When Governor Mike Parsons announced the expansion of Missouri’s “rapid rollout” vaccine distribution plan on January 18th, Nate Blackford, president of Mosaic Medical Center, a small rural hospital in Nodaway County, did what any small-town Midwesterner in crisis would do. He made a phone call.
Tom Patterson, head of the Nodaway County Health Department, picked up.
“I mean, I figured he would,” Blackford says. “Our kids play baseball together.”
Both men had many of the same concerns about the vaccine rollout: logistical challenges, staffing shortages, uncertain product quantities, communication barriers. But they also had a shared goal: to get as many vaccines in arms as possible.
Blackford pauses, then adds: “And we just kind of went from there.”
Parson’s announcement — making COVID-19 vaccinations available to an additional 550,000 Missourians just two weeks after a highly criticized Phase 1A effort — was met with widespread concern regarding the state’s ability to achieve effective allocation criteria, reliable dose administration guidance and equitable distribution, especially between rural and urban counties.
Opinions vary, but perhaps the worries were unfounded. Though struggling to keep pace nationally—the state is 38th in first-dose vaccinations, according to the CDC’s most recent report—Missouri’s rollout appears remarkably equitable, with less than 1 percent difference between rural and non-rural counties in the average percentage of population vaccinated.
However, these numbers can be deceiving. While Missouri’s urban counties remain roughly consistent (34-36%) across percentage of population vaccinated, it’s feast or famine for many rural areas. Some jurisdictions are vaccinating over one-third of their population while others struggle to reach double digits.
Blackford’s Nodaway County is one of the success stories. Ten days after Parson’s announcement, a collaboration among Northwest Missouri State University, the Mosaic Medical Center and the Nodaway County Health Department administered over 700 first-dose vaccines to Phase 1B candidates.
As of May 13th, Nodaway County has vaccinated 34% of its 22,092 citizens, placing it third in first-dose vaccinations among rural counties and eleventh statewide.
A collaborative model
One of Blackford’s second calls, with Patterson joining him, was to Matt Baker, the vice president of student affairs at Northwest Missouri State University. During the school year, the university’s 6,000 students make up a quarter of Nodaway’s population.
Minutes into their conversation, Baker offered Hughes Fieldhouse, the university’s track and field center — large enough to fit two and a half football fields — as a vaccination site. He also offered the staff and student volunteers needed for clinic clerical work.
After that, Blackford says, the scope of the new phase of vaccine rollout seemed manageable.
Instead of hoping for 300 to 400 state-allocated vaccines per week, the agencies could pool their doses and register over 1,000. Instead of trying to funnel hundreds of the newly eligible through a cramped clinic, they now had a college-caliber fieldhouse at their disposal. And instead of each Nodaway healthcare heavyweight working to create a rollout workflow independently, they did it together.
Mosaic Medical, set to receive the largest amount of vaccine, started to collect clinical supplies and train vaccination day staff. Students in Northwest Missouri State’s emergency response training program pivoted studies toward assembling a mass vaccination workflow, while the university engagement staff recruited clinic volunteers to free up nurses. Meanwhile, Patterson’s Health Department rolled out registration, using Facebook and word-of-mouth to let people know about the vaccine’s availability and taking sign-ups by phone.
When January 24th rolled around, the newly formed Nodaway Collaborative was ready. The success of the first clinic carried over into a second clinic, then a third. As of mid-May, the program has grown into a 15-week-long effort that many credit as a key driver behind Nodaway’s vaccination success.
“We kept it simple,” Blackford says, “We’re not doing this for business reasons, we’re not doing it for any other reason, we just have the holistic goal of trying to get folks vaccinated.’” He pauses to look around the fieldhouse, arrayed in green and gold. “And it worked.”
By all popular measurements, Nodaway County was a prime candidate for distribution disaster: rural, white, high poverty, low education and, if you keep score by politics, overwhelmingly conservative. Donald Trump carried the county in 2020 with 70% of the vote.
Bridget Kenny, a Mosaic nurse, attributes Nodaway’s success to the community’s ability to act “ahead of the curve.” When vaccinations stalled mid-February, the Nodaway Clinic stepped up: Mosaic Medical brought on staff to expand clinic hours to reach blue-collar manufacturing workers, University IT staff introduced an online registration system to capture a wider range of vaccine candidates, and Nodaway County Health expanded its information campaign to include local newspaper columns, radio ads and even church bulletins.
