The Rural Pandemic Isn’t Ending

Public-health leaders in rural America are turning toward the next and more difficult stage of the nationwide vaccination campaign: persuasion.

A painting shows a woman carrying an anti-vaccine flag and leading men to battle.
Eugène Delacroix / Adam Maida / The Atlantic

Americans will soon begin to fall back into the rhythms of pre-pandemic life—attending sunny summer weddings, squishing into booths at chain restaurants, laughing together at movies on the big screen—and it will feel like a victory over the coronavirus. But the virus might not actually be gone. In pockets of the country, vaccination rates could stay low, creating little islands where the coronavirus survives and thrives—sickening and killing people for months after the pandemic has ebbed elsewhere. In a worst-case scenario, the virus could mutate, becoming a highly transmissible and much more lethal version of itself. Eventually, the new variant could leak from these islands and spread into the broader population, posing a threat to already-vaccinated people.

This is the future that keeps some public-health experts awake at night. Right now America is in the simplest stage of its vaccination campaign: getting shots to people who want them. But many Americans are still reluctant to get a vaccine—especially those living in rural areas, who tend to be politically conservative and are among the most fervently opposed to inoculation. Public-health leaders will soon have to refocus their efforts toward the next and more difficult stage of the campaign: persuasion. Over the next few months, “the number of willing individuals to get vaccinated will be depleted,” says Timothy Callaghan, a rural-health researcher and professor at Texas A&M University. “Then the work begins.”

The politicization of vaccines will complicate this effort. Curiously, it’s a relatively recent phenomenon. Anti-vaccine sentiment has been around since the early days of the smallpox vaccine, and that sentiment grew stronger after the discredited British physician Andrew Wakefield published a now-retracted paper linking vaccines to autism in 1998. But vaccine opponents’ concerns were mostly medical rather than ideological, David Broniatowski, a professor at George Washington University who studies group decision making and behavioral epidemiology, told me. In a recent study analyzing a decade of anti-vaccine rhetoric on Facebook, Broniatowski and a research team concluded that vaccine opposition first became politicized in 2015. That year, a measles outbreak linked to two Disneyland theme parks in California affected more than 100 people and triggered a “multi-state public health incident.” Most of those infected were unvaccinated or had an unknown vaccination status, and the California state legislature responded by removing personal-belief exemptions from public-school immunization requirements. The backlash from vaccine opponents was fierce: Suddenly, the issue was less about medical safety and more about freedom and individual choice. The following year, the propaganda film Vaxxed helped crystallize vaccination as a civil-liberties concern, and vaccine opposition became much more common among conservatives, who were more likely than liberals to be critical of government interference in Americans’ private lives, Broniatowski said.

This history helps explain conservatives’ reluctance today to get the COVID-19 vaccine. Until vaccines are available to every person nationwide, it’ll be hard to accurately gauge how widespread vaccine hesitancy is. But new polling data indicate that serious investment in persuasion campaigns will be necessary, especially in rural communities. Rural Americans are twice as likely as people in urban areas to say they will “definitely not” get a shot, and nearly three-quarters of them identify as Republican or Republican-leaning, according to new survey data from the nonpartisan Kaiser Family Foundation. Rural Americans are more apt to see vaccination as a civil-liberties issue: “More (58%) rural residents view getting vaccinated as a personal choice rather than part of everyone’s responsibility to protect the health of others (42%),” the KFF survey found. (The reverse is true for urban residents.) This group is also much more likely than any other to say that the news media have exaggerated the pandemic’s seriousness, Liz Hamel, who directs KFF’s polling work, told me.

It’s possible—even probable—public-health experts told me, that months from now, some rural areas will still have very low vaccination rates, providing isolated havens for the coronavirus. That outcome could be calamitous. First, as long as unvaccinated individuals live together in a community, frequenting the same shops, offices, and classrooms, the virus can find hosts through which to spread. Second, and even worse, a virus left unchecked will evolve—that’s what viruses do best—and could become more infectious, more lethal, and more resistant to existing vaccines. Which means that, ultimately, a new, super-charged coronavirus variant could create the conditions for another epidemic, the experts told me. This is why “we need people vaccinated now, not four months from now,” says Alan Morgan, the CEO of the nonprofit National Rural Health Association.

