Republished with permission from Governing Magazine, by Alan Greenblatt

Oscar Humberto works in landscaping. All of his coworkers have been infected by the coronavirus. Humberto had a bad enough case of COVID-19 that he was forced to miss several days of work. Nevertheless, he remained reluctant to get vaccinated. “I was afraid a little bit,” he says. “It’s weird to me.”

Finally, his wife insisted. Once he was ready, Humberto received a free vaccine one Saturday at a pop-up clinic conveniently located a block from his home. He was even offered his choice of a $25 gift card from Target or a pair of grocery stores.

The clinic was run by the Marin County health department. Marin County lies north of San Francisco, just across the Golden Gate Bridge. It’s one of the most affluent counties in the country, but it has pockets of deep poverty, including the neighborhood where Humberto lives. “The Canal neighborhood in San Rafael is one of the poorest Census tracts in the state of California,” says Omar Carrera, CEO of Canal Alliance, the nonprofit that hosted the county’s vaccination clinic.

Concentrated poverty creates many problems, but in terms of public health it allowed the county to target its outreach efforts. Marin County worked with Canal Alliance — along with numerous other nonprofits, hospitals, schools and other partners — to reach populations that might lack the resources to arrange vaccinations easily for themselves.

Early on, the health department set a goal of keeping every community within 10 percent of the county’s overall vaccination rate. It hosts weekly meetings with health-care providers to track where vaccinations are lagging, and then deploys mobile vaccination clinics into those areas. “I would say 90 percent of our work was really dedicated to 30 percent of our community,” says Matt Willis, Marin County’s public health officer.

When Matt Willis took over as Marin County’s public health officer eight years ago, the county had the lowest measles vaccination rate in the state.

The result is that Marin has the highest vaccination rate of any county in California and one of the highest in the country. Now, 96 percent of its eligible population has received at least one dose, with 87 percent completing the series. Those percentages are actually dragged down by 5- to 11-year-olds, who have been eligible for vaccination for less than a month. More than 90 percent of Marin adults are fully vaccinated.

The median income in Marin County is well above $100,000, with more than half its residents holding college degrees — both far higher numbers than the national average. Aside from being affluent and educated, Marin’s population is relatively old and secular. The county is heavily Democratic, giving 82 percent of its vote last year to Joe Biden. All these traits are associated with higher rates of coronavirus vaccination.

But its current level of success was not guaranteed. In the years leading up to the pandemic, Marin had some of the worst vaccination rates in California. A decade ago, its population suffered a pair of whooping cough outbreaks. When Willis took over as health officer eight years ago, the county had the lowest measles vaccination rate in the state.

“We were ‘science-denying, affluent California liberals,’ mocked by Jon Stewart,” says Carl Krawitt, a Marin resident who became a vaccine activist due to his immunocompromised son. “We had the lowest vaccination rates in the state of California and now we have the highest.”

The coronavirus pandemic has been the largest mass casualty event in U.S. history, resulting in 235 deaths per 100,000 people. In Marin, the death rate is a third as high, at 77 per 100,000. The county’s public health approach has kept hospitals from being overrun, while its schools were among the first in California to reopen and business closures have been kept to a minimum.

“This was familiar and fresh territory for us, because we had been actively engaged in talking about vaccines as a community for the last five years,” Willis says. “There was that sort of positive reinforcement that people had already seen — that for diseases that are vaccine-preventable, the more people who are vaccinated, the fewer diseases you have.”

He can’t help but laugh when he says something that sounds so obvious, yet has been tragically lost on millions of people in this country.

The County’s Challenges

Willis is a veteran of the U.S. Public Health Service and the Centers for Disease Control and Prevention. He’s worked in health hot spots such as Haiti and the Navajo Nation. Yet his native Marin has posed its own challenges.

Dismayed by the county’s poor vaccination rate when he became health officer back in 2013, he undertook an extensive survey of parents in the local schools. He received more than 5,000 responses. Only about 3 percent refused vaccinations of all kinds for their children. Most were concerned that too many vaccines were required on an aggressive timetable.

