A Ford F-150, purchased for $81,433, is parked at the Capitol on West Virginia Day. It will soon be given to Ralph Paugh. Photo by Ian Karbal

Kanawha Boulevard was closed to traffic outside the Capitol on June 20 for West Virginia Day, as Gov. Jim Justice was set to announce the first winners of the “Do it for Babydog ” vaccine lottery.

Just before Justice was scheduled to speak at 1 p.m., the 85-degree heat had driven a large crowd towards a food truck selling shaved ice; worker Billy Holcomb estimated he’d sold between 80 and 100 servings in the last 30 minutes alone. The other vendors weren’t as lucky: BBQ, burgers and hot dogs were tough sells in the heat.

Apparently, so were vaccines.

Across from the shaved ice truck, National Guard troops staffed a mobile vaccination clinic in  an Enterprise rental van.

“One person is a victory, and we actually got about a dozen so far,” said Lt. Col.  John Snedegar as the troops began to pack up for the day. They’d been offering vaccines since 11 a.m.

While at first West Virginia was heralded as a “vaccine miracle,” the state quickly hit a ceiling. Now, despite spending more than $10 million on prizes, including the cash giveaways, West Virginia’s vaccination rate has stagnated. Recent studies and interviews with behavioral health experts, as well as West Virginians involved in the vaccine rollout, reveal that money may be best used elsewhere.

“We’ve basically done all we can do, so if the people who aren’t vaccinated — it’s their choice, and they absolutely made that choice and everything,” Justice said during a July 29 press briefing, attributing the sentiment to National Guard Maj. Gen. James Hoyer. “Let them suffer the consequences.”

Of course, the vaccinated and people who aren’t eligible for vaccines will suffer the consequences as well. Previous spikes in cases saw West Virginia hospitals overwhelmed, and rare breakthrough cases among the vaccinated are being reported around the country as the Delta variant continues to spread.

And now with the “Do It For Babydog” lottery ending and cases on the rise, it’s unclear what efforts, if any, the state will take to incentivize the vaccine hesitant. 

Neither Justice’s office, nor West Virginia Coronavirus Czar Dr. Clay Marsh, responded to requests for comment.

An ineffective, if inspired, effort

When the state of Ohio announced its vaccination lottery in May — the nation’s first and the inspiration for Justice — Dr. Allan Walkey, a researcher and professor at Boston University Medical School, was intrigued.

“While I had really hoped that the Ohio lottery would work, because I want as many people vaccinated as possible, I was surprised that it didn’t, initially,” Walkey said. 

While the state saw an immediate bump in vaccinations, Walkey looked closer.

“Media reports only looked at Ohio, which is understandable,” said Walkey. “But you have to have a control group.”

Walkey’s study, which compared Ohio’s vaccination rates before and after the lottery was announced to similar national numbers, found that the bump in vaccinations in Ohio coincided with a bump across the country. The program was announced just as the U.S. Food and Drug Administration cleared vaccines for use in people aged 12 to 16.

“We concluded that the Ohio lottery, while a good idea and a worthy try, didn’t seem to have a large impact on vaccinations,” Walkey said.

Data from the Centers for Disease Control and Prevention. Graph by Ian Karbal.

In West Virginia, vaccination rates continued to decline even after the lottery was announced, though a small increase around West Virginia Day coincided with a similar national trend. Though over 376,000 people registered for the “Do it for Babydog” lottery, it’s unclear how many received vaccinations because of it.

Take 74-year-old Ralph Paugh, the first winner of a luxury truck through the state lottery. He had received his vaccination in March.

Deterred by the taxes he would have to pay on the truck, Paugh was unsure if he would keep it. Moreover, his wife, Susie, 73, said, “I don’t think I’ll even be able to step up into [the truck],” which had doors over a foot off the ground.

A young couple passing the Paughs as they were leaving the Capitol grounds congratulated the winners, shouting, “Nice truck!”

“You want to buy it?” Paugh replied with a grin.

Asked whether in retrospect implementing a lottery was a mistake, Walkey said, “I think [states] needed to try something to increase vaccination rates. Knowing now that they haven’t had much of an effect, I think it would be a mistake to keep doing them in the future. We need to learn and change and move on.”

Lessons from the past

While the lottery program may not have been the success some hoped for, research and experience shows that other incentives may still prove effective.

Dr. Monica Gandhi, an infectious disease doctor at the University of California, San Francisco, who specializes in treating HIV, has been using incentives to increase treatment in HIV-positive communities for decades. She believes that history offers valuable lessons for today.

“We’ve employed a variety of ways to figure out how to get people to take their medications, despite all of the concomitant challenges of life,” Gandhi said about HIV patients, many of whom are homeless or food insecure. She’s found that offering people food and gift cards often gets them to the doctor. 

Her personal experience has been reflected in a number of studies, both in the U.S. and elsewhere, proving the efficacy of guaranteed financial incentives — not just a small chance of winning — in getting HIV patients into sustained, long-term care.

The Ford F-150, valued at more than $81,000, was ultimately given to Ralph Paugh. Photo by Ian Karbal

Unlike getting a COVID-19 vaccination, however, which requires just one or two shots, HIV treatment requires a sustained effort on behalf of the patient over a lifetime.

