Earlier this month, former President Donald Trump finally did what many had asked for since before he left the White House: He advised followers to get vaccinated against COVID-19.

The former president, who got vaccinated in January, called the doses available “safe” and “great.”

But, he added in an interview with Fox News, “… again, we have our freedoms, and we have to live by that, and I agree with that also.”

In Port Clinton, just off the Appalachian Trail in Schuylkill County, Trump’s recommendation didn’t sway Dennis and Darlene Himmelberger. They still display Trump signs in their windows.

“I’ll take my chances,” Dennis said of the vaccine.

Recent polls suggest that Republicans and people living in rural areas are among the Americans most resistant to getting vaccinated.

An Inquirer analysis showed that in Pennsylvania, where almost 72% of counties are considered rural, those with more robust support for Trump — 54 of the 67 backed him in 2020 — tend to have a higher percentage of unvaccinated people. The virus’ reach in rural counties varies widely, with some getting through relatively unscathed. Others have case rates that rival Philadelphia’s suburbs.

Political leanings aren’t the only factor that contribute to lower vaccination rates in rural areas, health experts note. Poverty, poor internet, and a dearth of places providing vaccine in rural areas also play a role. University of Pittsburgh Medical Center reported high demand for vaccination at its hospitals in red counties like Clinton, Lycoming, Potter, and Tioga. Tim Reeves, chief executive of Bucktail Medical Center in Renovo, which he described as the state’s most remote hospital, said his small facility gets calls daily for vaccine, but has received none. The nearest vaccine provider is 45 minutes away. About 88% of the people in the hospital’s Clinton County service area rely on Medicare or Medicaid, insurance programs for seniors, those with disabilities and lower-incomes, he said.

”For both of those groups reliable transportation is often an obstacle,” he said.

Gov. Tom Wolf has said Pennsylvania may make doses available to all adults by May 1. As eligibility expands to younger people less at risk from COVID-19, health care providers fear the rural skepticism in the vaccine may become even more pronounced.

“The acceptance rate may fall even further,” said Rutul Dalal, medical director for infectious diseases at University of Pittsburgh Medical Center’s five north-central Pennsylvania hospitals. “I think age definitely is a big, big factor.”

The state Health Department is not keeping data on where Pennsylvanians are declining vaccination, but acknowledged the widespread hesitancy.

“Despite the difference in demographics, there are a lot of commonalties around hesitancy,” the Health Department responded in an email Friday. “We’re arming our communities with vaccine facts because good information leads to good decisions.”

The differences in attitudes can be nuanced in areas like Berks County, which though considered urban shares a border with rural Schuylkill County. Democrats outnumber Republicans there and vaccine resistance is less calcified.

“I will definitely get it, but just don’t want to make two trips,” Will Ortiz said on Third Street in Hamburg. “I want to wait for the one shot.”

At Dave’s Barber Shop in Hamburg, owner Dave Fisher has been fully vaccinated. He doesn’t argue with customers who refuse the shots.

“I try to stay politically neutral,” he said. “They rant and I just let them go.”

‘Live-and-let-live guys’

People whose age or health conditions elevate their risk of hospitalization or death if they get COVID-19 tend to want the vaccine. But Dalal said that in more conservative, rural parts of the state, one-in-five patients with health issues refuse vaccination, and another 20% are postponing their shots.

Any person who isn’t immunized to the virus risks not just getting sick, but also transmitting it while providing COVID-19 with a living vessel in which it can mutate, potentially into a vaccine-resistant strain. Existing vaccines are already proving less effective against at least one variant.

Arguments about the need to protect others and slow the development of new viral variants don’t resonate with people like Chris Yerger, owner of Bum’s Rush Restaurant and Pub in Orwigsburg, Berks County.

“I’m one of those live and let live guys,” he said. “You want to get it, good on you. If you don’t, good on you.”

Yerger isn’t getting vaccinated. He believes he had COVID-19 around Thanksgiving of 2019 — though the first confirmed cases in the U.S. were reported in January 2020 — and just slept for four days.

Health experts say those who have recovered from the virus should still be vaccinated, since natural immunity is not certain. Yeager, 57, won’t wear a mask, either, not even to get medical care for problems he said he’s neglecting.

“There’s a big libertarian streak in the country,” said John Bridgeland, chief executive of the Washington-based COVID Collaborative, who served in the second Bush administration. “Conservatives in the country really value their own freedom. They don’t like anyone to tell them what to do.”

Among Republicans, 56% would not take the vaccine or are undecided, an early March COVID Collaborative survey found, compared to 13% of Democrats and 40% of independents.

