BISMARCK — In the first months of the COVID-19 vaccine rollout, North Dakota has emerged as a national leader, getting hundreds of thousands of shots into arms efficiently and immunizing more than a quarter of its population by late March.

But top public health officials have asserted that “vaccine hesitancy” — skepticism or cynicism about taking the quickly authorized vaccines — will be North Dakota’s most daunting challenge on its path to herd immunity, and already, the pace of inoculation has slowed as the state has expanded eligibility for the vaccines to the general public.

Nowhere is this more true than western North Dakota, where a handful of counties have fallen behind the rest of the state with rates of first-dose administration that are more than 30 percentage points below leading counties.

“Most everybody that I know is like, ‘Hell no, don’t even come near me with that (expletive),’” said Tara Paul, a Denver transplant to the oil town of Watford City, who added that “99%” of people she talks to in the bakery where she works say they won’t be getting vaccinated.

“They don’t trust it,” she explained. “They don’t trust anything that comes out that fast.”

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The seven lowest counties for first-dose administration in North Dakota are west of centrally located Bismarck. McKenzie County, which includes Watford City, has administered first doses to a quarter of its residents, nearly 20 points below the statewide rate.

Dr. Joshua Ranum, an internal medicine specialist who practices in the western North Dakota town of Hettinger, said vaccine promoters are facing an uphill trek to raise inoculation rates in the region with most of the willing takers having already gotten the jab.

“We’ve had that first pass of people that were, like pre-pandemic Black Friday, standing in line waiting to get the vaccine …. They were the easy ones — they signed themselves up,” Ranum said. “We’re starting to see the folks that are sort of on the fence that we’re trying to nudge to the right side.”

What sets the West apart?

Ethan Haynes and Jess Goetz grew up in the same town at the same time but have come to different decisions on getting the COVID-19 vaccine.

Haynes, an 18-year-old retail employee and radio announcer in Dickinson, sought out doses of the vaccine as soon as he could, saying he wants life to get back to normal and herd immunity through mass immunization is the fastest way. He’s a rare case in Stark County, where only 7.2% of residents ages 18 to 29 had been fully vaccinated as of Friday, April 9.

Haynes said he’s also a shareholder in Pfizer and Moderna, so getting the vaccine amounts to putting his mouth where his money is.

Goetz, a 22-year-old biology student at Dickinson State University, is holding off on getting a shot after learning about immunology and concluding that the time-compressed development of the vaccines hasn’t undergone a high enough standard of scrutiny.

Given her youth and good health, Goetz figures she would rather take her chances with the virus over the vaccine. But Goetz is “nowhere near anti-vax,” even noting that if she worked in health care, she would get the shot. The soon-to-be college graduate said she would reconsider her stance on the vaccine in a few years if peer-reviewed studies find the jab is safe.

Ranum said the record speed with which the vaccines were developed is the most frequently cited concern among his apprehensive patients.

The doctor has noticed that acceptance of the vaccine roughly breaks down by age.

Residents over 65, who are more likely to be vulnerable to COVID-19, have enthusiastically adopted the shot, he said. Those under 40 became eligible for the vaccine more recently and will be a much tougher sell for Ranum and his colleagues. In between the Baby Boomers and Millennials is a more “persuadable” group that has genuine questions at the doctor’s office but may have read false information about the vaccine online, Ranum said.

While he hasn’t heard it firsthand, Ranum knows that some in deeply conservative western North Dakota have dug into politically driven or conspiratorial oppositions to the shot. He rejects those fears, playfully noting that Bill Gates and the government probably don’t care enough about what people are doing to inject them with microchips.

Dr. Joshua Ranum, a Hettinger internal medicine specialist, speaks at a press conference on Nov. 20, 2020. Screenshot via North Dakota Department of Health
Dr. Joshua Ranum, a Hettinger internal medicine specialist, speaks at a press conference on Nov. 20, 2020. Screenshot via North Dakota Department of Health

Both Haynes and Goetz said they’ve heard similar politically rooted objections to the vaccine in their community, with Goetz noting that her grandfather refuses to get a shot because he thinks “the only reason it’s out is because of (President Joe) Biden.”

North Dakota Senate Majority Leader Rich Wardner, a Dickinson Republican, said “many of those people out in the West are rugged individualists” — an ethos that often translates to a general lack of reliance on medical experts and the government.

Paul in Watford City described the attitude more bluntly. “Everybody here is just a rebel,” she said of the region, a hub for the state’s many itinerant oil workers.