The Biden administration is recommending similar measures for COVID-19 vaccines to what Gandhi has tried with HIV patients, suggesting state and local health departments begin $100 giveaway programs for people who get vaccinated.

For one month between May and June, West Virginia offered a similar program: $100 savings bonds or gift cards to all 16-35 year olds who had been vaccinated. Two weeks into the giveaway, Justice announced that over 20,000 young people had registered, but his office stopped giving updates on that number by the time the program ended just weeks later. 

Neither DHHR nor the governor’s office responded to questions about the program’s efficacy, or the total number of people who ultimately registered.

The messenger matters

Financial offerings are only one way to motivate the vaccine hesitant, according to Gandhi. Outreach and trust building are just as important.

When PrEP, a preventative medication that lowers the risk of contracting HIV, was first approved for use in the United States, it wasn’t always widely trusted, especially in Black and other non-white communities that have lower rates of trust in health care providers.

“We always had cool, hip, young people doing the community-based messaging to young gay men,” Gandhi said. “We would certainly never think the mayor of a city should tell young gay men to take PrEP.”

The takeaway for encouraging COVID vaccination is an obvious one.

“This is the hard work, where you get people who are trusted messengers in the community, like a doctor, or the head of the Rotary club, or someone in that community who is important to you,” Gandhi said. “It isn’t effective to have the ‘expert.’ It isn’t effective to have Tony Fauci being the person telling you to get your vaccine. It’s so completely separate from your life.”

Babydog, Gov. Justice’s English bulldog – and the vaccination lottery’s mascot – is walked to the capitol steps on West Virginia day. Photo by Ian Karbal

To that end, having Gov. Jim Justice and his English bulldog being the face of West Virginia’s vaccination campaign might not convince more people to be vaccinated. But some West Virginia counties are trying something else. 

Hancock County has one of the highest vaccination rates in all of West Virginia, with 63.7% of residents over 18 having received at least one dose, compared to the statewide rate of 57.7%.

Jackie Huff, the administrator of the Hancock County Health Department, said she reached out to local businesses and teachers, enlisting them to encourage their employees and students to get vaccinated. 

“We were trying to be proactively seeking people that would need the vaccination,” she said.

With nearly 24% of Hancock County residents 65 years of age or older, the county made getting vaccinations to seniors as easy as possible. They set up multiple vaccination sites as quickly as possible and provided transportation where they could. They even went as far as to have nurses show up at people’s houses. They placed ads in local papers and aired TV and radio spots. And they recruited a local nurse with deep community ties to help spread the word.

Jim Justice holds Babydog at the 2021 West Virginia day vaccine lottery giveaway. Photo by Ian Karbal

Kathy Dray teaches nursing classes through the local career center and worked in local health care for four decades. She also went to high school with Huff.

Early in the pandemic, Dray rallied graduates of her nursing class to help administer tests, and later vaccines. The first doses she and her students administered were done on New Year’s Day. After that, she continued to run weekly clinics staffed by her students and school nurses. Once vaccines were approved for children 12 and above, she ran sites out of the local schools.

Dray also served as a positive messenger to those hesitant to get the vaccine.

“People ask me about getting their kids vaccinated,” Dray said. “What I’m telling them is, ‘well, kids do really well if they get [COVID], but do you want your kid quarantined?’ Because they’ll miss school, they’ll miss sports, they miss everything.” 

Dray firmly believes that everyone should have a choice when it comes to getting vaccinated, but her message to those reluctant is about the impact the shot can have on their lives and the lives of their loved ones.

“Honestly, I was not sure if I would get the vaccine in the beginning,” Dray said. “Because it was fast. But I decided that I would rather take my chances with the vaccine than with COVID, because you just don’t know how it’s going to affect you, and I didn’t want it to affect my family.”

Dray’s message may be a particularly effective one. Researchers at the Stanford University School of Medicine recently put together a guide for talking to the vaccine hesitant based on interviews with health care providers, reluctant patients and existing literature. The study found that appealing to people’s emotions by frankly discussing how their choice on whether to get vaccinated can affect their lives, and the impact their decision could have on others, had much more impact than just relaying facts about the vaccine’s safety or efficacy. 

Disincentives as incentives

 With vaccination growing stagnant across the country, Gandhi warns that governments are increasingly turning towards what she calls “disincentives.”

“You can see this new move to make life difficult for those who are unvaccinated,” Gandhi said. “What I mean by that is restaurants, and employers, and businesses saying ‘show me your vaccine card.’”

Recently, the Biden administration put a requirement in place for all federal employees to be vaccinated or undergo a rigorous testing schedule.

Justice has signaled that he is, at the moment, unwilling to take up such measures, refusing even renewed mask mandates, as well as vaccination requirements for state employees. This places the burden on local businesses to decide what measures they’re willing to take.

Ultimately, Justice had a much more grim take on what it might take to get people vaccinated. “The reality is if this thing gets terribly bad, will it take that for us to awaken to the fact that we absolutely should all be vaccinated?” Justice asked at a July 29 press conference, referring to the recent spike in cases with the Delta variant. “I hope and pray it doesn’t come to anything like that.”

Ian Karbal is a Report for America corps member, and the state government watchdog reporter for Mountain State Spotlight.