The COVID-19 vaccine has been hard to come by in Barnwell County.
The small rural county of about 21,000 people on the state’s western border has one of the highest per capita rates of coronavirus infection in South Carolina and is one of eight counties in the state without a hospital.
Until this week, only one vaccine provider in the county outside the local health department had even received any doses, and it’s no longer taking appointments.
Desperate to procure more vaccine for his community in recent weeks, Barnwell Mayor Marcus Rivera reached out to local state lawmakers for help. Within hours, he received a call from the Medical University of South Carolina. The hospital wanted to hold a vaccination clinic in Barnwell to pilot its rural distribution process.
“Some way, some shape, some fashion, they got in contact with me and we made it happen,” Rivera said.
On a fortuitously dry day last week, a team from MUSC vaccinated more than 400 people in a Barnwell shopping center parking lot. The pop-up drive-through clinic serviced more people in about eight hours than any county provider had in the previous two months.
“It was great,” Rivera said afterward. “Absolutely amazing. With the amount of people we had come out, how fluid everything went, it was just seamless for everyone involved.”
The triumph of the recent clinic aside, Barnwell, like many rural parts of the state, continues to get far from an equitable supply of COVID-19 vaccine doses.
If vaccine were being distributed to counties based on their relative population, as the state Department of Health and Environmental Control is currently considering, Barnwell would have received nearly 3,000 doses by now instead of the roughly 200 it had gotten prior to last week.
Eliminating disparities in the state’s vaccination rates won’t be easy, but it is achievable, said Georges Benjamin, executive director of the American Public Health Association.
The first step, he said, is identifying the problem.
DHEC did that this week when it released an online dashboard with demographic data on who is being vaccinated and where they’re getting shots. The agency has yet to release data on where vaccine recipients live, but officials said they’re working on it.
The new demographic data shows that white residents are getting vaccinated at far higher rates than Black and Latino residents, and that urban centers with large hospital systems have been the primary recipients of COVID-19 vaccine.
DHEC’s data shows that more than 40% of the roughly 727,000 shots in arms to date have been administered in Charleston, Richland and Greenville counties, whose combined residents make up just 26% of South Carolina’s population.
By comparison, a total of 4,946 doses have been administered in the eight rural counties that lack a hospital, roughly a third of what would be expected were the vaccine being administered equitably.
The disparities are particularly vexing given the impact the pandemic has had on rural parts of the state. Despite having much smaller populations than South Carolina’s metro centers, COVID-19 has spread broadly through some of the state’s least populous counties and killed residents there at alarming rates.
Over the past three months, the rural counties of Marion, Marlboro and Union have suffered the highest COVID-19 mortality rates in the state, according to public health data.
DHEC officials this week acknowledged the vaccination disparities between urban and rural communities, which they partially attribute to large metro hospitals receiving the state’s initial vaccine doses, and said they were working to combat them.
“We’re giving a lot of vaccine in rural counties, but we’re still lagging behind,” newly appointed DHEC director Edward Simmer told lawmakers Tuesday during a House hearing on vaccine distribution. “If you look at our vaccine rates, we are doing better in large urban counties than we are in the rural counties. And we need to do better in the rural counties.”
Rural residents face barriers to vaccine access
Getting shots into the arms of rural South Carolina residents is tricky due both to the dearth of local COVID-19 vaccine providers and the infrastructure limitations that exist in many rural parts of the state.
Rural counties, especially ones without hospitals, may have only one or two providers activated to dispense the vaccine, mostly in very small quantities. Many rural providers — typically family medical practices, federally-qualified health centers and pharmacies — have received fewer than 1,000 doses total to administer.
Even doctors and nurses in Barnwell County had major problems getting vaccinated initially, said state Senate Minority Leader Brad Hutto.
“If you practice medicine in a county without a hospital, they weren’t deploying any vaccine to those areas,” said Hutto, an Orangeburg Democrat. “So, for example, doctors in Barnwell County were having to drive to Aiken County.”
When doses do find their way into rural counties, spotty broadband service — about 650,000 South Carolinians do not have high-speed internet access — and a lack of reliable transportation can make it cumbersome to schedule and keep an appointment.
Rivera, the Barnwell mayor, said he heard from many residents who struggled with the tedious registration process, which, at least initially, required internet access, a working email address and the patience and tech-savvy to navigate a confusing federal sign-up system that even DHEC officials have roundly criticized.
Community members also have been forced to compete with those from outside the county for the limited number of local vaccination appointments, which has sometimes resulted in non-residents snatching up slots and leaving Barnwell residents in the lurch, he said.
“I don’t want to not welcome people coming in,” Rivera said, “but I want to make sure that if we’re having an event locally that our local residents get first dibs on the vaccinations.”
Technology issues also have tripped up residents trying to schedule vaccination appointments in Newberry, a rural county of about 38,000 people located 80 miles north of Barnwell.
Nearly two weeks after receiving its first 400 vaccine doses, the Emmanuel Family Clinic in Newberry had administered exactly one of them, and that was to an employee, office manager Debra Cleveland said.
