Christina Nunnally was driving to work when she heard on the radio that the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA) were recommending a pause in the use of the Johnson & Johnson vaccine last week.
As the chief quality officer for a network of primary care clinics in northern Mississippi, Nunnally knew she had just the rest of her 30-minute commute to formulate a plan for how her doctors would tell patients the news, reshuffle their schedule and ensure people kept coming in to get vaccinated. Vaccine delivery at North Mississippi Primary Health Care had already “not been a cake walk,” Nunnally says. Mississippi has one of the lowest rates of COVID-19 vaccines administered in the country, and has some of the highest rates of vaccine hesitancy, according to the CDC. “Back in January and February, we had huge demand and we couldn’t get any vaccine,” she says. “Now, we have vaccine and it’s hard to be able to get it out to patients as quickly as we would like.”
Similar situations are playing out in other rural areas, particularly across the southern and western United States, which create added challenges to achieving herd immunity, or the point at which enough of the U.S. population is vaccinated that life can return to some semblance of normal. Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases and the President’s chief medical adviser, has tentatively put this number at 85%. The country is trending in the right direction. The White House said Wednesday that over 133 million Americans—at least 50% of the adult population, including 81% of seniors—have received at least one shot.
But getting the citizens most hesitant about the vaccine to take it may prove to be the most difficult barrier to reaching herd immunity. For President Joe Biden, who has largely staked the success of his first year of office on getting to that point, this next phase represents a particular challenge. Partisan divides in vaccine hesitancy are stark, the pause on the Johnson & Johnson vaccine complicated delivery in rural areas, and many Americans are inherently skeptical of any messaging push from the federal government.
“Our objective is to reach everyone,” Biden said on Wednesday in a speech about the state of the country’s vaccination efforts. “We have the vaccine to deliver.”
To increase vaccine distribution, the Biden administration has leveraged federal resources, allocating $20 billion in the American Rescue Plan and mobilizing thousands of military staff to support community vaccine sites. But officials have said that when it comes to persuasion, they have to make sure their efforts won’t exacerbate skepticism. Their strategy largely hinges on channelling talking points and funding to community leaders who they hope will have more sway with many Americans than the federal government. “We recognize that the President, that all of us, may not be exactly the right messengers for some of these audiences,” White House Press Secretary Jen Psaki said earlier this month.
On Wednesday, the Administration announced it would reimburse businesses with fewer than 500 employees that offer paid time off for vaccinations. On April 1, the Administration launched $250 million in television ads in English, Spanish and Chinese promoting the benefits of the vaccines. It also announced the COVID-19 Community Corps, a group of more than 275 organizations who are working to disseminate information to various communities across the country. The corps includes faith-based organizations, public health groups, and organizations with ties to rural communities, like the National Milk Producers Federation.
Surgeon General Vivek Murthy holds weekly Zoom calls with these groups featuring different guests to discuss vaccine hesitancy. On April 13, the day the FDA and CDC paused the Johnson & Johnson vaccine, Murthy brought in Fauci, who answered questions from nearly 2,000 people on the call. Murthy also sent an email to corps members emphasizing that the instances of blood clots resulting from the Johnson & Johnson shot were extremely rare, and that the decision to temporarily halt doses demonstrated the “rigorous steps that the FDA are taking to ensure that the American people have clear and transparent information about the safety and effectiveness of these vaccines,” according to a copy of the email viewed by TIME. The Administration also recently launched a media blitz to raise awareness about expanded vaccine eligibility and provided corps members with a social media kit to promote on their own channels.
But for all the Biden Administration’s efforts, deep partisan resistance to the vaccine remains. An April 14 Quinnipiac poll, which was conducted before the temporary pause on the Johnson & Johnson vaccine, found that of the 27% of Americans who said they did not plan to get vaccinated, 45% were Republicans and 7% were Democrats. A March 30 poll from the Kaiser Family Foundation found the strongest hesitancy among Republicans and white evangelical Christians. Nearly 30% of those groups said they would “definitely not” get vaccinated, compared to 13% of the respondents overall.
Local health officials and providers in communities where hesitancy is high aren’t sure that a national messaging strategy from the Biden Administration or even the paid days off will do much good in conservative areas. “[Reimbursing small businesses] will definitely help with the logistics,” says Dr. John Waits, a physician and executive director of Cahaba Medical Care, a group of 17 health clinics in central Alabama. “But the people who are hesitant, they’re hesitant for other reasons.” Waits says he has seen interest plummet from when his staff held mass vaccination events this winter with thousands of people lined up to get shots.
