Public Health

William Melms, MD, on vaccination challenges in rural areas


Watch the AMA's COVID-19 Update, with insights from AMA leaders and experts about the pandemic.



In today’s COVID-19 Update, a discussion with William Melms, MD, chief medical officer of the Marshfield Clinic Health System, about vaccination in rural communities, including addressing hesitancy, misinformation and other challenges.

Learn more at the AMA COVID-19 resource center.


  • William Melms, MD, chief medical officer, Marshfield Clinic Health System

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Unger: Hello, this is the American Medical Association's COVID-19 Update. Today, we're talking with Dr. William Melms, chief medical officer of the Marshfield Clinic Health System in Marshfield, Wisconsin, about vaccination in rural communities. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Melms, we've seen a number of reports, including a recent study by the CDC that revealed substantially lower vaccination rates in rural areas as compared to urban ones. Is this reflected in what you see in the Marshfield patient population?

Dr. Melms: Yeah. Thanks, Todd, for having me on, first of all, and it absolutely is reflected in what we are seeing. First, for the state of Wisconsin, let me just say that we peaked in Wisconsin for vaccine administration around April 4.

Unger: Wow. That's early.

Dr. Melms: That was early. But since that time, if you look at the numbers, they have been dropping pretty consistently in terms of vaccines administered. And so, the week of May 25, if we compare that to the week of April 4, we administered about 25% of the vaccines the week of May 25 than we did the week of April 4.

Unger: So that dynamic, of course, is playing out to a certain extent in different places and we're running into a more hesitant population, more resistant population. That's obviously a challenge in our country right now. Is that what you see at the foundation of this slowing?

Dr. Melms: Well, we definitely see some variation. For example, let me compare Madison to Marshfield. That'll probably be pretty good to illustrate the point. Wisconsin is divided up into seven health care emergency regions. Madison is in the south central region. The rate of vaccine administration, so the percent of the population that's received at least one vaccine, in that area is 55%. And, in fact, for Dane County, where Madison is located, Dane County has a rate of 67%. For the north central region where Marshfield is and much of rural Wisconsin lives that rate is 43%. And, in fact, we have two counties in our service area that have rates of 25%. So yeah, there's a big difference.

Unger: Obviously it resembles, even at the statewide level, the blue, red divide. We're seeing that in the South right now. And then even within your state, what I'm hearing you say, is that dynamic is playing out. Is that part of the issue here?

Dr. Melms: Well, if we're going to go the blue, red divide, yes, it's part of the issue here, but I would say, and certainly along political lines there is no doubt that there's a difference in vaccine acceptance and administration rates. But those lines are very blurred when it comes to rural versus urban. There's plenty of political influence in the urban areas as well.

Unger: I mean, the other divide that we're seeing is that while we're seeing lower rates of COVID-19 infections and deaths, when you segment that between vaccinated and unvaccinated populations across the country, you see a different story. Are you seeing that play out as well in Wisconsin?

Dr. Melms: Well it is and, thankfully, our numbers are down so far from where we were back in November when we were surging in November and the number of deaths each day is low. I think that our rate of deaths each day is about five patients per day right now. But as we're seeing this, when we know that these people could have been vaccinated, I'm telling you, it is absolutely tragic.

Unger: It is. Are you concerned about some of these variants, like the Delta variant, that we're seeing pop up now and gaining ground?

Dr. Melms: Certainly. We have to be concerned about the variant and the majority of the isolates tested in Wisconsin now, I guess, it's now the Alpha variant B.1.1.7 out of the U.K., but over 90% of Wisconsin's isolates are variants, and the U.K. variant has been the most predominant one. But more contagious, more lethal and this is all the more reason we have to get people vaccinated.

Unger: Well, we've talked about hesitancy as a possible root cause of this issue. What are you seeing in terms of access, which is another thing that might be overlooked? Is that an issue?

Dr. Melms: Access is certainly an issue. We can't discount that. It's not just hesitancy. If we look at rural areas, lack of public transportation, the longer distances between vaccination sites, between clinics, between pharmacies and pharmacies have become a bigger source of vaccine certainly as the pandemic has gone on. Access to technology, access to broadband. At some point during this process, we really shifted our appointing process over to an online one. We did that for both the convenience of our patients and also for the efficiency of the process. But in doing so, we had to be mindful that many of our patients and residents in our part of the world don't have access. And so we had to maintain more traditional ways to appoint as well.

And also we truly need, from an access standpoint, we need the employers in our communities to buy in to all of this. They need to give their employees time to drive to distance sites to get vaccine and to get back from the vaccination back to work. And we'd like them to have paid time off to do that. I think that would increase the rate.

Unger: So what you're really facing is a double whammy problem. One, we're down into a more hesitant population and you've got real access issues in these rural locations. I mean, you mentioned a problem right there. What if you have to drive a long way and getting off work is a problem? Are there any other strategies you're having to employ to adapt to this new set of folks?

Dr. Melms: Yeah, from the standpoint of that aspect of all this, when we first started rolling out the vaccine program, because of the nature of the vaccine, because of the fact that we didn't get much vaccine, we really were providing that vaccine from some of our larger centers. And now what we've done is we've taken that vaccine out, we've moved it out to more of our rural primary care locations, so we've gotten it closer to the patients. We're in the process right now of operationalizing our mobile primary care van and determining how we'll use that as a platform for vaccine administration as well.

Unger: So bring it to them, I guess.

Dr. Melms: Absolutely.

Unger: This issue of incentives is something that's popping up all across the country. Some employers are giving incentives. Some state governments are giving incentives. Does this seem to be working as a strategy?

Dr. Melms: I don't know if it's working as a strategy. I'm not opposed to it, believe me, whatever an employer wants to do for their employee to incent them getting a vaccine. I do believe that just providing them the support to go get the vaccine is probably the most important incentive. As we were rolling out the program for our employees, we were debating incentives and should we pay them. Should we give them some sort of stipend for getting the vaccine? And what we landed on was we now provide a donation. The system donates to two different funds every time one of our employee gets a vaccine. We make a donation to the Care For Caregivers fund and to the Hope Fund.

Both of these funds benefit our employees. Care For Caregivers, we provide meals to front-line workers. The Hope Fund provides financial assistance to employees who find themselves in tough situations for a variety of reasons. We felt really good about doing it that way and I think it's at least been recognized by our employees as a good thing.

Unger: That's a nice incentive. Last question for you. The CDC awarded Marshfield Clinic $4 million in terms of a grant to study the occurrence and impact of COVID-19 in rural communities. I know it's an ongoing study right now and possibly too early, but can you share anything that you're learning and how it might shape our public health response?

Dr. Melms: Latest update, it is too early. I spoke to the principal investigator yesterday and we don't have data yet. But basically this study, it's the Prospective Assessment of COVID-19 in the Community Study, is the name of the study, and we're going to be looking at 1,500 rural residents over a period of a year looking at various aspects of how the disease is transmitted and how it affects them and how uptake of the vaccine somehow has an effect on all of this. So we're certainly hoping to get substantial information out of that study. Looking forward to it, but we just don't have anything to report on yet.

Unger: Well, that sounds like a reason to invite you back when you do have the data. We'll look forward to learning more about it. Dr. Melms, thanks for joining us today. We'll be back with another segment shortly. In the meantime, for more information on COVID-19, visit Thanks for joining us today. Please take care.

Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.