“We’ve had shots and weren’t able to give them,” said Cleveland, who explained that many clients struggled to make heads or tails of the Vaccine Administration Management System, or VAMS, the federal portal used to book appointments.
“We have patients who can’t read or write, who speak another language, elderly people who don’t have a computer in the house and don’t have cell phones, and they’re supposed to have an email to (register).” she said.
Fearing the spoilage of their vaccine doses, which had to be administered within 30 days, Emmanuel worked with DHEC and the U.S. Centers for Disease Control and Prevention to come up with a solution that would work for their clients.
Rather than making patients go through the registration process online, Emmanuel was given permission to take patient information over the phone or in person and enter it into VAMS for them, Cleveland said.
Within two hours of switching to the manual registration process on Feb. 9, Emmanuel had already processed and vaccinated 20 people, she said. Now 10 days later, the clinic has administered 325 of its 400 doses, according to DHEC.
“I’m having to put a lot of information in instead of the patients,” Cleveland said. “But if that’s what it takes, that’s what it’s going to take.”
Barnwell officials and MUSC also developed a workaround in advance of last week’s clinic to ensure local residents received vaccination priority.
Rather than posting information about the clinic on the MUSC and DHEC websites, officials shared the sign-up link only with community leaders and on local social media pages so residents from outside the county would be less likely to take appointments away from Barnwell residents.
Rivera said he also reached out to a local senior center about the clinic and encouraged its director to register interested residents.
“We tried to be proactive about it so when we had the opportunity, we jumped on it,” he said.
While some non-Barnwell residents found out anyway, including one whose son drove her about 50 miles from North Augusta to take advantage of the opportunity, most of those vaccinated were locals.
“I think I recognized everybody that came through that vaccination site for the time I was there,” Rivera said.
DHEC working to expand rural vaccine access
In addition to working with rural communities to help smooth over technology and access issues, DHEC has also expanded the number of vaccination clinics it’s holding in rural areas.
As of last week, the agency had vaccinated nearly 10,000 people at 79 separate events in predominantly rural counties, spokeswoman Laura Renwick said.
DHEC primarily holds its clinics at the health departments it operates in each county, but it has also held “mobile events” at recreation centers, churches and schools across the state.
The agency has delivered doses at dozens of such events in the past two weeks alone, including at a McCormick County church, a Marion County gymnasium and a Dillon County wellness center.
“We know a lot of our folks, especially 65 and over, do not have internet, do not have easy transportation,” Simmer said. “And that’s why we’re looking to things like these mobile units to get it out into communities where people are, to make sure that we’re maximizing equitable access to the vaccine.”
DHEC also continues to push out more vaccine doses and ancillary supplies such as gloves, Band-Aids and face shields to rural providers each week. As of Tuesday, it had activated more than 100 rural health clinics and federally qualified health centers in underserved areas across the state, Simmer said.
The agency also is planning to staff up to 46 teams to work with county health departments and assist vaccination efforts statewide, especially in rural and underserved areas. Renwick said the teams would be independent of health department staff and would rove between counties to improve access in all corners of the state.
DHEC also wants to connect with local leaders and trusted community organizations to make inroads in rural parts of South Carolina, where a greater proportion of residents are assumed to be skeptical about getting the vaccine.
A recent Kaiser Health News survey found that rural residents and Black adults — who comprise a significant chunk of South Carolina’s rural population — are among the groups most hesitant to get vaccinated.
“(Rural residents are) much more likely to listen to the people that they know and trust, and that’s going to be the people in their local community,” Simmer said Tuesday. “We want to get those folks engaged with us, get them on the team, educating folks about the vaccine, (and) when they’re eligible, have them getting the vaccine publicly, so the folks who look up to them for guidance know it’s the right thing to do as well.”
To build confidence in the safety and efficacy of the vaccine, state health officials have participated in more than 80 public speaking engagements since November, including virtual meetings with faith-based groups and interviews with Spanish language news outlets, Renwick said.
Going forward, DHEC plans to develop testimonials and public service announcements to encourage vaccination against COVID-19 and also is working with South Carolina businesses and nonprofits, including Columbia-based Hold Out the Lifeline, to target African American churches and community groups with pro-vaccine messaging, Renwick said.
“I’ve been going out into the community, even in the few days I’ve been here, our teams have been doing that,” Simmer said. “And we can educate the community leaders and our partners can educate the community leaders, and then let the community leaders take the message from there.”
Communication an issue for DHEC, rural officials say
But the agency’s communication with rural leaders and vaccination providers hasn’t always been consistent, some said.
Barnwell officials said DHEC’s repeated failure to notify them before holding clinics in their county has prevented adequate promotion of the events and may even have precluded local residents from participating in them.
The day before MUSC vaccinated hundreds of Barnwell area residents in the parking lot of a Cricket Wireless store last week, DHEC held its own clinic at the county health department, unbeknownst to city and county leaders.
“We had no notice that that event was even going on,” said Rivera, who added it was the second time in recent weeks that DHEC held a vaccination clinic in the community without telling him.
