The knock on Josie Hines’ door came just after 9 a.m. Tuesday.
On the front stoop of her Smithfield home, a trio of National Guard troops flanked a petite woman with a clipboard, her pink floral top stark against the camo uniforms at her back.
Hines was expecting them.
About two weeks ago, a similar crew arrived on her doorstep offering COVID-19 vaccines in Woodall Heights, a neighborhood of public housing off Interstate 95. Hines and Reginald Archibald, who she lives with, accepted. So did their neighbor across the street.
“We’ll be down here whenever you’re ready, okay?” Mary Banks from Johnson County Health Department told Hines through the screen door, gesturing to a white canopy tent popped up one door down on a grassy lawn.
Hines emerged a few minutes later in a T-shirt, face mask and hair cap, pushing Archibald in a wheelchair, lower legs bound tightly in flesh-colored bandages. Around their necks hung lanyards displaying their vaccination cards behind windows of protective plastic.
This is what the latest front in the fight against COVID-19 looks like in North Carolina.
As the vaccination rate statewide has plateaued just north of 50%, public health officials are shifting from mass vaccination events to smaller-scale, sometimes individual outreach in neighborhoods, workplaces, retail stores and churches. The state is pairing these efforts with financial incentives like a new lottery Gov. Cooper announced Thursday and more modest $25 gift cards to vaccine recipients and their drivers in some pilot counties.
To be successful, leaders of the vaccination effort must reach people living in the least wealthy areas across the state, a News & Observer analysis makes clear. A mix of state and federal data show unvaccinated residents are concentrated in places across the state where households earn the least.
That means that even if the state – as a whole – is more than 50% vaccinated, most North Carolina residents live in neighborhoods that are not.
And the reasons for that, health officials say, are complicated.
“If I have other pressing priorities because I am living at the lower end of the income scale and I’m managing to make ends meet, it’s hard for me to navigate those economic circumstances and add one more thing onto my plate – like getting a vaccine,” N.C. DHHS Chief Deputy Secretary Kody Kinsley said.
’Fault lines of inequality’
North Carolina remains among the 15 least vaccinated states in the country, according to Centers for Disease Control and Prevention data as of Thursday.About 4.6 million people in North Carolina have received at least one coronavirus vaccine dose so far, according to N.C. Department of Health and Human Services data. Among residents 18 and older, about 54% have received one shot – far short of Gov. Roy Cooper’s goal of vaccinating at least two-thirds of the adult population.
The potentially life-saving shots aren’t evenly distributed.
North Carolina has about 2,000 census tracts that subdivide each county, in many cases to the neighborhood level. About 800 of those tracts are more than 50% vaccinated, according to DHHS data as of June 1.
But those mostly vaccinated tracts are disproportionately clustered in areas with the highest median household incomes – places like Myers Park in Charlotte or Five Points in Raleigh with vaccination rates of 75% or higher.
And on average, the N&O analysis shows, for every additional $450 in typical household income, the vaccination rate of a tract increases by about a percentage point.
This disparity is consistent with what health officials see on the ground, said Kinsley, who heads up operations for vaccine rollout statewide.
“We’ve moved through the vaccine-eager, and we’re at this place now where it’s kind of like the vaccine resource-constrained,” Kinsley said.
It’s harder to get to the health department for a vaccine if you don’t have a car or affordable childcare, for instance. Or maybe you don’t have paid time off from a minimum wage job. A lack of insurance might mean you don’t often interact with a medical provider offering the shot.
“This pandemic is yet again exacerbating existing fault lines of inequality,” said Carolina Demography Executive Director Rebecca Tippett, who reviewed N&O’s findings.
New ground game
The area around Woodall Heights, located in a census tract where households earn $20,000 less than the state’s typical income, the vaccination rate has hovered around 30% for residents 12 and older for weeks.
On a particularly muggy, overcast Tuesday, Johnston County health workers had paperwork fanned out on folding tables under their tent next to a small portable freezer containing single vials of Moderna and Pfizer vaccines.
“Not too bad, right?” National Guard Sgt. Sabrina Caraballo said as she applied a bandage to Hines’ arm.
Caraballo applied a sticker to Archibald’s T-shirt declaring him fully vaccinated.
“If they hadn’t come out here – what ones of us that got it – we probably wouldn’t have got it. That makes a big difference for them to come out here and at least try,” Archibald said before Hines pushed him and his wheelchair home.
With their only appointments done and 13 vaccine doses in their freezer, Banks and a colleague paired off with a soldier and set off down the street to, for the second time in a month, go door to door.To reach lower-income communities, researchers and public health experts say, the mass vaccination model no longer really works. And that’s been apparent across North Carolina.
In Buncombe County in the western part of the state, Public Health Director Stacie Saunders has seen their mass vaccination site at a local community college dwindle from 4,000 vaccinations a week to 400 or so. Soon, they’ll transition to a smaller space at the health center.
“We are at a place where we have lots of supply,” said Saunders, who is also president of the N.C. Association of Local Health Directors. “We have many more vaccine providers than we did in the early days. But our demand curve has waned.”
From here on out, experts expect every additional uptick in the vaccination rate will be more difficult, more labor intensive.
“I think we’re gonna continue to trudge along at this slower rate now while we continue to make sure it’s available to everyone,” Kinsley said.
