Nearly 30 percent of the adult population in the country has had at least one dose of a coronavirus vaccine. By now, you probably know quite a few people who’ve been vaccinated. 

But actually getting shots into arms is not easy. And it’s not going to get any easier. At some point, the U.S. is going to run out of people eager to get the vaccine, and we’ll need to work hard to convert those who are still hesitant or don’t know how to get it. It won’t be the first time we’ve done so, of course. For months now community leaders have been working to overcome transportation challenges, language barriers and digital divides. 

To better understand the challenges to come, we talked to five people who’ve been struggling with these issues since the first vaccines became available. They’ve been obsessed with the questions of conversion and access. How do you get the shot to people who aren’t going out of their way to get it?

Each leader had their own answer to that question. But one overarching theme emerged: It’s about meeting people where they are. 

Todd Enlow: It’s really hard to say how many we’ve had in the Cherokee Nation, but in our health care system that we operate, we’ve had a little more than 14,000 cases.

My name is Todd Enlow. I am the chief of staff at the Cherokee Nation, located in Tahlequah, Oklahoma.

Anna Rothschild: Throughout the pandemic, Native American communities have been among the communities hit particularly hard. What has that impact been on you, watching this happen to your community?

Todd Enlow: One of the very first things that we discussed were our elder speakers. We have about 2,000 elder speakers that we’ve identified through a speaker roll book. And we were very concerned about that population, because there are so few speakers, we wanted to make sure we protected them as best as we possibly could.

Anna Rothschild: By “speakers,” Enlow means community members whose first language is Cherokee.

Todd Enlow: Median age for our speakers is about 65 years old. And so it’s a very vulnerable population, plus some of the underlying health conditions that many of them face, such as diabetes and hypertension. From food insecurity to all the way now through vaccinations, we held our speakers at a higher level, making sure that we protected them as best as we possibly could. 

Even with those efforts, we still lost several of our speakers, nearly 50 speakers during that time. On the 16 of March, we sent all of our employees that were over the age of 65 home, to be safe. And I remember one of our employees worked about 10 feet from my office. Seventy-two years old, and she looked at me and said, ‘I feel like you’re sending me home, because you don’t need me or want me.’ And I said, ‘Absolutely not. We are trying to protect you in trying to make sure you’re, you’re safe during this.’ And unfortunately, only a few days later she contracted the virus and passed away two weeks later. 

Honestly, she, she was like a grandmother to me. And so it made us very cognizant of how quickly things can change and that the threat of the virus was real in our community. 

Anna Rothschild: What is it about protecting the language that became such a priority? 

Todd Enlow: Even though we have a written language, it’s often passed down through stories. And that’s why our language is so important is because it’s not only the language, it’s also our connection to previous generations and our stories that have been there through, through some of the most difficult years throughout our history. So the fact that we only had those 2,000 speakers and we have 385,000 citizens, it is a language that is quickly slipping away from us, and we are doing everything that we can to try and preserve it.

So far, we’ve vaccinated about half, a little more than half of our speakers. 

Anna Rothschild: Enlow told me that many of the elder speakers don’t have social media or smartphones. So signing people up took some ingenuity. 

Todd Enlow: We sent people with our language department out to go knock on their doors or give them a personal phone call to say, ‘Hey, we’re offering the vaccine, would you be interested in taking it? And let’s get the appointment scheduled with you.’

The thing that we really focus on is trying to connect personally with each person to let them know it was available. And so we try to meet everybody on different levels. But we always realized that we needed to find them at the lowest common denominator, which was either personal interaction or  a phone call.

Anna Rothschild: The Cherokee have intentionally designed their health care system so that it’s easily accessible by everyone on the reservation. Even so, Enlow and his team have encountered some vaccine hesitancy.

Who among the community is more hesitant? Are there any trends you can sort of notice?

Todd Enlow: Yeah, especially younger. Those that would be in childbearing age, the fear and concern that they may become unable to produce children. There’s a greater number of women that have been concerned about that. But we’ve actually received that feedback from men as well that they were concerned of the impact it might have on them.

Anna Rothschild: Has seeing the speakers get vaccinated had an impact on other members of the community who might have been hesitant before?

Todd Enlow: Yeah, it has. I don’t think it’s converted everyone, obviously. But it has changed a lot of hearts and minds of seeing a grandmother, or an aunt — those grandmothers and those aunts in Cherokee culture, a lot of times are the ones that takes care of the younger kids. And so grandmothers and aunts are very special people, and so when they see those elders signing up and getting that it’s convinced quite a few people.

Anna Rothschild: The Cherokee Nation is now vaccinating anyone who lives on the reservation, even if they’re not a tribal citizen. 

