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Rural-Urban Gaps In COVID-19 Vaccination Rates Widen : Shots



Poverty and disability are associated with lower vaccination rates in some rural communities. The van, sponsored by the Vaccination Transportation Initiative, is helping rural residents get the COVID-19 vaccine in rural Mississippi. The effort is aimed at overcoming the lack of transportation and access to technology for rural residents. Rory Doyle / Bloomberg via Getty Images Hide caption

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Rory Doyle / Bloomberg via Getty Images

Poverty and disability are associated with lower vaccination rates in some rural communities. The van, sponsored by the Vaccination Transportation Initiative, is helping rural residents get the COVID-19 vaccine in rural Mississippi. The effort is aimed at overcoming the lack of transportation and access to technology for rural residents.

Rory Doyle / Bloomberg via Getty Images

Rural communities outside American cities continue to fall behind in the race to get vaccinated against COVID-19 as President Joe Biden’s July 4th goal of reaching 70% of American adults looms on the horizon.

Alaska is the only state where the average rural rate of fully vaccinated people since the 19th century has been control and prevention.

Everywhere else, rates in urban counties have exceeded those in rural counties.

Over a dozen states where rural rates actually exceeded urban rates seven weeks ago have turned and are now lagging behind their urban counterparts. These include Oregon, where rural areas are now 9 percentage points behind cities, and Maine, where they are now 7 points behind.

Florida, Massachusetts, and Nebraska have the largest differences, with rural counties lagging 14 percentage points. For Florida and Nebraska, these gaps are about twice the size of mid-April.

While these gaps are strong, they can hide a more complex history of vaccination rates, as the data shows many rural counties well above average and urban areas dragging their feet.

“There’s a lot, let’s call it, of rural community judgments and a lot of guilt placed on them for masks and vaccinations,” says Mark Holmes, professor at the University of North Carolina’s Gillings School of Global Public Health. “There is an overall continuum and it is not that easy as all large areas are fine and all rural areas are not.”

In fact, a mid-May CDC report contained a detail that surprised Holmes: The suburbs that encircled his state’s largest cities, Charlotte and Raleigh, NC, had vaccination rates significantly lower than their urban cores.

Not only that, these suburbs were worse off than even rural counties scattered across the state. Counties around Minneapolis, Birmingham, Ala., Seattle, Denver, and Portland, Oregon repeated this pattern, with the suburbs lagging both urban and rural counties in their states, according to the CDC’s analysis.

Bags with lower vaccination rates are a problem for people everywhere, experts say. If COVID-19 flared up in an unvaccinated rural or suburban area, these outbreaks would likely spread to nearby cities, according to Keith Mueller, director of the University of Iowa’s Rural Policy Research Institute.

“If we have learned something from 18 months of this pandemic, we have learned that it can spread from any location to any location. We are a far too mobile society,” says Müller.

As COVID-19 restrictions wear off and the summer travel season heats up, more Americans are likely to venture into national parks and other outdoor destinations in rural areas.

“You stop to refuel and suddenly that’s your point of contact,” says Holmes. “It’s ineffective to look at our borders, whether it’s national, state, or county borders, and say that’s over there. It doesn’t come here.”

Socio-economically endangered counties are struggling more

A second CDC report from early June sheds light on demographic and social factors associated with lower vaccination rates in all counties, whether rural or urban.

The CDC ranks over 3,000 counties across the country using a social vulnerability index that measures 15 factors, including poverty, poor transport links and overcrowded housing, that weaken a community’s ability to respond to disasters.

The researchers divided the counties into four categories – large cities, suburbs, small to medium-sized towns, and rural areas – and looked for demographic profiles associated with lower vaccination rates. Across all of these categories, households with children, people with disabilities and single parents were more likely to have lower vaccination rates. And researchers say these gaps are particularly pronounced in suburban and rural counties.

Counties with a higher number of mobile home residents as well as those with higher poverty and lower education rates also lagged significantly behind other counties in their rural-urban category, according to the CDC report.

“Rural communities often have a higher proportion of residents over 65 who have no health insurance, live with underlying illnesses or disabilities, and have limited access to healthcare facilities with intensive care capabilities, which increases the likelihood of getting sick or dying of COVID-19” says Vaughn Barry, a CDC epidemiologist and a lead author on the report.

The fight against hesitation should be “hyperlocal”

The CDC reports highlight hesitant vaccination as the main obstacle to reaching rural areas and urge public health leaders to do more to overcome it. According to a survey published in April by the Kaiser Family Foundation, one in five rural Americans said they were “definitely not getting” a vaccine. It met with the greatest opposition from Republicans, White Evangelical Christians, key workers in non-healthcare sectors, and adults under the age of 50.

Strategies to overcome this hesitation will look different for the hundreds of rural counties across the country, says Marcella Nunez-Smith, White House Chairwoman of COVID-19 Health Equality Risk, but they are likely to share one critical point.

