For months now, nurse practitioner Elizabeth Ellis has spent her afternoons, seven days a week, fighting the spread of the coronavirus alone, in a parking lot. The B.I.S. Community Clinic that she runs is the only health care provider for roughly thirty miles around the tiny town of Bedias, about midway between Huntsville and College Station. A recently installed carport has helped keep the sun and rain at bay, but it remains a lonely place from which to administer test after test for COVID-19, especially as the pandemic appears to be entering its darkest days.

“I’ve seen more positives and tested more people in the last two weeks than I have the entire pandemic,” she says. “By the time I get home, it’s all I can do to eat and then go to bed. I’m brain-dead. I think our health-care workers are beginning to wear out. They’re getting tired. They’re getting mentally tired, physically tired.”

Yet even as cases surge throughout Texas, and nationwide, there’s hope. Vaccines have proven highly effective in clinical trials and are expected to win FDA approval soon. On Wednesday, Governor Greg Abbott announced that the Centers for Disease Control and Prevention has allocated an initial 1.4 million doses of vaccines to be sent to Texas by the end of the year, enough for a first dose of vaccine for most, but not all, of the 1.6 million frontline health-care workers who will be prioritized in the first stage of an unprecedented campaign seeking to end a crisis that’s already killed more than 20,000 Texans.

So why is Ellis still lying awake many nights? She’s concerned about storing a vaccine that requires high-end equipment she doesn’t have, and about making sure her many patients without health insurance can get it. Most of all, she fears she’ll have to vaccinate alone, the way she’s worked for most of the last eight months. