NASHVILLE, Tenn. -- The U.S. vaccine campaign has heightened tensions between rural and urban America, where from Oregon to Tennessee to upstate New York, complaints are surfacing of at least a perceived inequity in vaccine allocation.
In some cases, recriminations over how scarce vaccines are distributed have taken on partisan tones, with rural Republican lawmakers in Democratic-led states complaining of "picking winners and losers," and urbanites traveling hours to rural GOP-leaning communities to receive covid-19 shots when there are none in their city.
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In Oregon, state GOP lawmakers last week walked out of a legislative session over the Democratic governor's vaccine plans, citing rural distribution among their concerns. In New York, public health officials in rural counties have complained of disparities in vaccine allocation, and in North Carolina, rural lawmakers say too many doses were going to mass vaccine centers in big cities.
In Tennessee, Missouri and Alabama, a dearth of shots in urban areas with the greatest numbers of health care workers has led senior citizens to snap up appointments hours from their homes. The result is a hodgepodge of approaches that can look like the exact opposite of equity, where those most likely to be vaccinated are people with the savvy and means to search out a shot and travel to wherever it is.
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"It's really, really flawed," said Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security, who noted there are even vaccine hunters who will find a dose for money. "Ideally, allocations would meet the population's needs."
With little more than general guidance from the federal government, states have taken it upon themselves to decide what it means to distribute the vaccine fairly and reach vulnerable populations.
Tennessee, like many states, has divvied up doses based primarily on county population, not on how many residents belong to eligible groups -- such as health care workers. The state health commissioner has defended the allocation as the "most equitable," but the approach has also exposed yet another layer of haves and have-nots as the vaccine rollout accelerates.
In Oregon, the issue led state officials to pause dose deliveries in some rural areas that had finished inoculating their health care workers while clinics elsewhere, including the Portland metro area, caught up. The dust-up last month prompted an angry response, with some state GOP lawmakers accusing the Democratic governor of playing favorites with the urban dwellers who elected her.
Public health leaders in Morrow County, a farming region in northeastern Oregon with one of the highest covid-19 infection rates, said they had to delay two vaccine clinics because of the state's decision. Other rural counties delayed vaccines for seniors.
States face plenty of challenges. Rural counties are less likely to have the deep-freeze equipment necessary to store Pfizer vaccines. Health care workers are often concentrated in big cities. And rural counties were particularly hard-hit by covid-19 in many states, but their residents are among the most likely to say they're "definitely not" going to get vaccinated, according to recent Kaiser Family Foundation polling.
Adalja said most of these complications were foreseeable and could have been avoided with proper planning and funding.
"There are people who know how to do this," he said. "They're just not in charge of it."
In Missouri, where Facebook groups have emerged with postings about appointment availabilities in rural areas, state Senate Minority Leader John Rizzo, a Democrat from the Kansas City suburb of Independence, cited a need to direct more vaccine to urban areas.
The criticism drew an angry rebuke from Republican Gov. Mike Parson, who said vaccine distribution has been proportional to the population and critics are using "cherry-picked" data.
"There is no division between rural and urban Missouri," Parson said during his covid-19 update last week.
In Republican-led Tennessee, Health Commissioner Lisa Piercey noted that the Trump administration deemed the state's plan among the nation's most equitable. Extra doses go to 35 counties with a high social vulnerability index score -- many small and rural, but also Shelby County, which includes Memphis, with a large Black population.
Last week, state officials revealed some 2,400 doses had been wasted in Shelby County over the past month because of miscommunication and insufficient record-keeping. The county also built up nearly 30,000 excessive doses in its inventory. The situation caused the Centers for Disease Control and Prevention to investigate and the county health director to resign.
In Nashville, Democratic Mayor John Cooper says the fact that city residents can get shots elsewhere is a positive, even if the road trips are "a little bit of a pain."
"I'm grateful that other counties have not said, 'Oh my gosh, you have to be a resident of this county always to get the vaccine,'" Cooper said.
A LESSER VACCINE?