Since Enlow and I spoke, The New York Times reported that vaccinations on the reservation are starting to slow down. They now have more open appointments than they can fill. Enlow, and those grandmothers and aunts, have their work cut out for them.

Anna Rothschild: Max Gonzalez is executive vice president of strategy with Chicanos Por La Causa, a nonprofit organization that advocates for the Latino community across the Southwest. I spoke with Gonzalez about the vaccine rollout to Latinos in Arizona, who make up 30 percent of that state’s population. Yet, when the state’s vaccine website first launched, it was not translated into Spanish.

Anna Rothschild: What sort of went through your mind when you noticed that the site was only in English?

Max Gonzales: How could you forget that? We’re in Arizona, for God’s sake, we’re a border state. And within the Latino community, it’s clearly a number one issue.

Anna Rothschild: Arizona did launch a Spanish-version of its vaccine portal in mid-February. But just because information is available, that doesn’t mean it’s getting accessed.  

Max Gonzales: The digital divide is real. It’s very real, particularly in rural Arizona. The one area where Latinos tend to overindex, though, is through mobile phones. Latinos are also very active on social media, we know this, they also overindex there. 

Anna Rothschild: Chicanos Por La Causa worked to get the word out about the vaccine through social media. They also targeted Spanish television stations to reach older people without internet access at all. 

Max Gonzales: Well, I mean, if you’re Spanish-dominant, and you’re live in the United States, your ability to communicate is very limited and Spanish media knows that. So they take that information of what’s important to this community and what’s important in the English community that needs to be shared with the Spanish-speaking community. So I think because of that they play that role of a bridge builder, if you will, of the issues that are going on that you need to be aware of. And again, if you’re Spanish dominant, you recognize that and so it’s appreciated.

Anna Rothschild: Chicanos Por La Causa has the challenge of working with communities in both urban and rural areas. In Phoenix, they focused on one Spanish-speaking zip code where there were significant transportation issues.

Max Gonzales: We sent taxis to their home, the taxis took them to the vaccination site, which were not in that zip code, mind you. And they’re starting to get some vaccinated, 

Anna Rothschild: They also had to reach migrant workers in extremely rural areas.

Max Gonzales: So migrant workers being those that go from crop to crop to crop, they often move a lot. That’s a very challenging population to deal with. But this is also a very Spanish-dominant population that we’re dealing with.

Anna Rothschild: Gonzales told me that there’s been some vaccine hesitancy among this group. So they partnered with the Head Start program that provides education to migrant kids in pre-K, as well as services for their parents. 

Max Gonzales: So our Head Start services actually put together some videos about any kind of myths — COVID Mythbusters. And we started doing this and sending it to the parents, we put fliers together, anything we could to reach our parents to try to get them to understand that some of this stuff is just simply not true. It’s in your best interest to go and get the vaccine.

Anna Rothschild: How much trust do you see in, in medicine generally?

Max Gonzales: Actually quite high. The relationship with a physician, with a doctor, is actually quite high, particularly with Spanish-dominant. What a doctor says is often paid very close attention to because they are the authorities, they know what they are talking about. And so when it comes to issues of medicine, doctors actually can carry a lot of credibility with the Latino community.

Anna Rothschild: In addition to access issues and vaccine hesitancy, Chicanos Por La Causa has the challenge of getting undocumented members of the Latino community vaccinated. 

Max Gonzales: Anything government does is met with a bit of skepticism from the the undocumented community, particularly coming off the last administration where the treatment of the undocumented community wasn’t necessarily one that was with open arms. And so they’re very, very jaded. That’s where entities like Chicanos Por La Causa comes in, that’s where Spanish media comes in. We’re the ones who can help bridge that credibility. Other entities beyond us have been churches. They have been working with their communities, and telling them that this is a safe place to go. If you fail to do that, you’re not going to reach the undocumented community.

Anna Rothschild: Rural areas across the country have faced serious challenges getting the vaccine to their residents. Surry County, Virginia, is about the size of Chicago, but has about 6,500 residents. A little over 50 percent are white, and 40 percent are Black. Residents of Surry County don’t have easy access to health care. There are only two doctors in the county, and the pharmacy closed about 10 years ago.

Melissa Rollins: if you want to look at the mileage that we had to travel, I would say between 20 to 30 plus miles to be able to get to a pharmacy.

Anna Rothschild: That’s Melissa Rollins, the administrator for Surry County.

Melissa Rollins: Our closest hospitals to Surry County are approximately between 30 and 40 miles away. So there is that challenge.

Anna Rothschild: When the vaccine rollout started, the county set up a call center to get information out to residents and help them book appointments. But those appointments were far away.

Melissa Rollins: One of the examples I guess I can cite is when it first started, we were given appointments such as in Franklin, Virginia, which is approximately 40 miles from Surry. Those who are elderly, 65 and older — obviously, you do not want those citizens who are less mobile to go the distance to be able to get the vaccine.  

