying that not everybody wanted it.

“The personal responsibility argument is very double-edged here. To just say, look, we’re offering vaccines and if people take them, good, and if they don’t, so be it, that is very short-sighted and ignores the history we have in this country. We can’t just assume vaccine hesitancy is a matter of informed choice. It can reflect deep distrust that we have to work to correct,” Schmidt said.

The problem with luck

In a follow-up interview, Jarboe said their parents have received their first doses of the Moderna vaccine, but their daily scouring on Facebook and Twitter for information wasn’t how they scheduled and secured shots.

They said luck won the day. Despite the fact that employees of the U.S. Postal Service are considered part of Kansas’s Phase 2 vaccination plan, some Walnut postal workers, like Vicki Jarboe, finagled a vaccine without much help from the county, according to Canese. Following a string of correspondences with a few people connected to hospitals in Neosho County, she and her husband locked down appointments and received their first doses.

Efforts to actually get the vaccine in both rural and suburban communities across the country have ended up being convoluted and are sometimes quickest resolved if you know the right people.

Schmidt warned state governors that allocating their vaccines where uptake is swiftest would end up with an imbalance where vaccine access can be most critical. The problem, he said, is that in the rush to get people vaccinated as quickly as possible, the incentives to coordinate with smaller, less resourced communities wane.

As initial vaccine rounds are used up, “the incentives are geared much more for the people who are better off, who are more integrated in the health system to get vaccinated than the worse-off people,” Schmidt said.

States receive new vaccines only after they’ve used up initial allocations, which plays into the pattern of have’s and have not’s, communities with widespread access to health care and isolated ones due to health care deserts in cities and in rural areas. These latter population groups have historically been shoved aside from the formal health care system or else experience structural racism in their encounters with health care providers.

“We want to plan very proactively, so that disadvantaged communities are receiving genuine offers to get vaccinated. It’s not good enough to say, ‘Oh, come to a big hospital and pick them up.’ That is not acknowledging the history that we have to be mindful of, that made many people reluctant to get in touch with health care providers,” Schmidt said.

Vicki Jarboe recently lost her cousin, Larry Williams, 55, to COVID-19. In his final Facebook message, Williams wrote, “[sic]Alot of you refuse to wear a mask…I have never been more sick in my life…Do the mask thing. Do the 6’ thing. [sic]Its no joke.”

Their Uncle Rick, in his 70s, languishes with lung cancer at home. A health aide comes to Rick’s house to care for him, but when he asked the aide about getting on a vaccine list, she said she didn’t know of one for him. Meanwhile, students at Kansas University, in Lawrence, have been able to sign up to get the vaccine.

“I don’t feel there’s a real sense of hope,” Canese said. “For us, it’s always felt the same.”

Natalie Eilbert is a health, environment and science reporter at Medill. You can follow her on Twitter at @Natalie_Eilbert.