Vaccine hesitancy is now the chief focus for rural-health experts like Morgan. They have an obligation to change minds, and fast. But persuasion works only with trustworthy messengers, such as local leaders, physicians, and pharmacists—people who already have relationships and friendships with community members, who share similar values, and whose children go to school together. “Rather than have these mass-vaccination sites through government-funded health departments with the National Guard” overseeing operations, health officials need to send vaccines straight to places such as doctors’ offices, churches, and familiar local clinics, Michael Meit, the research director at East Tennessee State University’s Center for Rural Health Research, told me. “It’s those relational pieces that are so, so important in our rural communities.”

Actually, personal relationships are important in all public-health messaging, regardless of geography. Take the 2019 measles outbreak in parts of New York City. In early spring that year, nearly 600 people across several Hasidic Jewish neighborhoods got sick, most of them unvaccinated children. Immunization rates there were low, in part because the Hasidic community had been targeted by anti-vaccination groups making false claims about vaccine safety. In response, city public-health officials enlisted the help of local doctors and rabbis to encourage locals to inoculate their kids. They also created informational booklets with accurate vaccine information in Yiddish, and distributed them to 30,000 households. Their efforts were successful: In the Williamsburg neighborhood of Brooklyn, where case numbers were highest, the share of people who had gotten the measles vaccine increased from 79 percent at the outbreak’s start to 91 percent by the end, Jennifer Rosen, the director of epidemiology and surveillance for the New York City Bureau of Immunization, told me.

Effective vaccine messaging has to be tailored to people’s specific fears: If someone is worried about government overreach, the messenger should use language that affirms their right to make their own medical decisions, Broniatowski says. “Of course it’s your choice,” he advises messengers to say. “Here’s why it’s the right choice.” Facts alone won’t do the trick, and neither will shaming. Many conservatives have found the discourse around COVID-19 and vaccines to be “very demeaning,” he added. “There’s a lot of communication from people on the periphery of science communication that say things that come across as ‘What’s wrong, you idiot? Don’t you trust science?’” But it’s natural for people to be reluctant about a brand-new vaccine, and people shouldn’t be scolded for having doubts. Roger Brock, the public-health administrator in rural Barry County, Missouri, told me that he tries to create a judgment-free zone. After listening to patients’ concerns, he explains to them that the vaccines were developed by the smartest scientists in the world, who have no political agenda. (He also reminds them that the vaccines don’t contain microchips, Brock said with a laugh.) “Sometimes you have success” persuading people, “and sometimes you don’t,” he added.

Morgan, at the National Rural Health Association, is working to enlist members of the National Corn Growers Association and the Farm Bureau to act as local persuasion leaders. Federally, the CDC is investing millions of dollars in local efforts to improve vaccine access and uptake, and the Biden administration recently launched an ad campaign to persuade holdouts. KFF’s polling offers reason to be optimistic about these efforts overall: Although the most staunchly vaccine-hesitant Americans haven’t budged from their position since December, the number of people who want to get a vaccine is higher than it was over the winter. Rural Americans are still the most hesitant group in the country, but as of this month, more than half of them say they have received at least one vaccine dose or intend to do so as soon as possible.

In rural Ripley County, Missouri, the public-health administrator Jan Morrow has been working overtime for months on the persuasion effort. Every night after she returns home from the public-health center, she takes calls from the nervous and the skeptical. Earlier in the pandemic, her neighbors would ask about the efficacy of face masks, or question whether the media were exaggerating COVID-19’s severity, she told me. Nowadays, they’re calling to ask for advice on whether to get the vaccine. “We’re not going to make you take this vaccine. That is your choice,” she usually responds. Sometimes Morrow emphasizes how devastating the pandemic has been for public-health professionals like her—how it felt to watch 19 people in Ripley County, population 13,000, die of COVID-19 in the past year. “I took the vaccine with no hesitancy at all because I have seen our case loads,” she tells them.

Just last week, a young man Morrow has known since he was a toddler called to get her opinion on booking an appointment. “I walked him through what the vaccine was gonna do,” she said. By the end of the conversation, she’d scheduled him for a shot.

The Atlantic’s COVID-19 coverage is supported by a grant from the Chan Zuckerberg Initiative.