Department of Health Secretary Carlos Mellado injects a child with a dose of the Pfizer COVID-19 vaccine at the Tomas Dones Coliseum, in Fajardo, Puerto Rico, Saturday, Jan. 8, 2022. (AP Photo/Carlos Giusti)

Media pundits have posited many theories about why some Americans refuse to get vaccinated against Covid-19 in rural regions of the United States.

Popular explanations include the refusers’ denial that the pandemic is a threat, their fear of the vaccine’s side effects, their suspicions about vaccines in general, and their belief in politically driven conspiracy theories about the vaccine.  But there’s one explanation that hasn’t been examined:  lack of enduring relationships with trusted medical and healthcare professionals – especially in medically underserved areas (MUAs) around the country.

While this impediment is restricting the acceptance of Covid vaccines in underserved areas, an effective workaround can be borrowed from the methodology that has been used in Puerto Rico, which achieved the country’s highest rates for the initial two doses of the vaccinations.

According to the Health Resources & Services Administration, a medically underserved area is designated as having a shortage of medical care providers for an entire group of people within a defined geographic locale.  By not having long-term connections with experienced clinicians, the residents of medically underserved areas don’t have the ability to have their concerns or scientifically misguided opinions addressed by professionals who have taken care of them in the past and whom they trust.  Such clarifications, especially when shared by medical service providers who are viewed as credible and honorable, could be useful in blunting many of the distresses of vaccine refusers living in heavily rural states that are also medically underserved.

A cursory examination of the initial two-dose vaccination rates in states across the country versus the number of physicians per capita in those states reveals a correlation of .80, which represents a strong positive correlation coefficient.  This statistic confirms that there’s a valid comparison that can be made between the low vaccination rates in medically underserved rural areas and the higher vaccination rates in less rural states that have a greater number of doctors.

(It should be noted that Medically Underserved Areas also exist in non-rural areas.  According to the Health Resources and Services Administration, the inner city locale of north St. Louis County in Missouri, for example, is designated as an MUA due its low concentration of physicians and health care providers.  The area also has one of the lowest rates of the initial two dose vaccinations in the state.)

Yet while the vaccination rates in mainland American medically underserved areas are hampered by the absence of positive contacts between the citizenry and trustworthy medical personnel, Puerto Rico offers the unusual example of a medically underserved area that has yielded the highest rates of the initial two-dose vaccinations in America.

As per the study “Puerto Rico Health Care Infrastructure Assessment” by the Urban Research Institute, “72% of Puerto Rico’s 78 municipalities have been deemed medically underserved areas by the U.S. Health Resources and Services Administration.” 

Despite this, Puerto Rico has some of the highest Covid-19 vaccination rates in the U.S. Eighty percent of the population is fully vaccinated and 44% have received a booster dose, according to a Daily Yonder analysis of CDC data.

How was the remarkable acceptance of the initial two-dose Covid vaccines achieved across Puerto Rico?  I believe that it’s because for many years, there has been a significant integration of doctors and healthcare providers into the daily lives of Puerto Ricans, especially those who live in rural regions.    

Because of natural disasters such as earthquakes, the outbreak of the Zika virus, and hurricanes/tropical storms (most recently, the highly destructive Hurricane Maria in 2017), doctors, nurses, therapists, and medical school students have consistently embedded themselves as dependable providers of critical relief across the island.  Relationships have developed between these providers and rural residents, so when the pandemic hit, the need to be vaccinated wasn’t an issue that was controversial, political, or suspect.

(DISCLOSURE:  I am the CEO of Ponce Health Sciences University, a medical school in Ponce, Puerto Rico, and I have coordinated the outreach efforts of our medical students, medical faculty, and healthcare staff among remote rural populations across the region.)

Based on the approach in Puerto Rico, how can bonds between the populations of rural state MUAs and doctors/healthcare providers be nurtured to boost credibility and comfort in order to reduce vaccine resistance?  A two-tiered solution is needed:

Medical and healthcare professionals in rural areas of America need to consistently be out and among the populations who live in the areas that they serve.  These “meet and greets”, Q&As, and presentations can include city council and school board meetings; get-togethers at churches, libraries, schools, and popular restaurants; town halls; and appearances at major centers of employment.  Webinars should also be available for residents who wouldn’t be able to attend in-person events.

While such opportunities for positive interaction between doctors and their communities existed in the past, they’re gradually disappearing:  hospital systems and regional/statewide medical groups have been buying local primary care physician practices in an effort to funnel and increase patient volume.  The unfortunate result of this consolidation is reduced contact with, and rapports between, medical professionals and citizens in rural settings.

Second, to stabilize the number of care facilities in rural states and make them less medically underserved, payment schedules to service providers need to be revised.  Currently, doctors and medical facilities in MUAs receive a significantly lower reimbursement rate for their services compared to those that are provided in more populated areas.  To turn this around, reimbursements should be adjusted to be more in line with what is paid in the nearest metropolitan centers.  In addition, reimbursement bonuses should be added to billable fees where residency training is provided.  These updates would not only make working in MUAs more desirable for doctors and healthcare professionals, they’d also incentivize the development of new care facilities and inspire existing facilities to upgrade and expand.

Would the successful trust-building process that was piloted across Puerto Rico be “the” solution to elevate the vaccination rate in rural states?  No – but it could be “a” solution that offers proven results to help control sickness, diminish spreading, reduce economic devastation, and prevent death.

A recent example of how this trust-building has been advantageous to overall health of Puerto Ricans can be seen in how the recent spread of omicron has affected the island.  While the omicron outbreak has been vast, the number of hospitalizations as of 2/4 (thanks to Puerto Rico’s acceptance of the initial two vaccine doses) has been dramatically lower than those in the states – especially when compared to rural regions of the U.S.:

REGION% OF POPULATION WITH TWO INITIAL VACCINES/ TWO INITIAL VACCINES
WITH BOOSTER
HOSPITALIZATIONS PER 100,000 CITIZENS
Puerto Rico80/444
West Virginia60/2245
Missouri60/2128
Mississippi56/1923
Arkansas59/1927

Source:  USDHHS and CDC data as of 2/24/22

Given the arrival of omicron as well as other new Covid variant waves that will likely emerge, we must be willing to pursue sensible ideas that will build confidence with those living in rural regions in order to diminish uncontrolled outbreaks and prepare for future contagions.  U.S. Surgeon General Dr. Vivek Murthy concurs with this notion:  “As a doctor, I was always trained you never give up on people — you show up,” he said recently.  “You build trust by listening to people, helping them feel they’re respected and valued.”

The relationship-driven methodology that has benefited rural residents of Puerto Rico could strategically be pursued in America’s rural states as a way to ramp up the crucial trust component, lower vaccine resistance, and bolster vaccine acceptance.

Dr. David Lenihan is CEO of Ponce Health Sciences University.

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