In the end it was the delta variant that drove Rose Mitchell, 89, down the winding mountain road in Smilax, Ky., to the Full Gospel Church of Jesus Christ to get the shot. Her pastor, Billy Joe Lewis, had told his congregation that, No, ma'am, a COVID-19 vaccine would not leave the "mark of the beast" nor rewrite their genetic codes.

Mitchell, who has known the deaths of eight of her 13 children over the years, was done taking chances with the virus stealing up the valleys along Cutshin Creek.

"That stuff's getting so bad, I was afraid to not take it," she says, sitting in her daughter's car in the church parking lot. "I said, 'Well, if all the rest of them are going to take it, I'll take it too.' "

Kentucky is in the midst of a COVID-19 wildfire that is sparing no part of the state; new case counts topped 4,000 a day for much of September, before easing somewhat this month. Hospital intensive care units are still at capacity in some regions, with COVID-19 patients occupying half the beds. Gov. Andy Beshear has called the situation "dire."

Across the nation, older people have been steadfast takers of the vaccines against COVID-19: About 95% of people 65 and older in the U.S. have received at least one shot. But geographic variations cloud that math. Older Kentuckians in rural hamlets far from Louisville and Lexington, for example, are trailing in vaccination, with rates as low as 55% in Wayne County, on the Tennessee state line.

While seniors are still more likely to be vaccinated than younger adults in Kentucky, the simple truth of the pandemic is that older people who forgo the shots face a far greater chance of severe sickness and death. People 60 and older account for nearly 90% of the 9,184 deaths in Kentucky related to COVID-19. Residents 80 and older account for 41% of deaths.

In Leslie County, in the foothills of the rugged Pine Mountain ridge that anchors the state's eastern coalfields, gravel roads wind through thick forests blanketed with kudzu vines. House by house, church by church, public health workers are trying to outsmart the fantastical tales spread on Facebook about the COVID-19 vaccines, while also helping residents overcome the everyday hurdles of financial hardship and isolation.

"Some of our older people don't have access to vehicles because their family works," says Maxine Shepherd, a regional health coordinator for Leslie County and four-decade-long member of Full Gospel Church. Even for people who have a car, gas is expensive, she says, and trips from secluded dells to town are rationed out carefully.

While Kentuckians watched the devastation of the pandemic's early months from afar, COVID-19 has long since made its arrival — and it hasn't spared the church on Cutshin Creek. In recent weeks, Lewis held a funeral service for a 53-year-old unvaccinated former coal miner, suspended Sunday services after more members fell ill and, with a heavy heart, canceled Homecoming — a cherished yearly gathering of area churches that marks the fall foliage with a celebration of the gospel and shared faith.

Local health agencies have been eager to enroll churches in the all-hands-on-deck vaccination effort; older residents are more likely to attend religious services, and in communities like Smilax, ministers are trusted advisers.

Some church leaders have refrained from encouraging vaccination, afraid of offending congregants in a state where mistrust of government intrusion runs deep. But not Lewis, who helped build Full Gospel Church on a rare flat parcel of land in 1972 and has led it ever since. Lewis, who has thick silver hair and a luminous smile, spends long stretches of the day in prayer, and he says God told him to protect his flock.

When "Sister Maxine" from the regional health department suggested a drop-in vaccine clinic in the church parking lot, Lewis says, he was all in favor. He promoted it from the pulpit and on the church's must-read Facebook page.

"We've still got to use common sense," he says. "Anything that can ward off suffering and death, I think, is a wonderful thing."

"We do not like to be shoved" by government directives

Vexed by the slow uptake in vaccinations by some Americans, President Joe Biden has mandated shots, with certain exemptions, for health care workers in facilities such as hospitals and nursing homes, as well as for federal workers and employees of large companies. While the exact timing and details of the private-sector mandates are still being hammered out, the specter of coercion outrages many Kentuckians, particularly in Appalachia, where government directives have been met with derision.

"We do not like to be shoved," says David McKenzie, who grew up in Louisa, a once-booming coal town on the West Virginia border, and now owns the local nursing home. "We resent it, and we shove back."

Opposition to the vaccines in Lawrence County, where the fully vaccinated rate is only around 39%, is not overtly political so much as defiant. "They're fearful of 'the Man,' " McKenzie says. "The Man could be your employer, it could be the government, it could be a newspaper reporter." People who boasted about refusing the vaccines cannot change their minds, or "they'll look like they're weak, or they caved to the Man."

In nearby Salyersville, the virulence of the delta variant has shaken some holdouts. Santana Salyers, 22, braved torrential rain to get her shot at the county health department, a one-story building on a stretch of freshly paved road. In her third trimester of pregnancy, she feared the hospital would not let her hold her newborn if she wasn't vaccinated. Salyers works at the IGA grocery store and says to vax or not to vax comes up in conversation there almost every day. "I'm a fence-straddler," she says. But around town, "you're either against it or for it."

Turnout for the recent Salyersville health fair was muted by the remnants of a tropical storm, but a few dozen people still showed up to get their COVID-19 shots. In the waiting room, vaccine takers received $25 Walmart cards and a chance to win a Fitbit or Instant Pot. The prizes were a big draw.