“Working with trusted, local community leaders is a must,” Nunez-Smith said at a news conference in May. “Equity work is always hyper-local. Communities are the experts for what they need.”

Doctors from the Navajo Nation, once one of the hardest hit areas in the country, say constant communication with their tribal members about battling the “monster” of COVID-19 has helped this remote area get some of the highest vaccination rates in New Zealand Mexico to reach Arizona.

Like most Indian tribes, the Navajo Nation has dozens of paid health workers who work with the Indian health service to venture into rural areas and build relationships.

“They know their field very well. They all speak the language,” says Dr. Loretta Christensen, Acting Chief Medical Officer of the Indian Health Service and a member of the Navajo Nation. “You can take the one-on-one with people who might be hesitant, and sometimes it was because they were afraid to leave their homes, but we went into the houses and gave those vaccinations.”

Friends and family can be among the most influential when it comes to convincing a reluctant person, adds Dr. Chris Percy of the Northern Navajo Medical Center in Shiprock, NM. added

Patients often tell him what made them show up at recent vaccination events: “They’ll volunteer that ‘my mother and sisters … were in my case to come in here,'” says Percy.

Christensen and Percy say they can’t hit someone over the head with data or get unwilling patients to take the vaccine, but what they can do is come across as kind and lower all barriers.

“Our systems that we set up on Navajo don’t have a pre-registration component, or you need to do these five things before you get an appointment,” says Percy. “If you come by on Tuesday, just come over. … When you have made up your mind and are ready, we will be here. “

Barry’s report echoes Percy, suggesting walk-in clinics with flexible evening and weekend hours to accommodate working hours and reach people in socially vulnerable communities. The CDC researchers also suggest that organizing vaccination clinics near childcare facilities and working with schools could improve the lower rates they have seen among single parents in suburbs and rural counties.


To Fix Healthcare After Covid-19, Doctors Must Have The Courage To Change



Doctors showed great courage during the Covid-19 pandemic. Now you have to show the courage to change … [+] the job.


Long before doctors battled the coronavirus, their professional ancestors risked their lives fighting the Black Death.

Throughout history, doctors have shown courage: the ability to act regardless of risk or fear.

Think sawing off a gangrenous limb or having brain surgery or treating a disease like Ebola which kills up to 90% of the people it infects. In these harrowing situations, courage alone is not enough. Doctors too, to a certain extent, have to deny objective reality. You need to suppress the existence of fear, detach yourself from its emotions, not admit weaknesses, deny any pain, show single-minded attention to the task at hand, and extinguish any feelings that are trying to escape in the process.

Until recently, no one questioned whether such extreme denial was mentally healthy. The doctors just thought it was necessary.

Courage and denial remain cultural imperatives in today’s profession. These properties are taught to every medical student and hardwired in every doctor.

And they have some unfortunate and tragic side effects.

I remember a talented doctor who returned to work the day after she received a final diagnosis herself. None of her colleagues, friends or patients knew about her illness until she died. In medical culture, this type of emotional distance is the rule, not the exception.

As a nation, we are indebted for the courage and refusal of our doctors. Without their courage and sacrifices over the past year and a half, Covid-19 would have killed many more of our friends and loved ones.

But now that our country has weathered the worst of the pandemic, it is time to address the American health care failures that harmed doctors and patients long before the coronavirus hit land. To do this, doctors need to play a leadership role both in transforming the health system and in challenging their own cultural assumptions.

These changes require more courage and less denial.

1. The courage to ask for help

In a recent article, I wrote about three critical care physicians who had recently gone through hell.

A doctor, a resident, had started his rotation in the intensive care unit with half a dozen Covid-19 patients under his care. All were dead by the end of the month. Another doctor, a die-hard ICU veteran, said she woke up in sweat every day before dawn. The third, a senior officer, watched four of his patients die in a single day.

Psychological defense mechanisms such as denial help doctors suppress fear and bypass grief over the loss of a patient. But as with any coping mechanism, denial is best used in moderation, not permanently. No level of denial, repression, harshness, or hardship could have prepared health care workers for the flood of death that Covid-19 wreaked. No amount of cultural conditioning could adequately prepare clinicians for the pain they have endured. As a result, many feel exhausted at work.

As the saying goes: “You can’t pour from an empty cup”. Too many cups are empty.

According to Medscape’s latest physician survey, 42% of all physicians are burned out. But only 7% of them say they see a therapist to improve their mental health.

It takes courage to challenge the medical profession’s culture of harshness and emotional repression. Doctors need a lot of strength to recognize their limits. And it takes courage to seek help when it is needed.

2. The courage to recognize one’s prejudices

It has become the standard in American culture to point your finger at others and blame others. Doctors are no different. On social media and at medical conferences, doctors are seldom willing to take responsibility for any of the many health care issues.

Take health differences, for example. Ask doctors why black patients have shorter lifespans and poorer health outcomes than whites, and they will blame socio-economic factors such as income, education, and the ills of American health insurance. They point to social determinants (where people were born and raised, work, play and socialize) and social dynamics (such as racial segregation, poverty and educational barriers). Of course, these external factors contribute to health inequalities, but they are not the only factors that play a role.

Research shows that two-thirds of doctors have an implicit black bias. This type of bias is different from open hatred or even conscious bias. But it is no less harmful.

At the start of the pandemic, when test kits were scarce, doctors tested white patients twice as often as black patients with identical symptoms. This makes no logical sense, as black patients were two to three times more likely to die than white patients.

Bias also helps explain why black patients receive 40% less pain medication than white patients after surgery. And it helps us understand why the average black patient receives $ 1,800 less in total medical care per year than a white person with the same health problems.

For decades, doctors have insisted that health inequalities are the fault of American society, existing policy, or other actors in the health system. While we must address these barriers to better health for all, doctors must also show the courage to hold up the mirror to the profession. After all, it is they who decide which patients will be tested and how much pain medication will be given.

Until doctors have the courage to face their prejudices, they will continue to violate the sacred oath of medicine to “do no harm first.”

3. The courage to treat patients like health partners

In the 21st century, the internet has flattened the gap between the experts and everyone else. In healthcare today, patients can explore diseases and treatments in unprecedented depth.

Many doctors believe that weeding out health information from the Internet is a recipe for “bad medicine.” May be. But doctors can’t expect patients to just stop looking for evidence on the internet. It’s not that people are suddenly asking for less information, less transparency, or less convenience from healthcare or other services.

American consumer culture is not going to go away. As a result, more and more Americans are demanding a new kind of doctor-patient relationship – one that looks far less paternalistic and more like a partnership. And this partnership must take into account the needs and wishes of the patient.

Telemedicine is a good place to start. Before the pandemic, only 8% of Americans had had a “virtual visit” to a doctor. Because most doctors had insisted that a good doctor’s practice can only take place in person. Covid-19 has proven that this perception is wrong. A recent survey found that 20% of consumers (55 million Americans) would trade their doctor for a doctor who offers telemedicine.

Historically, doctors have not valued or prioritized the patient’s time, convenience, or preferences. In the future, they won’t have a choice. A more equal doctor-patient partnership requires the courage to embrace alternative approaches to treatment and accept that patients have become (and will remain) savvy healthcare consumers.

4. The courage to uphold the true mission and purpose of medicine

For most of medical history, illnesses plagued doctors. Epidemics killed millions, including doctors who comforted the sick and dying. Entire civilizations died a gruesome death with doctors at their sick beds. And yet doctors never lost their nerve or the desire to help.

Many doctors today feel like victims of a broken system. They blame for-profit insurers, greedy pharmaceutical company executives, and hospital administrators for their professional dissatisfaction. And while they are right to call for sweeping health reforms that will free them from the administrative distractions that keep them from doing their jobs, they must also show the courage to change what they can control.

Doctors are the ones who write the prescriptions that contribute to 60,000 opioid deaths each year. They sign the surprising medical bills that have bankrupted millions of patients and their families. They contribute to the preventable medical errors that kill 200,000 people each year. They perform the 30% of all procedures that researchers at the Mayo Clinic have shown have no clinical value.

American doctors are at a crossroads. You are part of a wonderful and beautiful profession that is currently in crisis. Doctors must continue to uphold the righteous mission and purpose of medical culture. At the same time, they must have the courage to develop the most problematic parts of the culture. Not only does this benefit patients, but it also restores the appreciation the profession deserves.

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As COVID-19 cases wane, vaccine-lagging areas still see risk – The Denver Post



JACKSON, miss. – New COVID-19 cases are declining in most of the country, even in some states with vaccine-reluctant populations. But almost all states bucking this trend have below-average vaccination rates, and experts warn that pandemic relief in regions where few people are vaccinated may be temporary.

According to data from Johns Hopkins University, case numbers nationwide fell from a seven-day average of nearly 21,000 on May 29 to 14,315 on Saturday in one week. For weeks, states and cities have also been dropping virus restrictions and mask requirements indoors.

Experts said some states are seeing increased immunity because the disease has a high natural rate of spread, killing nearly 600,000 Americans to date.

“We certainly have some benefit to the population from our previous cases, but we paid for it,” said Dr. Thomas Dobbs, Mississippi State Health Commissioner. “We paid for it with deaths.”

More than 7,300 Mississippi residents have died from the pandemic, and the state has the sixth highest death rate per capita.

Dobbs estimates that about 60% of the state’s residents have “some underlying immunity”.

“We are most likely seeing this effect now because we have a combination of natural and vaccine-induced immunity,” said Dobbs.

