Rural communities outside America's cities are falling further behind in the race to vaccinate against COVID-19 as President Joe Biden's Fourth of July goal to reach 70% of American adults looms over the horizon.
Alaska is the sole state where average rural rates of fully vaccinated people have grown faster than urban rates since April 19, when every state opened shots to anybody 16 and older, according to NPR's latest analysis of county-level vaccination data from the Centers for Disease Control and Prevention.
Everywhere else, rates in urban counties have outpaced those in rural counties.
Over a dozen states where rural rates were actually beating urban ones seven weeks ago have flipped, so they now trail their urban counterparts. Those include Oregon where rural places now trail urban by 9 percentage points and Maine where they're now behind by 7 points.
Florida, Massachusetts and Nebraska have the largest disparity, with rural counties lagging by 14 percentage points. For Florida and Nebraska those gaps are about double what they were in mid-April.
Though stark, these gaps may hide a more complex story of vaccination rates, as the data reveals plenty of rural counties well above average and urban areas dragging their feet.
"There's a lot of, let's call it judgment of rural communities and a lot of blame that's being placed on them for masks, for vaccinations," says Mark Holmes, a professor at the University of North Carolina Gillings School of Global Public Health. "There's a continuum overall, and it's not as simple as all the large areas are doing great and all the rural areas are not."
Indeed, a CDC report from mid-May included one detail that caught Holmes by surprise: The suburban counties ringing his state's largest cities, Charlotte and Raleigh, N.C., had significantly lower vaccination rates than their urban cores.
Not only that, these suburbs were worse off than even rural counties scattered across the state. Counties surrounding Minneapolis, Birmingham, Ala., Seattle, Denver and Portland, Ore., all repeated this pattern, with the suburbs trailing both urban and rural counties of their states, according to the CDC's analysis.
Pockets of lower vaccination rates are a problem for people everywhere, experts say. If COVID-19 flares up in any unvaccinated rural or suburban area, those outbreaks would likely ripple into nearby cities, according to Keith Mueller, director of the University of Iowa's Rural Policy Research Institute.
"If we've learned anything from 18 months of this pandemic, we've learned that it can spread from any place to any place. We're far too mobile a society," Mueller says.
As COVID-19 restrictions ease and the summer travel season heats up, more Americans will likely venture to national parks and other outdoor destinations in rural areas.
"You're stopping to get gas, and all of a sudden, that's your contact," Holmes says. "It's ineffective to look at our borders, whether those are national, state or county, and say that's over there. It's not coming here."
Socioeconomically vulnerable counties struggling more
A second CDC report from early June sheds light on the demographic and social factors linked to lower vaccination rates among all counties, whether rural or urban.
The CDC ranks over 3,000 counties nationwide using a social vulnerability index that measures 15 factors such as poverty, poor transit and crowded housing that weaken a community's capacity to respond to disaster.
Researchers divided counties into four categories — large urban, suburban, small-to-medium urban, and rural — and looked for which demographic profiles were linked to lower vaccination rates. Across all these categories, households with children, people living with disabilities and single-parent households were more likely to see lower vaccination rates. And researchers say these gaps are particularly pronounced in suburban and rural counties.
Counties with higher numbers of mobile home residents, as well as those with higher poverty and lower education rates, also lagged significantly behind other counties within their rural-urban category, according to the CDC report.
"Rural communities often have a higher proportion of residents over 65 years of age, lacking health insurance, living with underlying medical conditions or disabilities, and with limited access to health care facilities with intensive care capabilities, which may make them more likely to get sick or die from COVID-19," says Vaughn Barry, a CDC epidemiologist and one of the report's lead authors.
Battling hesitancy should be 'hyperlocal'
The CDC reports present vaccine hesitancy as the primary barrier to reaching rural areas and call for public health leaders to do more to overcome it. One in five rural Americans said they would "definitely not" get a vaccine, according to a Kaiser Family Foundation poll published in April. It found the most resistance among Republicans, white Evangelical Christians, essential workers in fields other than health care, and adults under 50.
Strategies to overcome that hesitancy will look different for the hundreds of rural counties nationwide, says White House COVID-19 Health Equity Chair Marcella Nunez-Smith, but they will likely share one critical aspect.
"Partnering with trusted, local community leaders is a must," Nunez-Smith said at a news conference in May. "Equity work is always hyperlocal. Communities are the experts in what they need."
Doctors on the Navajo Nation, once among the hardest-hit areas of the country, say constant communication with their tribal members about fighting the "monster" of COVID-19 has helped this remote region achieve some of the highest vaccination rates in New Mexico and Arizona.
Like most Native American tribes, the Navajo Nation has dozens of paid community health representatives who work with the Indian Health Service to reach into rural areas and forge relationships.
"They know their areas extremely well. They all speak the language," says Dr. Loretta Christensen, acting chief medical officer for the Indian Health Service and a member of the Navajo Nation. "They can take that one-on-one with the people that may be hesitant, and sometimes it has been because they're afraid to leave their home, by the way, but we have gone out to the homes and given those vaccinations."
Friends and family can be among the most influential in convincing a hesitant person, adds Dr. Chris Percy with the Northern Navajo Medical Center in Shiprock, N.M.
Patients frequently recount to him what has convinced them to show up at recent vaccination events: "They'll just volunteer that 'My mom and my sisters have been ... on my case to get in here,'" Percy says.
Christensen and Percy say they can't beat anyone over the head with data or strongarm unwilling patients into taking the vaccine, but what they can do is seem welcoming and lower all barriers.
"Our systems that we set up on Navajo don't have a pre-registration component or, you know, you need to do these five things before you can get an appointment," Percy says. "If you're going to come in on Tuesday, just show up. ... When you make up your mind, and you're ready, we're going to be here."
Barry's report echoes Percy, suggesting walk-in clinics with flexible evening and weekend hours to accommodate work schedules and reach people in socially vulnerable communities. The CDC researchers also suggest organizing vaccine clinics near childcare facilities and partnering with schools could improve the lower rates they observed among single-parent households in suburban and rural counties.