Barnwell County Administrator Tim Bennett was so annoyed at being kept out of the loop that he posted about the fiasco on the county’s official Facebook page.
“Would have loved to have known this,” he wrote Feb. 9, upon learning DHEC was just wrapping up a clinic at the local health department and that all the slots for two upcoming COVID-19 vaccination events in Barnwell were already booked. “I guess we missed the email?!?”
Bennett said he felt better about the situation after emailing with a DHEC official the next day, but he stressed the need for the agency to improve in its communication.
“Help us help you get the good word out that DHEC is doing the dead level best it can to get shots in people’s arms,” he said he told the agency official. “DHEC needs to communicate, at least to our county, that shots are being done in our county. That’s good news, and to get that just by happenstance was pretty frustrating and exasperating.”
Renwick, the DHEC spokeswoman, said the agency typically reaches out to county officials when support or assistance is needed at local vaccination events, but did not explain why that apparently had not happened on multiple occasions in Barnwell.
She added that since last March, DHEC staff have attended weekly meetings with county administrators and emergency managers from around the state for the sole purpose of discussing local-level information.
Calhoun County EMS director Crystal Youmans said she also has struggled to get answers from health officials about vaccine issues in her county.
Youmans said she’s been approved to have the county EMS headquarters serve as a vaccine provider, but has yet to get any doses from DHEC to administer.
“The biggest struggle has been the communication with DHEC,” she said. “I’ve sent numerous emails to them and a lot of them have fallen without responses.”
Youmans said the agency told her the EMS building would not be activated until the state received additional vaccine supply, but has yet to give her an idea of when that might occur or answered her questions about how the allotment process would work.
For the time being, Calhoun County has only one vaccine provider, a family medical clinic that has administered fewer than 400 doses to date, and residents are aching for more vaccination options.
“We get called and asked frequently about when we’re going to be giving the vaccine,” Youmans said. “We’ve made it known that as soon as we’re allowed, we will do it.”
Graham Adams, CEO of the South Carolina Office of Rural Health, said he believes there is a role for the mobile units DHEC uses to fill vaccination gaps in rural counties, but said the agency shouldn’t lean on them at the expense of local providers that are able to administer vaccines.
“In my opinion, mobile units can fill in a gap when there are not enough local providers available, but we should be careful not to put mobile units in communities where there are local health care providers willing and ready to participate in the vaccine administration,” he said. “There are still rural providers that have enrolled, but not been activated, and should be activated in order to ensure that we have adequate access points in rural communities.”
Adams commended DHEC for working to ensure COVID-19 vaccine flows into all nooks and crannies of the state, but said he wants to see the agency develop a more coordinated system so efforts aren’t duplicated, as appears to have been the case recently in Barnwell and as happened with COVID-19 testing sites earlier in the pandemic.
“What I think can be improved is to have a broader coordination system among all hospitals and health care providers, so that we are not duplicating vaccination efforts in the same community, on potentially the same day,” he said.
Vaccine supply remains the limiting factor
Until the state starts receiving enough vaccine each week to meet demand, it is unlikely to overcome the COVID-19 vaccination disparities in rural areas, Sen. Hutto said.
Hutto said he wasn’t satisfied with the pace of rural vaccinations, but also recognized the difficulty of reaching rural residents and understood that vaccine supply is the limiting factor.
“It’s not a lack of willingness in rural areas to do it,” he said. “If we had enough vaccine, you could hold an event like (the one in Barnwell) in every rural county tomorrow.”
South Carolina’s vaccine allotment has increased steadily over the last month, reaching 80,000 first doses this week, and is expected to increase another 23% next week to nearly 100,000 doses, White House officials said Tuesday.
While that would represent a more than 50% increase in supply since mid-January, it would still fall well short of meeting demand.
About 40% of the nearly 1.3 million people in Phase 1a have received a single shot and only 14% are fully vaccinated, DHEC said.
While it may be some time before South Carolina is awash in vaccine doses, Hutto said it is critical that DHEC begin consulting with rural mayors, council members, faith leaders and representatives from historically Black colleges and universities so the agency can promptly and equitably push vaccine out to rural areas as soon as it has the capacity.
“When they get enough vaccine and want to have an event at a church in Denmark or Greeleyville, they need to already know who the contact is,” he said. “I hope they’re already doing the groundwork for when they get the vaccine, where they’ll hold events and who they contact.”
If DHEC officials make the right connections on the ground, Hutto said they should not have trouble filling up clinics in the furthest reaches of the state.
“The little towns and communities will be able to produce the lines,” he said.
Until that happens, Rivera and other local leaders will need to continue taking matters into their own hands to ensure their residents receive their fair share.
“I honestly think that leadership needs to voice their opinions, their concerns of their citizens and make sure they hold those who represent them’s feet to the fire,” the Barnwell mayor said. “And I think if you sit back and you sit on your hands, you’re going to really be forgotten about, especially now with the demand being what it is for COVID vaccinations.”