By Dhruv Khullar

Tiffany Chance has worked as a certified nursing assistant since 2005. As an African-American woman in her mid-thirties, Chance typifies the demographics of her profession: most C.N.A.s are young, over a third are Black, ninety per cent are women. She was born and raised in Ohio, and for years worked at a single nursing facility.

When the pandemic started and nursing homes faced dire personnel shortages, as many employees contracted the virus or quit in fear of it, Chance started picking up scattered shifts through IntelyCare, a staffing agency that allows health-care workers to choose jobs the way that Uber drivers accept riders. She often works six shifts a week, eight or twelve hours each, across several nursing homes.

When considering a shift, Chance, who has asthma, tries to choose nursing homes without active coronavirus spread. This information, however, is self-reported, and there’s often a delay. “I’d pick a place that said they don’t have the virus, then I’d show up and they’d say, ‘Actually, some of these people have covid,’ ” Chance told me. In early October, she scheduled a shift at a new facility, which, she was told, had no coronavirus-positive residents; she was given a surgical mask, not an N95 respirator.

A week later, as she started to develop a runny nose, she received a call: a resident had tested positive. Soon, her breathing worsened. “God, it was terrible,” she said. “It felt like an elephant was sitting on my chest. I couldn’t walk an inch without getting out of breath.” Chance couldn’t work for weeks; during that time, she received no sick pay. She tried to sign up for food stamps and unemployment benefits, but “I had to jump through so many hoops. They wanted my medical records, my test result, my pay stub, my last employer. I’m thinking, What does my last employer have to do with this? I need help right now!” She tried to e-mail the paperwork, but was told it would take longer to process than if she dropped it off. “I’m, like, I can’t drop it off, I have covid.” As the weeks wore on, she turned to family for help with food and money for rent. “I kept thinking, You work this hard, you care for so many people. And when you get sick, this is how you’re treated.”

While navigating these bureaucratic hurdles, Chance’s symptoms worsened; during one especially rough night, she considered going to the hospital. But the following morning her breathing eased, and slowly it returned to normal. Chance is convinced that her illness didn’t get worse only because, a few years ago, she’d received the pneumonia vaccine. “I really think it helped,” she said. “That vaccine saved me.”

Chance doesn’t want a coronavirus vaccine. (Because it’s not known how long naturally acquired immunity lasts, the C.D.C. recommends that people who have already had the virus still get vaccinated.) I asked her how she has come to believe that one vaccine saved her life but another threatens her health. The vaccine “came out too fast,” she said. “I think they removed a lot of barriers to get it done faster.” She continued, “It’s not that I don’t believe they’re trying to do a good job. I think they have awesome scientists working really hard. I applaud them for doing what they’re doing. I just don’t believe there’s been enough research yet. There’s no way they’ve been studying it for long enough.”

Beyond the speed of development, Chance has questions—about how long vaccine-generated immunity lasts, about how serious the long-term side effects might be, and about what could happen if the virus mutates further. Until these questions are answered to her satisfaction, she has no plans to get immunized. “I’m not saying never,” Chance told me. “I’m just saying not now.”

Like Chance, Kia Cooper has been a certified nursing assistant for nearly two decades. She works in and around Philadelphia; early in the pandemic, she would split her time between traditional nursing homes and assisted-living facilities. She prefers the latter. “Nursing homes give you too many patients, and they are much more dependent on you for everything—dressing, bathing, feeding, transport,” she said. “It’s backbreaking work.” In Cooper’s experience, it’s not unusual for a single C.N.A. to care for twenty nursing-home residents at a time. One evening in the spring, she arrived for an overnight shift to find that the other C.N.A.s scheduled to work hadn’t shown up. “It was me and two nurses for fifty residents,” she said. “The charge nurse kept calling people to try to get them to come in, but no one responded.”

Cooper now prefers to work in home care and assisted-living facilities, where the residents require less support; she’s found four assisted-living facilities on the outskirts of Philadelphia that she likes. Recently, a previous employer offered her a chance to get vaccinated. She passed. “I’m not totally against it,” she said. “But it was so rushed. I want to wait and see how others do.” Her experience with a health-care industry that seems to put profits over the interests of patients and staff—that denies hazard pay, that fails to provide adequate protective equipment—also contributes to her hesitancy. “I do wonder if it’s a money thing,” she told me. “These are big companies trying to force these products on everyone. You have to wonder, Are they doing it for us or are they just trying to make money?”

Destiny Hankins, a licensed practical nurse from Tennessee, currently working in Ohio, shares these concerns. “Sometimes, it feels like no one cares about us,” she said. “I’ve worked in places where pretty much the whole staff walked out because the facility lied to us. They said there was no covid when there was. They didn’t give us P.P.E. They didn’t have the decency to be straight with us.” During the pandemic, Hankins has been sleeping in her garage to avoid infecting her twelve-year-old daughter, who has epilepsy, and her fiancé, who has an autoimmune condition.