Only eight states – Alabama, Arkansas, Hawaii, Missouri, Nevada, Texas, Utah, and Wyoming – have seen a seven-day moving average for infection rates from two weeks earlier, according to Johns Hopkins University. All of them except Hawaii have fully vaccinated lower than the US average of 39.7%, according to the US Centers for Disease Control and Prevention.

The 10 states with the fewest new cases per capita during this period all have fully vaccinated rates above the national average. These include the three most vaccinated states: Vermont, Massachusetts, and Connecticut.

Medical experts said a number of factors were playing a role in the decline in case numbers across the country, including vaccines, natural immunity to exposure to the virus, warmer weather, and people spending less time indoors.

But dr. Leana Wen, a public health professor at George Washington University, said she was concerned that the natural immunity of those exposed to the coronavirus could soon wane. And she worries that states with low vaccination rates could become hot spots.

“Just because we’re lucky in June doesn’t mean we’ll continue to be lucky through late fall and winter,” said Wen, former Baltimore city health commissioner. “We could have variants here that are more transmissible and more virulent, and those that have no immunity or have declining immunity could be vulnerable again.”

In Mississippi, about 835,000 people are fully vaccinated, or 28% of the population, compared to the national average of 43%. But despite the lagging vaccination rate, the state’s moving average of new daily infections has declined by about 18% in the past two weeks, according to Johns Hopkins.

Dr. Albert Ko, chairman of the Department of Microbial Disease Epidemiology at Yale, said there was no accurate data to show the percentage of the population in “high exposure” states like Alabama and Texas, but he said estimates assume up to 50%.

“I think it doesn’t deny the importance of vaccination, especially because the antibody levels produced by natural infections are lower than what we have for our best vaccine,” Ko said.

Ko said it is important that those who have been exposed to the disease also get vaccinated because natural immunity doesn’t last as long as vaccine immunity and antibody levels are lower.

Wen said research strongly suggests that vaccinations are beneficial for those who already have antibodies from infection.

“I think it’s a fallacy that many people don’t need to be vaccinated after they recover,” she said.


Pat Eaton-Robb contributed to this report from Connecticut.

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Marin mandates COVID-19 sick leave at small businesses



Companies with 25 or fewer employees in unincorporated Marin County are now required to provide paid sick leave to employees who are absent from work due to the pandemic.

The supervisory board unanimously accepted the mandate at its meeting on Tuesday.

“This law is designed to help our efforts to contain the spread of COVID-19,” Marin County Councilor Matthew Hymel told managers. “It complements some of our previous efforts to provide rental support and emergency assistance for COVID-positive, low-income residents.”

The ordinance expires on September 30, after which there will be no federal tax credit to reimburse companies for the cost of providing sick leave.

“This regulation is therefore a paid-for tool to help keep small business employees safe,” said Supervisor Damon Connolly.

The Families First Coronavirus Response Act, which went into effect on March 18, 2020, guaranteed certain employees who were unable to work due to the health crisis to receive paid sick leave. When that law expired in late December, President Joe Biden signed the American Rescue Plan Act, which extended the tax credit but did not mandate employers to grant paid sick leave.

On March 19, Governor Gavin Newsom signed Senate Law 95, which requires all employers with more than 25 workers to give their workers paid sick leave related to COVID-19 by September 30.

“This regulation establishes parity by ensuring that small business employees can take the necessary precautions to prevent the spread of COVID,” Connolly said.

Supervisor Dennis Rodoni said: “This is simply a hole in the safety net that we are closing with this action.”

According to the new regulation, a full-time employee who works 40 or more hours per week is granted up to 80 hours of additional paid sick leave. Part-time workers who work less than 40 hours per week are entitled to sick leave no more than their average number of hours over a two-week period, calculated over the last six months.

Employees do not have to have COVID-19 to be eligible for the benefit. You are also entitled if you are in quarantine due to COVID-19; Caring for a person who is sick or in quarantine due to COVID-19; have to look after a senior citizen or child whose normal carer or school is closed due to COVID-19; or make an appointment for a COVID-19 vaccination.

“This problem really affects mostly low-wage workers, mostly black women,” said Maddy Hirshfield, North Bay Labor Council policy director. “The system we have forces people to go to work sick, which is a public health issue at the best of times. It’s a public nightmare during a pandemic. “

Pedro Conceição, an organizer of SEIU-United Healthcare Workers, said, “Most low-wage California workers have no more than three days of paid sick leave as required by the state, and only 25% of private sector workers receive at least 10 days of paid sick leave annually. We firmly believe that no employee should be forced to choose between working sick and unpaid sick days. “

Rollie Katz, executive director of the Marin Association of Public Employees, said, “Hopefully we’ll get Marin cities to do this too.”

Officials in San Rafael and Novato said there are no plans to consider a similar measure.

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