Still, Paul, who curates a local community support Facebook page with close to 2,000 members, described a phenomenon she called “social norming,” that may be at play — many people in town have adopted similar views to one another when it comes to COVID-19 and its vaccines.

“Because everybody’s against getting (the vaccine), I think if somebody really got it, they wouldn’t tell anyone,” she said. “It’s just not the thing to do here.”

Tara Paul and her son, Shawn, sit in their home in Watford City, N.D., in January 2021. Tara said "99%" of people she talks to in the bakery where she works say they won’t be getting vaccinated. Adam Willis / The Forum
Tara Paul and her son, Shawn, sit in their home in Watford City, N.D., in January 2021. Tara said "99%" of people she talks to in the bakery where she works say they won’t be getting vaccinated. Adam Willis / The Forum

There were only seven counties in North Dakota where less than 30% of the eligible population had received at least one dose of the vaccine as of Friday, according to health department data. All of them are in the westernmost third of the state.

In two of those counties — Williams and Grant — less than a quarter of the eligible population had gotten at least one shot by Friday. That’s compared to a statewide first dose administration rate of 44%, above 50% in Fargo’s Cass County and over 59% in several other eastern counties.

State Immunization Program Manager Molly Howell points out that population figures on file for oil-producing counties in the West might be slightly overstated given last year’s economic downturn and resulting out-migration, which could mean the counties’ vaccination rates are actually a bit higher than stated by the department. But Howell said a possible shortcoming in the data is likely a minor factor, outweighed by the apparent lack of vaccine acceptance among western North Dakotans.

A survey conducted earlier this year by a research team at the University of North Dakota testifies to a similar trend. Isaac Karikari, a professor of social work, said his team received responses from some 1,400 people across North Dakota and found that in eastern North Dakota counties, close to 16% of respondents to the UND survey said they “definitely” or “probably” wouldn’t get the vaccine. In western counties, that same figure clocked in at 27%.

And though Karikari noted that his team’s survey didn’t show statistical significance in this regional trend, they collected responses on the reasons for vaccine skepticism from across the state. Some respondents expressed general mistrust stemming from the government’s pandemic response, while others noted the speedy authorization of the vaccines, citing a lack of study into their effects. Some questioned whether the new products are vaccines at all, with others noting a wariness of profiteering big-name pharmaceutical companies. Still some offered explicitly political answers, naming Dr. Anthony Fauci or the North Dakota governor’s office in explanations of their mistrust.

One through line is that skepticism about the vaccines tends to track directly with misinformation about COVID-19 itself, said Professor Bret Weber, a member of the UND team and a Grand Forks City Council member.

Transportation challenges in more rural areas may be contributing to a western lag, suggested Weber, but Ranum notes that access to vaccines hasn’t been a problem in the region.

Western county population centers like Williston and Watford City tend to draw transient oilfield workers, and Karikari noted that this younger demographic has shown less inclination toward vaccination since its health risks are lower.

Though North Dakota remains among the top states in the country in its vaccine rollout, a block of vaccine hesitancy could prevent the state from putting COVID-19 thoroughly in the rear view. The latest reports from the Department of Health show that uptake of the vaccines has recently slowed down, especially for age groups under 70 who were less likely to have gotten their shots in the initial wave.

COVID-19 vaccinations are prepped for use at the former Gordmans store in Fargo. David Samson / The Forum
COVID-19 vaccinations are prepped for use at the former Gordmans store in Fargo. David Samson / The Forum

Leading health organizations have put the goalpost for herd immunity around 60% of the population, though some medical experts have estimated that the barrier could be as much as 15 to 20 points higher. With vaccine hesitancy threatening to delay the state’s arrival at herd immunity, Howell stressed the milestone’s importance: Reaching the inoculation threshold will mean fewer COVID-19 deaths, fewer people faced with the long-term consequences of the disease and full reopenings for nursing homes.

And Ranum is hopeful that as time passes, promotional efforts ramp up and unvaccinated residents see their neighbors “aren’t growing a third arm” after getting the shot, the fence sitters and even vaccine deniers will come around. The doctor said those aiming to win over the skeptics should tie their vaccine messaging to something everyone wants, like a full economic reopening or more convenient travel.

“We all like to think we’re selfless and altruistic, but deep down in all of us there’s an ego and an element of ‘what’s in it for me?’” Ranum said. “I think that’s really what we’ve got to find and tap into in order to reach that more resistant audience.”