She told me that she’s managed to stay safe by adhering to a mantra she’s dubbed the “three ‘P’s”: prayer, precautions, and P.P.E. When the vaccines first became available, she decided that she didn’t want to get immunized. She thought that the vaccines might contain live virus, which would pose a threat to her family; she saw a video of a woman who, after receiving the vaccine, claimed that she was unable to move properly. She heard from some colleagues and acquaintances that the vaccine contained microchips. Eventually, she learned more, and decided that she wanted the shot. But because she works part time at several facilities, and full time at none, she hasn’t been able to get one.

Despite confronting the damage of covid-19 firsthand—and doing work that puts them and their families at high risk—health-care workers express similar levels of vaccine hesitancy as people in the general population. Recent surveys suggest that, over all, around a third of health-care workers are reluctant to get vaccinated against covid-19. (Around one in five Americans say they probably or definitely won’t get vaccinated; nationwide, hesitancy is more common among Republicans, rural residents, and people of color.)

The rates are higher in certain regions, professions, and racial groups. Black health-care workers, for instance, are more likely to have tested positive for the virus, but less likely to want a vaccine. (Thirty-five per cent turned down a first dose.) Compared with doctors and nurses, other health professionals—E.M.T.s, home health aides, therapists—are generally less likely to say that they’ll get immunized, and a recent survey of C.N.A.s found that nearly three-quarters were hesitant to get the vaccine.

At Yale-New Haven hospital, ninety per cent of medical residents chose to get the vaccine immediately, but only forty-two per cent of workers in environmental services and thirty-three per cent of food-service workers did. The problem may be most pressing in nursing homes. In December, the governor of Ohio, Mike DeWine, said that sixty per cent of the state’s nursing-home staff had declined the vaccine; in North Carolina, the number is estimated to be more than fifty per cent. According to the C.E.O. of PruittHealth—an organization that runs about a hundred long-term-care facilities across the South—seventy per cent of employees in those facilities declined the first dose.

This hesitancy is less outright rejection than cautious skepticism. It’s driven by suspicions about the evidence supporting the new vaccines and about the motives of those endorsing them. The astonishing speed of vaccine development has made science a victim of its own success: after being told that it takes years, if not decades, to develop vaccines, many health-care workers are reluctant to accept one that sprinted from conception to injection in less than eleven months. They simply want to wait—to see longer-term safety data, or at least to find out how their colleagues fare after inoculation.

Another major hurdle is mistrust of both the political and the health-care systems. The problem is most acute in historically marginalized communities, which already live with racial disparities in life expectancy, maternal mortality, access to medical care, representation in clinical trials, informed consent, the physician workforce, and covid-19 outcomes. And it’s exacerbated among health-care workers who are underappreciated and poorly paid. “In many cases, vaccine hesitancy is not a lack-of-information problem. It’s a lack-of-trust problem,” David Grabowski, a professor of health-care policy at Harvard, told me. “Staff doesn’t trust leadership. They have a real skepticism of government. They haven’t gotten hazard pay. They haven’t gotten P.P.E. They haven’t gotten respect. Should we be surprised that they’re skeptical of something that feels like it’s being forced on them?”

Health-care leaders have resorted to various carrots and sticks to get their employees vaccinated. Given the newness of the vaccines and the lack of long-term safety data, most employers have opted to encourage—not mandate—vaccination; some have offered cash bonuses, days off, even Waffle House gift certificates. (“If that doesn’t get you in line, I don’t know what will,” the governor of Georgia, Brian Kemp, said.) But officials at some organizations have started mandating vaccination. (The law generally allows companies to pursue compulsory vaccination, and recently the U.S. Equal Employment Opportunity Commission signalled that employers might begin requiring it for the coronavirus.) “I have very mixed feelings about mandates,” Grabowski said. “I see this a lot on Twitter: just mandate the vaccine and good riddance. Putting the ethical issues aside, the people who say that have no understanding of the labor market here. It’s a very fluid workforce. A number of employees would just say, ‘No, thanks,’ and nursing homes would be even more understaffed than they already are. That’s a very dangerous place to be.”

Relative to the staff, nursing-home residents have very high levels of vaccine acceptance—above ninety per cent in many places. This is good news, considering the devastation that covid-19 has visited upon these facilities. So far, nursing homes and long-term-care facilities have accounted for some hundred and forty thousand covid-19 deaths—forty per cent of the total U.S. death toll, though these facilities represent only five per cent of the country’s cases. But, even in nursing homes, vaccination efforts have not proceeded with the requisite urgency. In the month after the vaccines were released, less than a quarter of the doses made available for nursing homes were administered; even today, nearly a quarter of residents of long-term-care facilities have not received their first dose of a vaccine, according to the C.D.C.