Naturally, Willis disagreed with that conclusion. Waiting to get a child vaccinated is like waiting until you’re 10 miles into a trip to strap on their seatbelt, he says. But he realized that parental concerns were valid and had to be addressed in specific and individualized ways. He convened pediatricians from throughout the county, shared the data and then helped coach them on how to allay fears.

California laws ending most vaccination exemptions helped, but many holdout parents in Marin had already come around before those were enacted. “In a way, overcoming that vaccine hesitancy really paved the way for doing the same with COVID vaccination,” says Naveen Kumar, physician-in-chief for Kaiser Permanente San Rafael Medical Center.

While many hospitals around the country have been overrun with COVID-19 patients, that hasn’t been the case in Marin. With beds free, they’ve been able to import patients from other jurisdictions. The fact that they’re not under tremendous strain has paid indirect dividends, with other types of care not being deferred or delayed. “Since we’re not paying so much attention to COVID, we’re able to take care of heart attacks, strokes, cancer screening, all the usual care,” Kumar says.

Turning Vaccination into Celebration

The sun is bright but the air is cool on an October afternoon at Hall Middle School in Larkspur. Most of the kids seem to be wearing some combination of sweatshirts and shorts. Dozens run back and forth across the soccer field at lunch. “I’m not wearing a mask!” one boy yells, drawing cheers from his buddies.

The district had recently dropped its outdoor mask mandate. Throughout the Bay Area, there’s still a strong masking culture, and more caution in general than most of the country. In the schools, there was an “assumption” that teachers would get vaccinated, says Brett Geithman, superintendent of the Larkspur-Corte Madera School District. Their classrooms were covered if they left for appointments and an online system made it easy to keep track of holdouts.

Geithman was able to reopen his schools earlier than most in California thanks to “the confidence and trust that the community and the school had with Marin County public health.”

“When it comes to the vaccination, there wasn’t a question of, are you going to get vaccinated,” Geithman says. “It was, when are you scheduling your vaccination?”

Among the district’s 159 employees, he says, only three have refused vaccination. In another Marin school district this spring, an unmasked and unvaccinated teacher infected about half the students in a kindergarten class, the CDC reported in August.

Willis and his team had laid the groundwork long before any vaccines were approved. From an epidemiological standpoint, he says, it was clear that vaccines were going to be the most important tool in combating the pandemic. One in four Marin residents is a senior citizen, and its nursing homes are the source of most of the county’s COVID-19 deaths (which remain below 200 in total). As late as January, there were 28 outbreaks occurring simultaneously across the 68 facilities in the county.

Getting that population vaccinated was the first order of business. “It was this microcosm of what this could mean for us as a community as a whole,” Willis says, “by taking that most vulnerable setting that everyone was so aware of and demonstrating the success of vaccinations in terms of reducing case rates, hospitalizations and deaths.”

During the vaccine rollout, as each successive group became eligible — health-care workers, teachers, then adults in general and finally kids of various ages — Willis and his team sought to turn it into a celebration. It was health care turned into a party, with balloons and plenty of media coverage. “I remember it being a very emotional day,” Geithman says, recalling the January day when educators first lined up at a designated mass vaccination site. “People were cheering as they were going through the line.”

Amplifying the Message

Marin County has a few large employers, such as Autodesk and Restoration Hardware, but most of its businesses are small. About 85 percent have less than 10 employees. Most have fewer than five. The county is suburban and — in contrast to the global firms headquartered to the south in San Francisco and Silicon Valley — most local businesses are just that, geared toward serving residents.

Prior to the pandemic, the county didn’t have an agency focused on private business. That’s changed. As part of the county’s Marin Recovers initiative, the health department meets weekly with county supervisors and business groups to provide updates. “That open dialogue allowed businesses to remain informed and provide a safe environment for consumers,” says Mike Blakeley of the Marin Economic Forum.

As it did with pediatric vaccinations, the health department has taken a “trainer of trainers” approach, offering data and talking points to partners throughout the county, including nonprofits and schools. All its messaging has been positive, avoiding the type of shaming of the hesitant that’s never productive. “You can’t turn your head without finding some advertisement about getting a vaccine, which is wonderful,” says Sandy Prentice, a retired nurse-practitioner in San Rafael.

