A vacant vacation cottage sits on Cape Cod Bay in Outer Cape's North Truro, Massachusetts. The town of Truro is one of the communities that pose challenges to mass vaccination efforts due to their remoteness, a fact made particularly obvious during the off-season. (AP Photo/Michael Dwyer)

Cape Cod bustles in the summer, with vacationers and second-home owners soaking up surf and sun. But the remote Outer Cape reveals its rural nature in the off-season, creating challenges for community leaders who are heading up efforts to get permanent residents there vaccinated for Covid-19.

For towns like Provincetown, Truro, Wellfleet, and Eastham, land is plenty but residents are few. Getting to some of them to administer the Covid-19 vaccine takes an all-community effort, according to Andy Lowe, chief strategy officer of Outer Cape Health Services and director for the Cape & Islands Area Health and Education Centers.

The Outer Cape, the north-south stretch on the east side of the cape, is geographically isolated with extremely limited public transit and only one two-lane highway connecting it to the rest of the cape. Most of the land is part of the Cape Cod National Seashore. This leaves year-round residents with up to an hour-long drive to get to the nearest clinic for a Covid vaccine, Lowe said.

“It doesn’t look rural to some people, especially if they go there in the summer because of all the tourism stuff that goes on,” Lowe said. “But if you are there any time from November until May, you realize how isolated it really is.”

The 12,600 permanent residents have a significantly older median age than the rest of the United States, Lowe said. And within that population are hidden pockets that require greater levels of outreach for vaccination efforts.

The first hidden community, he said, was the homeless.

“They were one of our first priorities,” he said. “Working with Duffy Healthcare, we were able to go to some sites and homeless shelters to get that population vaccinated and tested.”

The second population was the home-bound.

“We realized early on that the home-bound was one of the core populations that we’d have to deal with,” he said. “And those may be elders who may not be able to travel, or those who’ve lost a loved one who was the primary driver, or those who may be shut-ins.”

Working with the area ambulance companies, police departments and the Council on Aging, the public health agency was able to take the vaccine to those who couldn’t get to it. First responders and the Council on Aging knew where those who were home-bound would be, he said, saving the public health agency from having to search for them.

“In some cases, we’d go along with first responders,” he said. “Our nurses would administer the vaccine and the EMS personnel would stay to monitor the patient for the next 20 minutes.”

Working together with other communities allowed the coalition to maximize their vaccination efforts.

Andy Lowe

Lowe said the health care providers also worked with local businesses.

Because the Cape is a tourist draw, it’s also a draw to migrant and immigrant workers, he said. Businesses were concerned that missing the migrant workforce in vaccination efforts could put everyone at risk. 

“By all accounts, this is shaping up to be the biggest tourism year in decades,” he said. “Employers were very concerned about vaccinating and testing their migrant work force. So we provided pop-up testing and vaccination sites. In some cases, the businesses sent busloads of people to us.”

Through those programs, the health care provider administered more than 15,000 doses, of which about 800 went to homebound residents. Complete vaccination requires two doses.

Despite these efforts, Barnstable County's overall vaccination is low, according to the Centers for Disease Control and Prevention. Only 4% of the county's population is fully vaccinated. The June 1 community report says that 8,536 of the county's 213,000 fulltime residents are fully vaccinated. That figure includes the more populated southern arm of the cape.

Lowe said the focus is now on getting vaccines to kids. Effectively reaching that segment of the population, while continuing to address the vacation spot’s workforce, will be a community effort.

“One of the things about living and working in a rural area is that there's a sense of community that you don't always get in other urban areas,” he said. “This is something that we've worked on for many years, and it has really strengthened our bonds with our community partners. We depend on all of them so much. The bulk of the Lower and Outer Cape region are so interdependent that we’ve really come to trust each other and to work well with each other, and really to leverage and draw from some of those strengths that we've developed over a long period of time working together.”

CORRECTION: An earlier version of this story incorrectly said the permanent population of the Outer Cape was 20,000. In fact, 2019 Census estimates for the towns of the Outer Cape is 12,613.

Also, we misstated the number of vaccine doses that have been administered, according to Andy Lowe of the Outer Cape Health Services. Lowe said the health service programs have administered 15,000 doses, not 800. (Eight hundred doses were administered just to homebound residents.) The Centers for Disease Control and Prevention reports that 10,762 residents of Barnstable County have received at least one dose of vaccine. County-level data is available via the CDC (links to Excel spreadsheet of June 1 national report).