Anna Rothschild: So Ms. Rollins lobbied the state to set up a vaccine clinic in Surry County. Her plan identified sites for a vaccine clinic, and a strategy to recruit and train vaccine administrators.

Melissa Rollins: We actually solicited volunteers in the community who were nurses. Two of our school nurses and then an additional three nurses from the community.

Anna Rothschild: And her plan worked.

Melissa Rollins: We have had four successful vaccine clinics, and we’re looking to have another second dose clinic in the next two weeks or so.

Anna Rothschild: With these four clinics, Surry County has given shots to about 1,900 people, or about 30 percent of their population.

 

Karen Lincoln: My name is Karen Lincoln, and I’m an associate professor in the School of Social Work at the University of Southern California here in Los Angeles. I’m very much preoccupied with the issue of race and ethnicity and discrimination and how that impacts health outcomes and mental health outcomes among underserved populations. 

Anna Rothschild: Dr. Lincoln primarily works with older African Americans in South Los Angeles. She told me that while sometimes this population has difficulty accessing health care, more often Dr. Lincoln hears a different concern.  

Karen Lincoln: For the seniors that I work with, access is not as much of an issue, if you define it by, ‘Is there a place where you can go?’ It’s more how you’re treated when you’re there. So it can be anything from how long you have to wait to how you’re spoken to by the staff, whether your concerns are dismissed. So it really has a lot to do with how you’re being treated in those domains versus having a place to go to get treatment.

Anna Rothschild: A lot of the media stories right now are about how Black Americans distrust the health care system and how that’s leading to vaccine hesitancy. How true have you found that in practice?

Karen Lincoln: There’s a difference between distrust and mistrust. You know, mistrust is sort of a general suspicion [because of] events that have happened historically. And then there’s distrust that’s more associated with people’s lived experience. And so what we found is that most of the seniors distrust the medical system and health care providers and clinicians overall, because of what they themselves have experienced, or what family members have experienced, or someone that they know, and it’s more contemporaneous, it’s not something that happened in the 30s, 40s or 50s. It’s something that happened very recently, to them. 

Anna Rothschild: Dr. Lincoln told me that among the people she works with, there’s some suspicion of the health care system. And when it comes to vaccines …

Karen Lincoln: We’re hearing a lot of concern, and attaching the COVID vaccine in particular with the previous administration. 

Anna Rothschild: What do you think that we can do to sort of combat the distrust of the vaccine or disentangle it from, you know, feelings about the previous administration?

Karen Lincoln: That’s tricky, because the current approach is to, you know, watch Black people get vaccinated on TV. And that’s not necessarily the most effective approach, right? Because my seniors say, ‘Well, I’m not going to get the same vaccine that Obama gets.’ Right? So there’s a general suspicion about what you’re going to get versus what other people get. 

Anna Rothschild: Do you mean that the brand that they’re getting, so like, Pfizer and Moderna versus Johnson and Johnson? Or is there something else there?

Karen Lincoln: So it’s not the brand, it’s not the manufacturer. It’s more whether they’re getting, what I’ve heard many seniors say, the real thing, or something else. And so the something else could be a number of things — it could be a placebo, or it could be something that’s more harmful. And both some of the mythology that is sort of circulating in the community has to do with, ‘Well, you know, it might cause infertility, it might give me COVID.’ And I’m not sure how to even address that, because that is prevalent, that even though the message is that it’s safe, and that it’s effective, there’s still a heightened level of concern about what they would be getting as an African American versus what someone who’s white might be getting, even if it’s in the same facility.

Anna Rothschild: What are the most important factors to achieving vaccine-hesitancy conversion, to becoming more amenable to getting a vaccine if you have some preconceived ideas about what getting the vaccine means?

Karen Lincoln: People are sort of waiting to see how it’s going to sort of behave in other people’s bodies. And so I think one of the ways that we can sort of at least sort of convert people is to have more people like them in their situation in their neighborhood, like someone that they know, who’s gone through that process, to demystify it for them, and you might convert some people. Some people just, you know, will never be converted. But I do think the more people that you know who can share their stories is very important, in terms of, you know, sort of clearing out some of the mythology — lowering the level of anxiety and making it more real.

Anna Rothschild: In late 2020, the city of Minot in North Dakota was hit hard by the coronavirus. In fact, Ward County, where Minot is based, was the hardest-hit county in the whole United States. Lisa Clute is the executive officer of First District Health Unit, a public health provider that serves Ward county and six others.

Lisa Clute: It is a combination of rural, and very rural, and some urban. For the most part, it is primarily white. Second population would be Native American, and then African American. 

Anna Rothschild: Like most of the country, Minot pretty much shut down in March of 2020. 

