The pharmacy in Hankinson, North Dakota, a town of about 900 people at the state’s extreme southeastern tip, has been in operation since 1897. The town was a decade old by then and had quickly swelled with settlers enticed by ads for good farmland along the railroad. A pharmacy was one of those signs of a town’s arrival; a knowledgeable druggist was essential. This remained true through the years, even though it turned out that the region’s population had already peaked and was slowly dwindling, as it still is. The earliest owners of Hankinson Drug had kept a stock of jewelry as well as pharmaceuticals, and both traditions remain alive with the current proprietors. In recent years, their pharmacy has been the only one in the county outside Wahpeton, a bigger town 30 minutes away on the Minnesota border.
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Last month, the gift shop was stocked with Valentine’s Day pendants, and Julie Falk, the latest owner and pharmacist-in-charge of Hankinson Drug, was awaiting the arrival of 100 doses of Moderna’s Covid-19 vaccine. Falk already had a rough idea of who would be receiving the shots. In November, at the state’s direction, her staff had gone through their computer system and organized their customers into categories under North Dakota’s vaccine prioritization plan. Since then, other people had called in to be added to the list. The requirement that week was to be 65 or older, and so Falk’s pharmacy technicians were preparing to call 150 newly eligible people to see if and when they might want to come in. This required haste. Once Falk got the doses, she would have one week to use them; if she didn’t, the state wouldn’t send her the next batch. But Falk didn’t expect any trouble. The shipment was their third so far, and the first two sets of doses had plenty of takers among the regulars. “They were thankful to get it right in their hometown,” she says.
For a time this fall, North Dakota seemed to distill the distinctly American problem of navigating personal liberty during a pandemic. The state was grappling with the highest per capita rate of Covid-19 cases in the world, but its leaders had long resisted a stay-at-home order or mask mandate, issuing the latter only once it became clear that hospitals would be overwhelmed. (The temporary order has since lapsed.) Instead, it was left to counties and towns to figure out how to respond—and often, the answer was to ask people to act sensibly, whatever that meant. And as the vaccine process ramped up, there were signs of a different kind of trouble. Supply chain experts worried that the cold storage requirements of the initial Covid-19 vaccines would favor large urban hospital systems with ample freezer space, meaning rural areas would be left out.
Instead, ruralness has proven to be an advantage. Amidst a national vaccination effort marked by confusion, overloaded supply chains, and millions of doses delivered to states that remain unused in hospital freezers, North Dakota, along with a handful of other rural states, including New Mexico, Alaska, and South Dakota, has consistently set the pace for giving shots. Week after week, the state reports having managed to distribute more than 90 percent of its vaccines, even during periods when stragglers such as California and Alabama were struggling to dole out half.
In the vaccination marathon, the pacesetters have certain natural advantages. Rural states have fewer doses, which makes it easier for public health leaders to decide where they should go. They also have plenty of practice delivering health care to remote places. Even routine influenza campaigns take planning. But each plan is different, and success is hard to summarize. In Alaska, for example, efficiency has hinged in part on well-honed plans to airlift doses to small villages in the tundra. South Dakota depends on a system of five highly networked health systems that each take full control of the process in their region of the state, eliminating the confusion seen in urban areas where health officials are juggling doses between many providers.
North Dakota has taken another route: going small. The strategy involves clinics, hospitals, and county public health departments, as in other states, but also local pharmacies like Hankinson Drug, which remain common in small and often shrinking towns due to unique rules that require pharmacies to remain independently owned. The goal, in a rather large state, is to close the distance as best they can. “The important thing is getting vaccines to where people are,” says Molly Howell, the immunization program manager at the North Dakota Department of Health.
Sounds logical. But not so simple in practice. There’s the matter of how to arrange appointments and keep track of doses being sent to a large variety of destinations. Smaller providers are also less likely to be dialed in to state systems to keep track of health records and vaccinations and may be equipped to handle only a few dozen doses at a time. As a result, most states have chosen to go big, at first relying on regional hospitals and pharmacy chains with more infrastructure and capacity, with plans to enroll smaller providers as they could later on. But this fall, Howell says, her department saw no sense in waiting. “It’s not as though we were going to have more time later on,” she says.
Howell points to the 2009 vaccine campaign against H1N1 flu as a catalyst for preparations. “I still have nightmares about all the paper forms,” she says. “I knew we were not going to do that this time around.” While many states scrambled this fall to enroll providers into systems that track immunizations (or were building those systems from scratch), most North Dakota clinics and pharmacies were already signed up to handle routine vaccine campaigns, like seasonal flu, and more than 90 percent of adults in the state have an existing record. At the end of each day, providers upload who has received the vaccine, giving state health officials a window into where, exactly, shots have been given, how many remain unused, and who has received them. That also allows the state to share with the public exactly where vaccines are available on a given day.