When it came to the health sector itself, county officials were able to draw on existing relationships with hospitals and other providers built through its opioid initiatives and work on traditional vaccines. “Even prior to the vaccines being distributed, we partnered with Matt Willis and others to get facilities trained with PPE (personal protective equipment) and how to isolate people appropriately,” says Kumar, the Kaiser Permanente physician. “When the vaccines came along, we were very fortunate for our partnership with Matt and the county. We recognized no entity could do this alone.”

Across the country, more than 250 top health officials have been fired or quit during the pandemic, frustrated by pushback from the public and lack of support from elected leaders. That wasn’t the case in Marin. Willis and the health department were able to draw on county resources as a whole, with personnel from the fire, sheriff, parks, district attorney — you name the department — available to help out at mass vaccination sites or wherever they were needed.

“We viewed our role as really amplifying the message coming out of public health,” says County Supervisor Damon Connolly. “It was crucial that we had a unified voice. That was not always the case with other jurisdictions around the state, or the nation for that matter.”

Katie Tellman, a nurse on contract with the county, fills vials at one of Marin’s mobile vaccination clinics. Katie Tellman, a nurse on contract with the county, fills vials with vaccine at one of Marin’s mobile vaccination clinics.

Remaining Flexible

The boxer Mike Tyson once said, “Everyone has a plan until they get punched in the mouth.” It’s a bit of wisdom Willis has kept in mind as he’s navigated the pandemic’s many twists and turns.

For all the planning and coordination, real-world conditions have often meant things don’t work out as expected. Online appointments seem like a good idea, for instance, until confronted with the reality that not everyone has reliable Internet access.

Willis seeks to be transparent in his decision-making — 50,000 residents, or roughly one out of five, subscribe to daily coronavirus data updates from the county. When something goes wrong or conditions change, it’s important to communicate why the county’s approach is changing.

“We can’t be afraid to change the plan, even if it implies that you were wrong,” he says. “We made that clear with our community, that we were going to be revising our plan continuously as we learned.”

Marin is less diverse than the Bay Area as a whole, but 10 percent of its population is Asian or Black and nearly one out of five residents is Hispanic, including about 30 percent of San Rafael, the county seat. Working with nonprofits, the county helped deploy a corps of trusted messengers to speak to as many different people as possible. It wasn’t just talk. During earlier phases of quarantining and social distancing, the county paid for housing for people willing to isolate away from their families.

Reaching minority populations has been a major factor in the county’s overall success. Breaking with national trends, a higher percentage of Marin’s Latinos are vaccinated than whites. “There was an assumption that lower-income communities are not going to respond to vaccines because of the history and misinformation,” says Carrera of Canal Alliance. “That’s why it required a huge mobilization, to understand the science behind it.”

With new groups eligible all the time — vaccines for 5-year-olds, boosters for all adults — the county continues trying to reach anyone who needs convincing. Its mobile vaccination vans are still rolling around, making shots close and convenient for anyone who is finally ready to act.

Along with other health officials, Willis has learned that science and data alone aren’t enough to convince everyone. People need to hear compelling stories told by trusted or relatable figures. During its previous vaccination efforts, the county’s efforts were greatly enhanced by Rhett Krawitt, a young leukemia survivor. “It scared us as a family,” says Carl Krawitt. “We worried that if he got measles, it would impact his ability to take chemo, and he might die.”

Starting as a kindergartener, the younger Krawitt proved to be an effective spokesman in media appearances and legislative testimony. On a Make a Wish visit to Africa in 2017, he helped take vaccines to remote areas. Last month, county and state officials recognized him as a vaccine champion.

Now 13, Rhett Krawitt was determined to get vaccinated against COVID-19, despite facing real risks. Kids who’ve had chemo can sometimes suffer reactions to the new mRNA vaccines. Rhett and his doctors concluded that if he did have a reaction, they could deal with it, but if he got COVID-19, he could die. In order to get the vaccine, he spent a night in an oncology ward for observation.

“He reacted like any other kid — sore arm, a little tiredness, fever,” Carl Krawitt says. “He said himself, ‘Even if I react to the first shot, I’m still going to get the second shot. I do not want to die of COVID.’”