As a federal advisory committee meets this week to decide whether providers can begin using the Johnson & Johnson vaccine again, public health experts say it’s a crucial time for the White House to ramp up its outreach to conservatives. The Biden Administration should identify “key champions” that conservatives trust, says Dr. Peter Hotez, a vaccine scientist and dean of the National School of Tropical Medicine at the Baylor College of Medicine. “The concern that I have is, after the pause, will Americans accept the J&J vaccine, or will this frighten many Americans?” Hotez says. “It really depends on how the U.S. government responds and acts and manages this.”
Joe Grogan, who led former President Donald Trump’s domestic policy council and now works with the COVID Collaborative, a group that is part of the Biden Administration’s Community Corps, says Biden should be hosting meetings with conservative leaders to tout the benefits of vaccinations. “He needs to make [conservative outreach] a priority and let every American know he’s fighting for them and wants them all to do well,” says Grogan. “I am worried that if they keep saying ‘they can’t speak to conservatives’ and if they keep on harping on this as if this is an ‘us versus them’ thing, as they’ve done in the larger policy discussions, people will perceive scapegoating, and their resistance may harden.”
But part of the problem is that more than a year into the pandemic, not all elected officials and public figures have gotten on board with encouraging Americans to get vaccinated, and conservative media outlets are still spreading doubts and conspiracy theories about the available vaccines.
Trump, who got vaccinated privately before leaving the White House in January and did not join the other living former presidents in producing a PSA about the vaccine, said this week he was unsure why his supporters were still reluctant to get vaccinated. “They all want me to do a commercial, because a lot of our people don’t want to take vaccine. You know, I don’t know what that is exactly, Republican, I don’t know what it is,” Trump told Sean Hannity on April 19. At the Fox News host’s prompting, Trump then said he would encourage people to take the vaccine, but he also criticized the FDA for its handling of the Johnson & Johnson situation.
Republican pollster Frank Luntz says it might help convince some Trump supporters if the former President appeared alongside Biden to encourage more Americans to get the shot. In Alabama, Waits says he prayed for Trump to get vaccinated on Facebook Live because he thinks that might have helped convince some of his patients.
Asked on Wednesday about outreach to conservatives, Andy Slavitt, a senior adviser to the White House COVID response team, said the Administration was confident that hesitancy would decrease as more people get vaccinated, but did not respond about reaching Republicans specifically. The most important thing, he said, is “making sure we have direct very clear information to the public about what it means to get vaccinated and the changes that people observe in their lives around them.”
So far, polling indicates he may be right. In a poll released April 20 by the de Beaumont Foundation, which studies public health, 40% of respondents, including 38% who supported Trump, said they were more likely to get the vaccine than they were a month ago. Brian Castrucci, an epidemiologist and head of the foundation, said this shift is the result of a “cauldron of messaging and conversation,” including the Biden Administration’s efforts.
But the question now is whether this decrease in hesitancy can continue to the point where the country can achieve herd immunity. “[Resistance] is declining overall, but those who are concerned and hesitant are even more so,” says Luntz, who conducted the de Beaumont poll. “Among Trump voters, particularly those who live in rural areas, in small towns, the hesitancy is significant.”
That was true before last week, and the Johnson & Johnson pause has brought added complications for medical providers trying to reach rural areas and marginalized populations, such as homeless and homebound people. But while public health experts feared the Johnson & Johnson halt could make hesitancy worse, the de Beaumont poll found most Americans believe the pause shows that safety measures are working. Many of Waits’ patients in Alabama prefer the Johnson & Johnson shot because they view it as a familiar brand name, or believe false claims about the mRNA vaccines changing their DNA. In Arkansas, the halt has proven difficult too, Republican Gov. Asa Hutchinson says. “We are really having a challenge with our factory workers and service workers, and there is a natural hesitancy within that group. The one dose J&J vaccine was preferred by these workers, and the pause just presents an additional hurdle for vaccinating some of those most in need,” he tells TIME.
In Mississippi, Nunnally believes more local outreach from local doctors and medical providers will help combat these obstacles. Her health center is using funds from the American Rescue Plan to hire more nurses and create a dedicated team that will travel around the northern part of the state administering vaccines. This needs to be combined, she says, with consistent messaging from all levels. “If we had everybody, as we say in the South, singing from the same hymnal, we could really make a difference with vaccine penetration and the population,” she says. “But unfortunately, that doesn’t seem to be the way that things are working right now.”