In response, health workers are no longer waiting for patients to walk through the door. Instead, they’re bringing the vaccine to the public’s doorstep.The new ground game response looks a little different in each county because there is no single solution, says Amy Underhill, public health education supervisor for Albemarle Regional Health Services, which serves an eight-county area in the northeast.
“I wish it was something fabulous that we’ve done here that we could just say, ‘This works. And you can replicate this everywhere.’” Underhill said. “But that’s not the case.”
ARHS is partnering with public transit to offer free rides, Meals on Wheels to reach the homebound and churches to set up pop-up clinics.
“I do think that has helped tremendously in bringing some of those individuals who might have been on the fence prior to,” Underhill said. “And it’s in a place where they feel comfortable.”
In Buncombe County, many of what Saunders calls her “small, but mighty” events are centered at major employers in the region, like GE Aviation and Thermo Fisher Scientific. Another one of her targets: primary care providers, where people are already seeking services.
“We are trying to think about the places that folks are likely to go, what are their trusted sources of information and medical care and where else might they be that they might be more open or interested in getting a vaccine,” Saunders said.
But the smaller and more targeted the effort, the bigger the lift for public health agencies that in many places have seen a marked decline in funding.
Agencies have seen an influx of one-time money during the COVID-19 crisis. But public health advocates are pushing lawmakers to increase the recurring funding earmarked to tackle the larger universe of communicable diseases.
Such a measure was part of the 2019 budget vetoed by Gov. Roy Cooper in a standoff with Republican leaders of the General Assembly. Similar legislation filed this year – House Bill 61 – would establish $36 million in recurring funding for the more than 80 diseases managed by public health agencies.
That measure could be rolled up into the larger appropriations bill state House and Senate members are hammering out in advance of the June 30 deadline.
One person at a time
About 50 apartment units sit along the bow-shaped loop of Woodall Heights in Smithfield. They sat largely silent Tuesday as the Johnston County Public Health Department’s vaccine clinic wore on through the morning.
But nurse practitioner Erin Smith and her colleagues were on the move.
The construction crew hammering away at a new roof in the neighborhood had been vaccinated – she already asked. The DoorDash driver who rushed a breakfast order to one of the apartments wasn’t interested.
One by one, Smith and National Guard Spc. Stephon Williams tag teamed the duplexes, while their counterparts worked the opposite side of the street. Most people didn’t answer, and the pair didn’t linger long before moving on to the next address.
Through the screen door, one woman told Smith she didn’t want the shot. Another said she was already fully vaccinated. Some were still on the fence.
Over the drone of the interstate 150 feet away, the team repeated again and again that they’d remain until 11 a.m. under the tent on the other side of the neighborhood’s grassy common lawn.
For the most part though, staffing clinics like these means waiting.
National Guard soldiers browsed their phones in camp chairs. Smith periodically logged the temperature of the trunk-sized vaccine freezer plugged into a nearby housing authority office with a long extension cord.
With about 15 minutes to go, a young woman in a mask walked up the lawn, young daughter in tow, to ask for a shot.
When health workers knocked on her door that morning, 23-year-old Briona Davis had already considered making her way down to the health department.
For Davis, the pandemic has been intensely personal. She lost her job at a retail outlet when the store closed last year, and several family members have died or experienced long-term symptoms after contracting the virus.
Like many others, she was skeptical at first that the new vaccines could be safe. She wanted to see how the rollout went before getting it herself.
“If people are getting it and you’re not hearing a lot of bad things about it, a lot of people aren’t tipping over and dying after they get it, then why not?” she said with a laugh.
The convenience of Tuesday’s neighborhood clinic was hard to ignore.
“This your first one?” Mary Banks asked as she prepared to give Davis her shot.
“First one,” Davis responded.
After two hours, with the street empty, the crew began folding up tents and tables. They filed forms, pamphlets and unused vaccine sticker sheets back into portable file boxes. The little freezer and its 12 remaining doses were returned to the trunk of Smith’s SUV.
“We’re just trying to eliminate every barrier that we can to make the vaccine as accessible as possible,” Smith said as the final pieces of gear were packed away. “That’s what these outreach clinics are about.”
It wasn’t her last stop that day, or even the next.
To get two-thirds of Johnston County’s adults vaccinated – the governor’s goal – health workers here will have to provide doses to about 28,000 more people, less than half the county residents reached so far. Statewide, North Carolina is 1 million people short of Cooper’s target.
All told, Smith estimates they’ve knocked on more than 100 doors in the county since early May. That’s not counting their outreach efforts at pop-up clinics at other locations and businesses, like the nearby I-95 truck stop they visited in late April.
In Woodall Heights Tuesday, four shots were progress enough.
BEHIND OUR REPORTING
How we did this story
In May, the N.C. Department of Health and Human Services began publishing vaccination data on the census tract level as part of an effort to focus outreach on areas with particularly high “social vulnerability,” an index created based on a range of factors like poverty and access to transportation.
While state officials have long published aggregate data on vaccine disparities among racial groups, tract level data gives us the opportunity to look for other potential relationships between vaccination rates and other factors like income.
McClatchy Newspapers analyzed the data by matching it with tract-level data from the U.S. Census Bureau’s 2019 5-year American Community Survey and rural-urban designations from the U.S. Department of Agriculture.