Lisa Clute: And then we had what they called the North Dakota Smart Restart. 

Anna Rothschild: North Dakota was fully open by June. But by the fall, their numbers were growing rapidly. Clute said First District did a ton of testing to try to do effective contact tracing. But it was hard to get people to follow their guidelines.

Lisa Clute: We started having about 30 percent of our population were not following those recommendations for isolation and quarantine. I think that played a huge role in it.

Anna Rothschild: Why do you think that was?

Lisa Clute: Well, I think there were so many factors that played into that. Some of it was all of the misinformation on social media. It was also very political, you can’t deny that.

Anna Rothschild: There was also a lot of contentiousness around masks. Clute told me they struggled until the hospital capacity became a big deal. At that point, First District held a press conference.

Lisa Clute: … and said, ‘We are in trouble here. North Dakota is in crisis.’ That was not the message that everybody else was giving across the state at the time. That press conference seemed to resonate. And we did pick up mitigation strategies. After that we saw much more compliance with the masking. 

Anna Rothschild: When First District began rolling out vaccines, they didn’t bother setting up an online system. Internet access in the area is pretty good, but they knew their older patients wouldn’t be comfortable with that.

Lisa Clute: We did it all over the phone. So we set up a call center. We had 10 people at First District just making appointments. People were talking to a real person making their appointments. And I think in this community, with the elderly population, that was very important.

Anna Rothschild: The first time they opened up for vaccines, they took 250 calls in the first two hours.  

How much trust do people in your community tend to have in the medical establishment like even before COVID?

Lisa Clute: I remember going through training at the University of Illinois in Chicago for this, pandemics, bioterrorism and so forth. You know, it pretty much so played out, just as described, with the exception of: No one ever talked about that we would have trouble convincing the public that this was an emergency. For the most part, you plan for the worried well and a panicked public. That was not the case. That was, I think, almost a surprise, like, ‘What, don’t you understand? This is a big deal.’

Anna Rothschild: How much overlap have you seen between people who are anti-mask and people who have some hesitancy about getting the vaccine?

Lisa Clute: There are a lot of anti-maskers that are ready to take the vaccine. There is a small population that are just anti-vaccine, anti-mask, anti-mitigation, anti … anti. However, you know, that because they are anti-maskers, doesn’t mean that they’re anti-vaccine.

Anna Rothschild: What are the main concerns when you have heard hesitancy? What are the main concerns that people have had?

Lisa Clute: That it was developed very quickly. We hear that comment all the time. Um, I think that’s the primary thing. And so, you know, we’ve explained I mean, the platforms that were used to develop this vaccine were sitting there ready to rumble. 

Anna Rothschild: Despite some hesitancy, Clute told me that for the most part, vaccine demand has remained high.

Lisa Clute: We have about 80, little over 80 percent of our long-term care facilities wanted to be vaccinated and have been vaccinated. We are at 70 percent of the 75 and older population. You know, the unfortunate situation is vaccine hesitancy has continued to grow over the last several years, right when we were in a public health crisis that a vaccine is our primary tool.

Anna Rothschild: Do you know which messages have really resonated most with people who might have been skeptical of the vaccine or just it maybe hadn’t occurred to them to go get one?

Lisa Clute: Just the ability for people to talk to somebody, that’s hard in large populated areas. But we know that in our area, that is the most effective way to do that. So it truly is the opportunity to look at every situation individually.

Anna Rothschild: That’s the refrain we heard from everyone we talked to over the past few days. Whether you live in the city or the country, regardless of your race or the language that you speak, the way to get people vaccinated is by having one-on-one conversations, tailored to specific needs and concerns. And I suppose that really isn’t so surprising. Most of us have spent a year missing out on social interactions with the people who really get us. That’s been painful and difficult. It’s no wonder that those same types of interactions are what can change a mind.

Lisa Clute: I keep saying I want to be alive 20 years from now and truly understand the impacts of this pandemic. Because our communities aren’t necessarily healthy right now. We’re working at getting the people healthy but now we’ve got to heal the communities.

We’ve been at this now for a year, you know, I haven’t had a day off in 365 years … er, days. And neither has a lot of my staff. So people are tired, the public is tired, they just want to see some normalcy. Spring is coming, crops will be going in, you know, calves are being born on the farms, all of those things. It is kind of a season of renewal. And I think that is, those are all things working in our favor right now. But, as I said, we’ve got a lot of healing to do.

Anna Rothschild: That’s it for this episode of PODCAST-19. If you have a question you’d like us to answer on the show, email us a voice memo at askpodcast19@gmail.com. That’s ask podcast one nine at gmail dot com. I’m Anna Rothschild. Our producer is Sinduja Srinivasan. Chadwick Matlin is our executive producer. Thanks for listening. See you next time.



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