Though administering a little over 150 doses, Nodaway’s twelfth clinic, held on April 20th, is a master class in efficiency. Twelve to 16 nurses, split between Mosaic Medical and Nodaway Health Department staff, vaccinate 16 people every five minutes. Four Health Department staff enter patient information into the Missouri vaccine database, a Mosaic Medical IT specialist standing by. Taped patterns zigzag across a football field’s worth the fieldhouse, waiting areas marked by highlighter-yellow signs—Registration, Consent Completion, Vaccination, Observation. University-recruited volunteers handle paperwork and observation support instead of nurses, allowing both Mosaic Medical and Nodaway Health County Department to stay open while the clinic operates.
Though relishing the clinic’s success, the tNodaway County mindset extends beyond the pandemic.
“It’s been a great team builder,” says Kenny, who grew up 10 miles from the fieldhouse. Flitting from patient to patient, vaccine to vial, the nurse taps syringes, checks paperwork, trades stories. Kenny and her team envision expanded rural medical care, a stronger local primary care network, a college-to-county nursing pipeline.
In the middle of the clinic, a trio of harried deliverymen, arms piled high with boxes that smell of fresh bread and salad dressing, stumble through the fieldhouse doors. Lunch, provided to free-of-charge to nurses and volunteers, courtesy of the local deli.
Kenny points them toward a back table.
“I said we wouldn’t need more than 20,” she says, laughing. “They must have sent 50. Nodaway, right here.”
Similar counties, different results
Four and a half hours south — four, locals say, if you don’t hit traffic in Kansas City —sits a county almost identical to Nodaway. It’s hilly, industry-driven, largely red on the political map. It’s also vaccinating at 14%.
After the governor’s announcement, McDonald County Health Department officials foresaw many of the same challenges as Nodaway. However, with the two-week period between the announcement of Phase 1B and its rollout overshadowed by a spike in COVID-19 cases, McDonald County was largely left off the boat.
Months later, many county health department workers—including nurse Erin Eagel, a McDonald County native—say that the Missouri ordering process makes it hard for them to catch up. In charge of allocating over 50,000 weekly doses across the state, Missouri doesn’t let vaccinators know who gets how much vaccine until 48 before the dose ships. This gives McDonald County’s understaffed department less than a week to pull together registrations, find clinic space, and launch a campaign to inform the public about availability — hardly enough time to look for partnership.
The disadvantage is also structural. Unlike Nodaway, McDonald County doesn’t have a centralized hospital in which to seek supplemental staff or additional vaccines. It’s only other collaborative options are three Ozark Hospital satellite offices scattered across the southern part of the county, all of which are just as short-staffed as McDonald Health.
On April 21st, minutes before the opening of a McDonald midweek vaccination clinic, the parking lot of the Pineville Community Center—the only place in town large enough for the occasion—was already full. Across the street, a large CLOSED FOR CLINIC sign tacked to the door, the McDonald Health Department sat empty.
By the end of the hourlong clinic, 31 people had been vaccinated.
A long time coming
McDonald County’s plight is not an unfamiliar one. Missouri’s decades-long underfunding of public health left many rural counties without a centralized hospital or resources for a multi-clinic collaboration. Instead, state legislatures scattered health clinics across low-resource rural counties as end-of-year surplus allowed, making crunch-time collaboration difficult.
With the COVID-19 vaccination rollout, the cracks between the clinics are showing. While rural counties as a whole are vaccinating a little over a quarter of their populations, those without a centralized infrastructure barely touch 22%. When including areas with no local hospital, this number drops even more, placing some rural counties as much as 15% behind their urban counterparts.
“Missouri was just so behind,” says Mary Gordon, state program manager for the Missouri Rural Health Association. She mentions past efforts at increased collaboration between state public health agencies that died on the Department of Social Services floor. “And we’re all sitting there going, gee, if this group had been working when COVID hit, we could have implemented so much stuff,” she says.”If we had been sitting around the table talking about access years ago, we would have been so much quicker.”
Gordon says increased public health funding could help low-capacity counties deal with the next public health crisis, giving policymakers an opportunity—or perhaps an ultimatum—to allocate resources toward local agencies’ health efforts.
She won’t find any argument from those between the track lanes of Nodaway County.
“At the end of the day, I believe a high tide raises all ships.” Blackford says. “We have to get to a place that prioritizes the population, health, and well-being of the patient, not just in Nodaway. We’ve got to do local health, together.”