A recent analysis by the Rural Policy Research Institute found that 111 rural counties, mostly located between the Mississippi River and the Rocky Mountains, have no pharmacy that can give the vaccines. It could make thousands of vulnerable Americans struggle to find vaccines, which in turn threatens to prolong the pandemic in many rural areas hit hard.
And in areas without local pharmacies, rural residents may have to take long distances to get shots, and that twice for vaccination at two doses. An analysis by the University of Pittsburgh School of Pharmacy and the West Health Policy Center found that 89% of Americans live within 8 miles of a pharmacy. But more than 1.6 million people have to travel more than 20 miles to the nearest pharmacy, which can lead to difficult weather and road conditions in remote areas.
“If pharmacies are closed, especially in places where there is no other healthcare provider, you have a health desert,” said Michael Hogue, president of the American Pharmacists Association. “You have to depend on whether a mobile clinic comes in from another area to provide vaccines, or that the citizens will have to drive further to get a vaccine.”
So far, with a limited amount of doses and strict restrictions on who is eligible, this has not been a problem. But as vaccination opens up to the general public and the stock of vaccines increases, local health departments may be overwhelmed by the demand and have to outsource the task of vaccinating locals to other health care providers.
“It’s probably not playing out yet because we are not getting enough supplies,” said Keith Mueller, director of the Rural Policy Research Institute’s Center for Rural Health Policy Analysis. “That means we have some time for the local health departments to figure it out: Who in my radius has, if you will, the ability to administer vaccines?”
From 2003 to 2018, 1,231 independent rural pharmacies closed, Mueller’s team found, leaving about 630 rural communities without a retail store. The changing economy in the pharmacy industry has managed it, a combination of national pharmacy chains that have expanded and consolidated, large box stores and supermarkets that have opened their own competitive pharmacies and pharmacy benefit managers, who are eating up their profits for small pharmacies. Mail order options have abolished business.
And you can not get vaccines by mail.
‘No medical infrastructure’
In many towns, those pharmacies represented the last bastion of health care in their communities. Residents now feel more than ever before.
“We have no medical infrastructure,” said DeAnne Gallegos, a spokeswoman for the San Juan County Department in southwestern Colorado. “We do not even have a doctor.”
With the nearest pharmacy located in Durango in a neighboring country, vaccinations in San Juan County were handled by the health director and two nurses. They have weekly vaccination clinics when they get doses. On February 18, the health department completely vaccinated 298 of its 700 residents.
Provinces are allocated doses based on their populations throughout the year, but the Department of Health hopes to vaccinate outside states who also visit. San Juan County has an influx of tourists and homeowners coming from states like Texas, Arizona and Florida, where the pandemic has intensified and vaccination rates are declining. Thus, the Department of Health could eventually vaccinate more than 200% of the official population of San Juan County to keep Covid-19 out.
“Our attitude is, no matter what your driver’s license or zip code says, if you live within our close-knit community, this is someone we hope the state will allow us to bring into the kraal,” Gallegos said.
But it underscores what she called the weak structure the department had in the first place.
“It’s our responsibility to make appointments, manage the data, make contact, receive calls,” Gallegos said. “If you do not have the staff or the budget to hire extra staff, it also makes it very difficult.”
Further east, Custer County has no pharmacy for years. Recently, a pharmacist who lives in the country but works in a county an hour away has begun delivering prescriptions to Custer residents when she returns home after each shift.
But she can not bring vaccines home.
Instead, a public health nurse who would retire at the end of 2020 decided to continue vaccinating residents with the help of another nurse and retired health workers who retain their licenses. According to the director of Custer County Public Health Agency, dr. Clifford Brown, they vaccinated more than 630 of the province’s 5,200 residents.
In an ideal world, they would be able to hand over the task to a pharmacy.
“We do feel the pinch,” Brown said. “I wake up at about 3 in the morning and think about how in the world are we going to stretch things out to cover for this day?”
Pharmacies offer clear benefits as vaccine providers. Hospitals, which traditionally did not vaccinate the general public, had to set up programs to distribute their assigned doses.
In Colorado, pharmacies produce more than a million flu shots a year, says Emily Zadvorny, executive director of the Colorado Pharmacists Society, and has a much closer relationship with their customers, especially in smaller towns than larger healthcare providers do. She points to a pharmacist in Kiowa County, Colorado, who compiled a list of all his clients aged 70 and older and called each of them to plan their vaccinations for Covid-19.
“They have so much more capacity than they have supplies,” Zadvorny said. “It’s just a slow process to rush up.”
A ‘learning curve’ for pharmacies
Even where pharmacies exist, it was a challenge for independent drugstores to participate in the Covid-19 vaccination. For flu, pneumonia or shingles vaccines, stores usually order as many doses as they think they can sell, which are delivered along with the pills they distribute.
The Covid-19 vaccines, on the other hand, are distributed through a national program that has a significant learning curve for pharmacies. The federal Centers for Disease Control and Prevention has partnered with 21 pharmacy chains, including four networks of independent pharmacies that give smaller drugstores more purchasing power. According to the National Community Pharmacists Association, the four networks comprise approximately 8,000 of the 21,000 community pharmacies nationwide. Pharmacies that are not part of the networks can apply to be vaccine providers in their states.
“The biggest hurdle for most pharmacies is just getting approved,” said Kyle Lancaster, pharmacy director at Our Valley Pharmacy, a chain of three pharmacies in rural Lincoln County, Wyoming.
Our Valley applied to federal and state health agencies and had to upgrade its freezers with digital data loggers, which upload the refrigerator and freezer from pharmacies and report directly to the CDC.
According to him, most small pharmacies were limited to the Moderna vaccination, which has less stringent temperature requirements than the Pfizer version. The Johnson & Johnson vaccine, recently approved, will be even easier to handle for rural pharmacies.
Lancaster said he is not sure how many doses of the vaccine will get his chain or when.
These uncertainties leave residents like Nan Burton, 63, worried about getting vaccinated. Last year, she and her husband decided to eradicate the pandemic in their vacation home in Lincoln County, and they exchanged apartments in Seattle for the wide open spaces of Star Valley Ranch, about 14 miles from the nearest Our Valley branch. With the plan to retire fully next year, they stay forever.
So far, Lincoln County – a region more than three times the size of Rhode Island – has vaccinated about 2,500 of its nearly 20,000 residents, mostly through the local hospital. But without large chain pharmacies in the region, the country has to wait until independent pharmacies in the community, such as Our Valley, get up and running.
Burton said she and her husband have only one choice but to wait and hope the distribution of vaccine logistics is sorted out. They would be willing to drive for hours to get a vaccine if they knew they were not taking it away from someone else in need.
“Until there is a national effort to reach out to rural communities, I think we’re going to be in trouble,” Burton said.
KHN (Kaiser Health News) is a non-profit news service that covers health issues. This is an editorial independent program of KFF (Kaiser Family Foundation) that is not affiliated with Kaiser Permanente.