In most states, CVS and Walgreens, in partnership with the federal government, are responsible for vaccinating people in long-term-care facilities. The federal government sends vaccines to the states, which allocate doses to nursing homes; teams from the pharmacy giants then visit the facilities on pre-specified days. In mid-December, Alex Azar, the head of Health and Human Services in the Trump Administration, suggested that all nursing-home residents could have their first dose by Christmas. But, even before Azar spoke, many states had informed the C.D.C. that their programs responsible for nursing-home vaccinations wouldn’t be active until at least December 28th. Four weeks later, some facilities are still waiting for their first appointment.

“It’s worth saying that this was never going to be easy,” Grabowski told me. “Given the number of facilities and the population you’re dealing with, it was always going to be an operations and logistics nightmare. You can’t just set up a drive-through or bring people to Dodger Stadium en masse. You have to go to every facility, make sure every resident has a chance to get vaccinated—that requires very high levels of management and coördination.” The speed of vaccinations has been further complicated by what some believe is unnecessary paperwork, including, for example, gaining written consent from residents, many of whom have dementia or other cognitive deficits. Large pharmacies also don’t have established relationships with care facilities and cannot use nursing-home staff to help administer the vaccines. “If you talk to them, I think they’d tell you that things are actually proceeding according to schedule,” Grabowski said. “It’s just a slow schedule.”

Some states have opted out of the program. West Virginia has relied on local pharmacies, in addition to the big chains, to administer vaccines; by the end of December, the state had the highest nursing-home-vaccination rate in the country—all two hundred and fourteen facilities had been offered the vaccine, and more than eighty per cent of residents in two hundred homes had received their first dose. Nationwide, each CVS or Walgreens is responsible for vaccinating around twenty-five nursing homes; in West Virginia, there are more pharmacies than nursing homes participating in the vaccination program. Many nursing-home residents in West Virginia received their second dose before those in other states got their first.

Kimberly Delbo has been the director of nursing services and innovation at an assisted-living facility in central Pennsylvania for three years. Delbo takes great pride in the culture that she’s helped create. “We’re a small, tight-knit family,” Delbo told me. “The most important thing we can do as an organization is make sure people know that we truly care about them.” In an industry where a fifty-per-cent annual staff-turnover rate is not uncommon, Delbo’s facility did not lose a single employee in 2019; last year, it had a ninety-per-cent retention rate. During the pandemic, employees have had access not only to adequate protective gear but also to what she calls the “health-care heroes’ room,” complete with a massage chair, aromatherapy, antioxidant drinks, and fresh fruits and vegetables. “They work hard,” she said. “They deserve a tranquil environment.”

Around Thanksgiving, the facility had a coronavirus outbreak in which nearly one in seven residents and half of the staff were infected. One woman—a C.N.A. for more than forty years—contracted the coronavirus and lost her husband and her father within the same month. “She still came back to work,” Delbo said. “She said, ‘This is what I’m made for.’ When you see that kind of resilience, it’s truly humbling. You think, These are the real heroes.” To manage the staff shortage, Delbo lengthened shifts from eight to twelve hours, and reached out to contacts in the state’s health department to arrange emergency staffing. Her son, also a nurse, took time away from his regular job to help out. “It sounds bad—and it was—but, compared to some other facilities, we were relatively spared,” Delbo said.

In early December, Delbo was told that her facility would be vaccinated by the end of the month. As the New Year approached, however, the projected date was revised to mid-January. She sent some staff members to a local hospital to see if they could get immunized; it wasn’t until January 23rd that the pharmacy team finally delivered the first doses to her facility. “The vaccine-distribution process has been very discouraging,” she told me. “It was presented one way on paper but turned out to be completely different in reality.” The residents at her facility are aged seventy-eight to a hundred and eight. “You would think this is a priority population,” she said. “We were like sitting ducks, just praying we could dodge the bullet of another outbreak. We were watching as the general public started getting vaccines, and we were still waiting.”

Like staff at nursing homes across the country, those at Delbo’s facility are split on whether to get vaccinated. “I have a staff member who’s been with us for twenty years and said, ‘Can I be the first person to get it?’ ” Delbo said. “But others are very unsure about it. They ask me, ‘Kim, what do you think about this vaccine? Is it safe?’ ” Delbo has made educating residents and staff a central priority. “We’ve been very proactive about building confidence in it, about getting them the facts, about debunking conspiracy theories and social-media myths,” she said. “We can engage in this dialogue because they trust us. I think what’s important for people to understand is that you don’t build trust in a day and you don’t build it for a specific purpose. We’ve been investing in trust for years. We were doing this before the pandemic, and we’ll do it after.”