by Christian Green, Carolina Public Press May 7, 2021

In late April, Gov. Roy Cooper set the end goal for North Carolina’s COVID-19 vaccination rollout at two-thirds of adults. When that number is reached, Cooper said, then he would end the statewide indoor mask mandate, effectively ending pandemic restrictions. 

But it may prove difficult to reach that number soon, as there has been a slowdown in vaccinations in some parts of Western North Carolina, driven by a lack of demand. 

“In Rutherford last week, we had a clinic and, in a place where we were previously doing 1,100 (doses) a day, we did 190, and we were open all day,” said Karen Powell, health director of Foothills Health District, which covers Rutherford and McDowell counties. 

“Right now, we’re like at this … it’s not a screeching halt, but it’s a trickle,” she said. 

Health directors across the region voiced the same story. 

“We’ve hit a wall, basically,” said Kathy McGaha, director of the Macon County Public Health Administration. 

The least vaccinated counties in the west are Rutherford, Cherokee and Graham counties, with an estimated 34%, 36% and 37% of adults vaccinated, respectively. 

“At this point, we’ve pretty much vaccinated everybody who wanted to be,” said Beth Booth, health director of the Graham County Health Department. “Even those who were on the fence.”

Booth was pleasantly surprised that her county reached those numbers.

“When we passed (having vaccinated) a quarter of our population, that was a higher uptake than I thought we would have,” Booth said.

“If you’ve spent any time out here, you would quickly figure out that it’s a very suspicious, closed group out here. … So, I got to say I’m pretty proud of how many folks have taken it.”

Though some individual western counties are lagging, the total percentage of vaccinated adults in the 18 westernmost counties is around 47%, according to an analysis conducted by Carolina Public Press, not far behind the 50% of adults vaccinated statewide.

While vaccine hesitancy in Western North Carolina is not dissimilar from the state and the country, some of the reasons for hesitance or resistance differ by region.

Local differences for hesitancy 

As has been previously reported, no single factor drives vaccine hesitancy, and no single group is uniquely hesitant. 

Booth said Graham County is uniquely distrustful of influence from outside the county. She thinks that mindset contributes the most to low rates of vaccination in the county. 

“They’re very private, and so if they have a belief system, if outside government is trying to step in or if the government is trying to overreach, they aren’t having it,” Booth said.

“It’s really hard to change their mind because … it’s not necessarily the science or any medical reason. It’s a belief system.”

This aligns with previous survey studies that have reported that conservatives appear to be more hesitant to receive a COVID-19 vaccination than liberals, but that does not tell the full story. 

For instance, Avery County voted for former President Donald Trump at a similarly high percentage as Graham County in the 2020 election; however, Avery County has vaccinated roughly 45% of adults, compared with Graham’s 37%. 

In general, a county’s 2020 election results had a weak correlation with the level of vaccination, based on CPP’s analysis. 

Instead, education levels, measured in this case by how many people over the age of 25 held a bachelor’s degree or higher, were the strongest predictor of vaccination levels. The percentage of residents living below the poverty line was the second-strongest predictor. 

This disparity can be seen in the margin of vaccinations in the neighboring counties of Swain and Jackson. Swain has vaccinated roughly 37% of its adults while Jackson has vaccinated around 42%. 

The two share similar demographics, poverty levels and cultures, but Jackson is home to Western Carolina University and has nearly double the number of residents with bachelor’s degrees as Swain. 

It is possible that higher levels of education are not directly responsible for increased vaccine uptake, but that educational achievement is correlated with other socioeconomic factors like income, living conditions and access to health care, which may also affect vaccine enthusiasm.

When looking at county trend-line data, one in particular stands out: Macon County. 

Macon County voted heavily Republican in 2020, it has a below-average number of bachelor’s degrees and an above-average number of people living in poverty. By all metrics, it should be lagging in vaccinations. 

But Macon apparently has vaccinated over 51% of its adults, putting it just ahead of the statewide average. 

McGaha, director of Macon’s Public Health Administration, said she wasn’t entirely sure why the county’s vaccination rate was so high. If she had to guess, she said, it was because of her department’s approach to contact tracing and communication throughout the pandemic. 

“Anyone who tested positive for COVID-19 was called by our staff every day to check in on them,” she said.

“We did very intensive contact tracing with them, and we spent a lot of time on education. … The community developed relationships and trust for this agency over the past year. I think that probably is part of what we see now.” 

In other counties, people have said personal relationships with individuals and agencies matter. 

Powell said she would have expected McDowell County to have a lower rate than Rutherford, but McDowell is almost 10% more vaccinated. Powell said she thinks the strong relationship between McDowell residents and their local Emergency Management Services Department is key. 

“Their residents trust them. So, if emergency management says, ‘Hey, you need to do this,’ they say, ‘OK, because you never, ever led me astray.’” 

Rutherford County, on the other hand, had less trust in institutions on average, which makes it tougher to overcome people’s doubts about vaccination, Powell said. 

‘This pandemic is not over’

The slowdown in vaccinations means that it may take months to reach the 66% goal set by Gov. Cooper, and even that number would likely not produce a level of “herd immunity” that would completely squash the disease. 

While cases and deaths are way down from their January peaks, the state is still reporting over 1,000 new COVID-19 cases per day and local health departments remain worried about outbreaks.

“We have right now, we have a cluster in McDowell,” Powell said. “An outbreak with 11 positives in a business, and none of them are vaccinated, and they probably won’t be. They probably will not do it.”  

Booth also said that after nearly two weeks of zero new cases, Graham County had recently begun to see cases rise again. Graham has found seven new positive cases in the past week.

To try to quash the possibility of more outbreaks, health departments are shifting tactics to try to reach and convince more people to get vaccinated. Powell said her department is using mobile clinics to reach into neighborhoods with low vaccination rates. 

She hopes that even if people don’t immediately choose to get vaccinated, it will be an opportunity to educate them and make a contact that might eventually change their minds. 

Booth said she thinks that hearing from neighbors will prove to be even more important than education from health officials. 

“I think the only way at this point to really see an increase in vaccinations in Graham County is just time,” Booth said.

“They’re not going to believe the science behind it. They want to see that their neighbors are OK. And I don’t mean two weeks or a month. … They want to see that over a long period of time that it really is OK.”

Powell has less patience. 

“This pandemic is not over,” she said. “The outbreak we have right now in McDowell is a clear indication of that. And it scares me. You know, with the low vaccine rate that we have in the county, these outbreaks will just continue to happen.”

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