Another H1N1 lesson: the benefits of a warehouse. The state takes the unusual step of shepherding many of its doses through a centralized location—equipped this time around with supercold freezers, which the state purchased against the advice of the Centers for Disease Control. (The agency feared a run on the appliances.) Howell says those freezers have proven essential to ensuring that doses move through the process efficiently. The vaccines arrive in packs of more than a thousand for the Pfizer vaccine, and 100 for Moderna’s, and are then repackaged into smaller lots—as few as 10 doses at a time for the smallest providers—and shipped out via truck using software to plot the most efficient route to many far-flung stops. (Bigger shipments go straight to providers, as in other states.) “It's a very centralized control structure there,” says Julie Swann, an expert in vaccine supply chains at North Carolina State University. “If you go to a different state that doesn’t have this level of centralization, each hospital and pharmacy does it a different way.”
That pharmacies like Falk’s exist at all is a historical anomaly. In 1963, the state passed a law that required pharmacies to be majority-owned by pharmacists—all but assuring that most would remain independent. The law, which is unique in the country, has been repeatedly challenged with ballot proposals funded by the likes of Walmart and Walgreens, but North Dakotans have fiercely defended it. The state has a handful of grandfathered CVS locations, and Thrifty White, a Midwestern regional chain, is qualified to operate under a stock-sharing arrangement with its pharmacists. Most of the others, like Hankinson Drug, remain independent.
Compared with chains, independent pharmacies are more likely to serve rural areas and low-income ones in cities, says Stacy Mitchell, codirector of the Institute for Local Self-Reliance, a nonprofit that advocates for small businesses, and who has studied North Dakota’s pharmacy law. One helpful comparison is with the state’s southern neighbor, where chains are dominant and rural areas are a third less likely to have a pharmacy. Independent pharmacies are also more likely to be a dependable source of routine medical care, making them especially useful in a crisis. “North Dakota has been able to effectively marshal local institutions to meet a sudden challenge,” Mitchell says. She points to other pandemic successes involving local pharmacies, including the speedy vaccination of long-term care residents in West Virginia. Big chains enlisted by the federal government struggled to do the same task elsewhere.
Falk grew up in Lidgerwood, an even smaller town due west of Hankinson. She decided to become a pharmacist because she loved chemistry and because she believed the career would allow her to pursue science and have a family, which she planned to do. She attended pharmacy school in Fargo, about an hour north, but she knew that she would be back. “My husband was not leaving Hankinson,” Falk says. It just so happened that the owner of the town’s pharmacy had long been looking to sell. After 37 years on the job, he was well past retirement age, but he wanted to keep passing that century-old baton. “He waited and waited and waited,” she says. “He didn’t want the town to go without a pharmacy.” And so, in 1998, after Falk graduated, the young couple purchased Hankinson Drug. It was meant to be.
The business was successful, and after a few years they opened a second location in Lidgerwood, when the owners of the pharmacy there were set to retire. It is a “telepharmacy” equipped with a videoconferencing booth where people could consult with the pharmacists in Hankinson. They named it Julie’s Pharmacy. When the pandemic arrived last spring, Falk was managing a staff of 11 people; at home, six of her eight kids were attending Zoom school.
Each week, Falk joins a Zoom meeting with the other providers in the surrounding Richland County. The goal is to avoid stepping on one anothers’ toes, says Kayla Carlson, the county’s public health director. “Sometimes it's very easy. Sometimes it's a little messy,” she says, given the relatively large number of providers doing vaccinations and that people will often sign up for more than one vaccination list. This week, Falk’s pharmacy was delivering second doses to the 65-plus group from three weeks before, which had gone smoothly. But the county was also moving on to first doses for younger people with health conditions. It was important that they all kept pace with each other, and that no one would be overwhelmed by demand or wind up with leftover doses. “The doses aren’t doing any good sitting in the fridge,” Carlson says. “So by the end of the week they should be out of the fridge.”
Recently, this became more complex when the federal government announced it would begin sending doses to pharmacy chains directly. Locations that participated in the plan would stop getting doses from the state, thus making the Zoom negotiations all the more important. In Richland County, a Thrifty White in Wahpeton was taking part in the national plan. The first federal shipment was 200 doses, and Carlson was surprised to hear who had received 195 of them: out-of-staters who signed up through the pharmacy’s regional website.
Most had come from “the cities,” as Carlson puts it—Minneapolis and St. Paul, about three hours away—having seen that North Dakota was further along in the process than Minnesota, which was not yet vaccinating younger people with health conditions. Carlson didn’t see this kind of eligibility travel as particularly problematic; she was pleased more people were getting vaccinated, and it was a little gratifying to know how well Richland County was doing. The state was less pleased. On Monday, Thrifty White closed the “loophole.” Minnesota would have to catch up.