Related: Rural residents continue to fall behind on health and health care access

And in those areas without pharmacies, rural residents may have to drive long distances to get shots, and do so twice for two-dose vaccines. An analysis by the University of Pittsburgh School of Pharmacy and the West Health Policy Center found that 89% of Americans live within 5 miles of a pharmacy. But more than 1.6 million people must travel more than 20 miles to the nearest pharmacy, which can mean facing difficult weather and road conditions in remote areas.

"If pharmacies are closed, especially in places where there's no other health care provider, then you've got essentially a health care desert," said Michael Hogue, president of the American Pharmacists Association. "You have to be dependent on either a mobile clinic coming in from another area to provide vaccines, or the citizens are going to have to drive farther to get a vaccine."

So far, with a limited quantity of doses and strict limitations on who is eligible, that hasn't been a problem. But as vaccination opens up to the general public and supplies of the vaccines increase, local health departments may be overwhelmed with demand and may need to offload the task of vaccinating local residents to other health care providers.

"It's probably not playing out yet because we're not getting enough supply," said Keith Mueller, director of the Rural Policy Research Institute's Center for Rural Health Policy Analysis. "That means we have some time for those local health departments to figure this out: Who in my radius, if you will, has the capacity to administer vaccines?"

From 2003 to 2018, 1,231 independent rural pharmacies closed, Mueller's team found, leaving some 630 rural communities with no retail drugstore. The changing economics in the pharmacy industry did them in, a combination of national pharmacy chains expanding and consolidating, big-box stores and supermarkets opening their own competing pharmacies and pharmacy benefit managers eating into small-pharmacy profits. Mail-order options siphoned off business.

And you can't get vaccines in the mail.

In many towns, those pharmacies represented the last bastion of health care in their communities. Now more than ever, residents are feeling the void.

"We have no medical infrastructure," said DeAnne Gallegos, a spokesperson for the San Juan County health department in southwestern Colorado. "We don't even have a doctor."

With the closest pharmacy located in a neighboring county an hour away in Durango, vaccinations in San Juan County have been handled by the public health director and two nurses. They hold weekly vaccination clinics if they get any doses. As of Feb. 18, the health department had fully vaccinated 298 of its 700 residents.

Counties are allocated doses based on their year-round populations, but the health department hopes to vaccinate out-of-staters who visit as well. San Juan County deals with an influx of tourists and second-home owners coming from states such as Texas, Arizona and Florida, where the pandemic has hit harder and vaccination rates are lagging. So the health department could end up vaccinating more than 200% of San Juan County's official population to keep COVID out.

"Our attitude is, no matter what your driver's license or your ZIP code says, if you are living within our tight-knit community, that is someone we hope the state would allow us to bring into the fold," Gallegos said.

But that stresses what she called the frail structure the department had in the first place.

"It's our responsibility to make appointments, manage the data, make contact, receive phone calls," Gallegos said. "When you don't have the staff or the budget to hire additional staff, that also makes it very difficult."

Farther east, Custer County hasn't had a pharmacy for years. Only recently, a pharmacist who lives in the county but works in an adjacent county an hour away has started delivering prescriptions to Custer residents when she returns home after each shift.

But she can't bring vaccines home from work.

Instead, a public health nurse who was due to retire at the end of 2020 decided to stay on to vaccinate residents with the help of another nurse and retired health care workers who maintained their licenses. According to Custer County Public Health Agency Director Dr. Clifford Brown, they have vaccinated more than 630 of the county's 5,200 residents.

In an ideal world, they could have handed off the task to a pharmacy.

"We do feel the pinch," Brown said. "I wake up about 3 o'clock in the morning thinking about, how in the world are we going to stretch things to cover for this day?"

Pharmacies offer distinct advantages as vaccine providers. Hospitals, which didn't traditionally vaccinate the general public, have had to create programs to distribute their allocated doses.

In Colorado, pharmacies give over a million flu shots a year, said Emily Zadvorny, executive director of the Colorado Pharmacists Society, and, particularly in smaller towns, have a much closer relationship with their customers than larger health care providers do. She pointed to a pharmacist in Kiowa County, Colorado, who pulled a list of all his customers age 70 and up and called each of them to schedule their COVID vaccinations.

"They have so much more capacity than they have supplies," Zadvorny said. "It's just a slow process of ramping up."

Even where pharmacies exist, it's been a challenge for independent drugstores to participate in the COVID vaccine rollout. For influenza, pneumonia or shingles vaccines, stores typically order as many doses as they think they can sell, which get delivered alongside the pills they distribute.

The COVID vaccines, on the other hand, are being distributed through a national program that comes with a significant learning curve for pharmacies. The federal Centers for Disease Control and Prevention partnered with 21 pharmacy chains, including four networks of independent community pharmacies that give smaller drugstores more purchasing power. According to the National Community Pharmacists Association, those four networks include about 8,000 of the 21,000 community pharmacies nationwide. Pharmacies that are not part of those networks can apply to be vaccine providers in their states.

"The biggest hurdle for most pharmacies is just getting approved," said Kyle Lancaster, pharmacy director for Our Valley Pharmacy, a three-pharmacy chain in rural Lincoln County, Wyoming.

Our Valley applied to federal and state health agencies and had to upgrade its freezers with digital data loggers, which upload the pharmacies' refrigerator and freezer temperatures and report them directly to the CDC.

Most small pharmacies like his, he said, had been limited to the Moderna vaccine, which has less stringent temperature requirements than Pfizer's version. The Johnson & Johnson vaccine, which was recently approved, would be even easier for rural pharmacies to handle.

Lancaster said he's unsure how many doses of the vaccine his chain will get or when.

Those uncertainties leave residents such as Nan Burton, 63, worried about how to get vaccinated. Last year, she and her husband decided to ride out the pandemic in their vacation home in Lincoln County, trading apartment living in Seattle for the wide-open, physically distanced spaces of Star Valley Ranch, about 8 miles from the nearest Our Valley branch. With plans to retire fully next year, now they're staying for good.

So far, Lincoln County — more than three times the size of Rhode Island — has vaccinated about 2,500 of its nearly 20,000 residents, mainly through the local hospital. But with no major chain pharmacies in the region, the county must wait for independent community pharmacies, such as Our Valley, to get up to speed.

Burton said she and her husband have little choice but to wait and hope that the vaccine distribution logistics are sorted out. They'd be willing to drive hours to get a vaccine if they knew they weren't taking it away from someone else in need.

"Until there's some kind of a national push to do outreach to rural communities, I think we're going to be in trouble," Burton said.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation. This story also ran on CNN. It can be republished for free.

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