Meanwhile, officials are facing similar issues deciding where to allocate doses of Johnson & Johnson's vaccine, which gained regulatory clearance Saturday.
Decisions to send the shots to harder-to-reach communities make practical sense, because Johnson & Johnson's single-shot vaccine is easier to store and use. But they could drive perceptions of a two-tiered system, riven along racial or class lines -- with marginalized communities getting what they think is an inferior product.
The issue came up on a recent call between governors and Biden administration officials coordinating the country's coronavirus response. Massachusetts Gov. Charlie Baker, a Republican and former health insurance executive, stressed the need for prominent health officials to communicate clearly about the benefits of the one-shot vaccine, according to three people who heard his remarks and spoke on condition of anonymity to discuss a private conversation.
The Johnson & Johnson vaccine proved safe and effective in a clinical trial, completely preventing hospitalization and death, including in South Africa against a more transmissible variant. When moderate cases were included, however, it was 66% protective, compared with efficacy of more than 90% reported for the Pfizer and Moderna vaccines.
The apparent differences, Baker said, could create uncomfortable questions for state and local leaders promoting the new vaccine to people who might ask, as one person paraphrased his comments, "Why didn't you give us the good stuff?"
In North Dakota, which has achieved one of the fastest rates of inoculation, Republican Gov. Doug Burgum said the new product intensified concerns not just about "vaccine hesitancy, but the potential for brand hesitancy as well."
The challenge is especially acute in the context of the racial and economic disparities exacerbated by the pandemic, according to state and local officials. If a vaccine thought to be less effective -- though still well above the threshold of 50% set forth last summer by federal regulators -- is used overwhelmingly in communities of color, it could erode trust. The Biden administration signaled Sunday it was concerned about that possibility, as senior administration officials stressed that the new vaccine would be shared equally throughout the country.
Fulfilling that promise is critical, advocates said.
"If we end up with a hierarchy that says all rich white people get Pfizer, and all poor Black people get J&J, that would be a problem," said Helene Gayle, president and chief executive of the Chicago Community Trust, one of the largest community foundations in the country.
SHOTS FOR TEACHERS
Within weeks, teachers in most U.S. states will be eligible for vaccines. It's unclear whether school openings will follow as promised or whether supply can keep up with demand.
Eight states are allowing teachers to get shots in March and two soon after, bringing the total to 44, according to data from Bloomberg News. That adds pressure to reopen school systems that have resisted until educators are protected.
The CDC has said vaccinating teachers isn't a prerequisite for reopening schools, but some unions have resisted. State struggles over who to prioritize come as the Biden administration says in-person learning is a priority, as well as a key step in the economic recovery.
CDC guidance urges vaccination for teachers and staff "as soon as supply allows." As of Monday, 37 states had made at least some teachers eligible, though many educators may be waiting for weeks. The Bloomberg News tally doesn't account for states where teachers have gotten the shots because they met other criteria, such as age or health issues.
Teachers are essential workers, but "from a logistics perspective, there's still not enough vaccines being distributed to take care of everyone who's in that category, across all the states," said Jodie Guest, professor and vice chair of the department of epidemiology at the Rollins School of Public Health at Emory University in Atlanta.
On Monday, Wisconsin, Connecticut and Mississippi teachers joined the priority list. Georgia is expected to follow next week, and Missouri the following week. Teachers 50 and older could soon be eligible in Florida, and are next in line in New Hampshire, South Dakota, New Mexico and South Carolina.
Just six states -- Washington, Texas, New Jersey, Montana, Massachusetts and Indiana -- haven't yet made teachers eligible or announced concrete dates for doing so. Still, most schools in Montana and Texas are open for daily in-person learning, as are many in Indiana. In New Jersey, Massachusetts and Washington, a majority of schools are teaching virtually.
Information for this article was contributed by Travis Loller, Jonathan Mattise, Gillian Flaccus, Jim Salter, Bryan Anderson and Carla Johnson of The Associated Press; by Isaac Stanley-Becker of The Washington Post; and by Anastasia Bergeron of Bloomberg News (WPNS).