James Shepherd, who is both the town's mayor and director of the Magoffin County Health Department, bemoans his county's 44% vaccination rate: "In a small community like this, they make up their mind 'yes' or 'no,' and that's it." What will it take to boost vaccinations? "A miracle," he says, with an exasperated laugh.

Deaths of friends change some minds, but not others, as delta spreads

Shepherd's close friend Carter Conley, the beloved captain of the county rescue squad, died last month of COVID-19, despite being vaccinated. Conley's death has been deeply felt around town, but also has given fuel to those who see vaccination as pointless.

Doubts about the vaccines' effectiveness extend to nursing homes in Kentucky despite the persistent correlations between nursing home outbreaks and low vaccination rates among staff.

On a mid-September weekday in Danville, a small city southwest of Lexington, residents at the Landmark of Danville Rehabilitation and Nursing Center sat on a quaint covered porch playing a game of 20 questions with the activities staff. At the time, 80% of the patients in the facility were fully vaccinated against COVID-19, according to the Centers for Medicare & Medicaid, but only 28% of the center's health care personnel, who dashed out and back at lunchtime ferrying takeout fast food, had gotten their shots.

A short drive away, the city's other nursing home, the Danville Centre for Health and Rehabilitation, also had a staff vaccination rate of 28% in September, according to federal records. (A month later, staff vaccination rates at both facilities are still below 60%.)

The unprotected workforce did not faze one man who was moving his elderly father into Landmark that day. The man, who works as a registered nurse at the local hospital, and a family friend accompanying him did not want to give their names, but both said they doubt the vaccines' efficacy.

The man's parents were vaccinated in March but fell ill with COVID-19 in August, he said. His mother was put on a ventilator and died; his father was still in the hospital recovering, and would soon be moved to the nursing home.

The facility's low staff vaccination rate is "not necessarily pertinent," the man said, since his father would be receiving "end-of-life care." His companion said she personally knew four people who had died of COVID-19 and that two had been vaccinated and two had not. These cases, she said, "don't get reported because they don't fit the narrative." (The CDC estimates unvaccinated people are at least 11 times more likely to die from a COVID-19 infection.)

Standing on the porch amid festive fall decorations, Landmark's administrator, Cindy Hollins, declined to discuss what might account for her staff's low uptake and politely asked a reporter to leave.

A different approach: "The safest nursing home in the state of Kentucky"

In Louisa, Ky., three hours east of Danville, McKenzie believes the high rates of vaccination among residents and staff at his Jordan Center will be a selling point. "I advertise I'm the safest nursing home in the state of Kentucky to live and work in," he says.

McKenzie and his sister lived in the nursing home as kids; their parents opened the home and couldn't find another house to rent when the town was overflowing with coal miners. He learned to play piano from a resident, by then down a few fingers from diabetes, who had once played in Duke Ellington's band.

Last winter, COVID-19 ravaged the nursing home for months, infecting nearly every resident. An employee's 33-year-old daughter, who didn't want the vaccine, was buried in early September; then a former employee, who had quit to work at a hospital that didn't require vaccination, died.

As soon as vaccines became available, McKenzie and his staff went room to room, explaining the science to residents. Only one family refused. Then he gathered the staff, many shaken by the loss of residents, who included family members and friends.

Now, nearly every resident of the Jordan Center is vaccinated with three shots, and the staff vaccination rate hovers at 85%. But the holdouts keep McKenzie on edge.

"I sat over here on this front porch until 2 o'clock in the morning talking to two of the nurses that don't want to vaccinate," McKenzie says. "One has been here for 37 years and the other for 15 years. They're dug in. They're adamant."

Testing staff members who refuse to get vaccinated falls to Misty Robertson, a registered nurse who has worked at the facility for decades. She views every interaction as a chance to educate her co-workers about why they should get the shot. "I'm not mean about it," she says. "I say, 'I really don't want you to be on a vent and die.' "

Robertson's father, who lived at the Jordan Center, died of COVID-19 in January. Most of her family is vaccinated, including her three children and her husband, who works at Walmart. The exception is her twin sister, a receptionist for a local pediatrician. That sister tells Robertson COVID-19 is fake and "it's all because of Biden."

"I get mad," says Robertson. She vehemently disputes the conspiracy theories circulating through the town's social networks. And she admits, with a sour laugh, that she sometimes goes too far. "I was put in Facebook jail."

McKenzie's public stance in favor of vaccination has made him a pariah in some quarters, too. A customer attacked him at Walmart and threatened to wait for him in the parking lot. The darkened mood has carved the town into opposing camps, and McKenzie worries Biden's vaccine mandates will just stiffen that divide.

Certainly, they are proving too much for some of his nursing home staffers. Many of the unvaccinated workers at the Jordan Center are on the same shift, and McKenzie fears he may lose his entire night crew.

"They told me Sunday night they were going to leave health care and work at Tractor Supply," he says, "where they can make more money per hour."

This story comes to us from Kaiser Health News, a national, editorially independent program of the Kaiser Family Foundation. KHN is not affiliated with Kaiser Permanente.

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