Republican men are particularly uninterested in vaccination, with almost half of them saying they would not get a shot, compared to 6% of men who identified as Democrats, a PBS NewsHour/NPR/Marist poll found. Rural residents, too are less likely to get a vaccine and more likely to think they are unsafe, according to a poll done for groups including the American Public Health Association.

Where the pandemic isn’t real

Pennsylvania doctors have seen vaccine distrust, concern, and refusal from patients across a spectrum of race, income, and political affiliation, much resulting from incorrect information or disinformation from social media, friends, and family. Far-right groups are using the internet to undermine the vaccination effort, the New York Times reported Friday, misrepresenting data to claim doses are dangerous.

Hesitancy in the Black community often focuses on whether the vaccine is safe, a concern rooted in the very real history of racism in the health care system, Dalal said. Vaccine-resistant rural patients can share those concerns, but are also more likely to doubt the need for a vaccine at all.

“Some people, especially in rural areas, do not even believe there was a virus which was of pandemic proportions,” he said. “If you have a lack of concern about the virus you’re eventually not going to take it seriously and you’re not going to get the vaccine.”

At 3rd Street Cafe in Hamburg, where masks are not required, a sign on the door warned customers not to enter if they were “scared.”

The Himmelbergers said they try to patronize only businesses that don’t require masks.

“Even if they do require one, we still don’t wear them,” Dennis said.

The Berks County Patriots, a group dedicated to “life, liberty, property, free speech, a free market, and the pursuit of happiness,” said its board has not taken a position on vaccine hesitancy.

“Too many unknowns on both sides this is an individual’s decision,” the group said in a message to The Inquirer.

State Sen. Doug Mastriano, a potential candidate for governor in 2022, introduced the “Medical Freedom Act,” to bar government or private employers from requiring vaccinations, though few if any employers have imposed such a rule. Mastriano, who spoke at anti-mask rallies, does post links on his Facebook page with information on where to get vaccinated.

“Pennsylvanians are perfectly capable of making our own health and safety decisions,” Mastriano wrote on March 4. He did not respond to requests for comment.

State Rep. Russ Diamond, (R., Lebanon), said he’s heard from constituents who are not getting vaccinated.

“There’s some skepticism out there among people, to like rush in line to get this,” Diamond told The Inquirer.

Diamond, 57, said he is not getting vaccinated.

“Maybe if I was 77 years old,” he said.

Convincing the skeptics

Trump’s support for the vaccine did little to change Republican opinions, one study from the data and marketing research company Morning Consult reported this week.

Attitudes do change, though, Bridgeland said. He noted mask wearing has gradually become more broadly accepted, even among the more conservative of his fellow Republicans. Bridgeland’s organization is enlisting sports leagues to encourage vaccination. But messaging campaigns should stress that vaccination leads to more freedom as pandemic restrictions become less necessary, he said. And compassion, he said, is an emotion that crosses political lines.

“This is part of a spiritual calling,” he said, “to think about your neighbors and your nation as much as yourself.”

Local doctors and community leaders, Bridgeland added, can have more impact than celebrities.

“Most of these conservatives, they don’t trust government, they don’t trust politicians much, but they sure do indicate they trust their own doctors and nurses,” he said, “and to some extent the community leaders like the pastor in their church.”

Alan Morgan, CEO of the National Rural Health Association, endorsed a similar approach.

“We need to make sure that we’re hearing from trusted resources in these rural communities about the safety of these vaccines,” said Morgan.

The state is partnering with “trusted messengers” like government, grassroots and community organizations, health care providers, and unions, to share vaccine information in 13 languages, and is planning a paid media campaign as well.

Rural Wyoming County’s only geriatrician, Edward Zurad, said most of his patients are eager to be vaccinated, including those he described as, “staunch Republican, dyed in the wool, MAGA hat wearing.”

His office lobby displays signs encouraging vaccination, and he has constant conversations with patients about the vaccine’s benefits. He emphasizes he had no hesitation about taking it.

“They all know I got mine the minute I was able to get it,” Zurad said. “I’ve been here 33 years, so these people really trust me.”

Making time for one-on-one conversations about vaccination, the science behind it, and the extensive testing done to confirm the doses’ safety is critical, Dalal said, and he always asks vaccine hesitant patients, “Why?”

“The vaccine-induced immunity will probably last longer than natural immunity,” he tells those who think they’ve had the virus already.

To those who parrot baseless internet conspiracy theories about tracking devices being injected along with the vaccine: “My answer to that is everybody has a cell phone.”

Dalal tells those who think they’re too young to need a shot, “This is done to protect your family and your near and dear ones.”

The people who believe their youth is a reason to avoid vaccination, though, are the least likely to be receptive.

“‘We probably aren’t going to die,’” is a common attitude among younger people in rural areas, Dalal said, “and they are willing to bet on that.”