Dr Clay Marsh sits in his first-floor office at West Virginia University and stares at two large monitors displaying the state’s latest Covid-19 case numbers and vaccination rates.
Neither are good. The state is coming out of a brutal third wave in which local hospitals ran out of beds and intensive care units filled up with severe cases of the disease.
“It's been really tough,” said Dr Marsh, who is heading West Virginia’s efforts against Covid-19.
“It's also tough because this was something that we knew was coming and we started to kind of sound the alarm bells, you know, a month and a half before we really even had that many cases of the Delta variant.”
Despite ample warning about the Delta variant and its high levels of transmissibility, the state's vaccination rate of about 40 per cent left West Virginians extremely susceptible.
It swept through the rural, mountainous state, infecting as many as 2,300 people in a single day, a shockingly high number in a state of about 1.8 million residents.
West Virginia’s elderly population, many with underlying health conditions, is especially susceptible to more serious cases of Covid-19.
To date, more than 4,000 people there have died from the virus.
A recent study on Covid-19 by Wallethub — which examined data on state vaccination rates, rates of transmission, positive testing, hospital admission and death — showed West Virginia was one of the least safe states to live in during the pandemic.
The study also showed that West Virginia has the highest death rate from Covid-19 in the country.
What went wrong?
In February, West Virginia, long associated with poverty and health problems, shocked experts across the country by becoming the first state to vaccinate the entire population of nursing home residents and, at one point, by having the second-highest vaccination rate in the country, closely trailing Alaska.
It was also the only state to opt out of the federal government’s vaccine programme, which united with major US pharmacy chains Walgreens and CVS to inoculate residents of long-term care homes.
Instead of running their programme through major pharmacies, West Virginia went local, using the deep roots that small-town pharmacies have in their communities.
At first, this approach was highly successful. With the help of the West Virginia National Guard, who are in charge of logistics and the distribution of the vaccine, local pharmacists were able to administer shots at an extremely fast pace, even in difficult-to-reach areas.
But eventually, the state ran out of willing patients.
West Virginia was once the epicentre of American coal production, home to millionaires and thriving towns. Today, however, coal production has slowed to a trickle and the economy is struggling. Locals pride themselves on their rural roots and possess a fierce independent streak that often manifests itself as a deep mistrust of Washington.
The State’s Republican governor, Jim Justice, has tried everything apart from mandates to convince people to be inoculated.
In June, he offered residents the chance to win a hunting rifle in exchange for being vaccinated.
Then, in August, Mr Justice launched a vaccine lottery called “Do it for Babydog”, named after his 1-year-old English bulldog, to incentivise people to take the shot.
“If you won’t do it for me, if you won’t do it for your family, you’ve got to get vaccinated for Babydog,” Mr Justice said.
“She wants you vaccinated so badly.”
But efforts have been mostly in vain and as the months went by, the hope state officials had of seeing a majority of West Virginians vaccinated slowly faded.
Dr Marsh admits a huge portion of the state is unlikely to change its mind.
“We know that in our country, people enjoy the right to make decisions about what they want to do and don't want to do,” Dr Marsh told The National.
“In the current environment, we respect that right. And even though for us, we know the consequences of not being fully vaccinated as potentially getting severely ill with Covid-19, going to the hospital [and possibly] dying.”
The Covid-19 chief and his team continue to work tirelessly to offer the vaccine to as many people as possible.
Dr Krista Capehart, an associate professor at West Virginia University's School of Pharmacy in Morgantown, recalls travelling more than three hours along rugged roads, one way, to vaccinate a few people at a coal mine.
“When you get into rural areas, they need to have that connection and understand that people do care,” she said.
“They need to have that one-on-one connection; they need their questions answered.”
Dr Capehart said many are hesitant to take the vaccine and have been filled with misinformation, leading them to question whether the shot will really protect them.
Mr Justice has lashed out at conspiracy theorists.
“For God’s sake, how difficult is this to understand?” he said during a September press conference.
“Why in the world do we have to come up with these crazy ideas — and they’re crazy ideas — that the vaccine has something in it and it's tracing people wherever they go?”
But it’s not only conspiracy theories that officials have to combat — it's apathy as well.
“Mostly, it's just an inconvenience,” said a student at West Virginia University who hasn’t yet been vaccinated. “I’m not going to go out of my way to go get it.”
Apathy combined with a belief in the need to defend civil liberties has stymied not only West Virginia's vaccination efforts but those of the country as a whole. Only 58 per cent of Americans are vaccinated, which is above the world average but far behind many G20 countries.
With hope this frail, Dr Marsh often turns to the parable of the starfish for motivation.
In the story, a young boy on a beach sees dozens of stranded starfish and slowly starts throwing them back in the water. When an adult tells him to give up, that there is no way he can save them all, the boy says, “You may be right, but for the ones that we do help, it will make a big difference.”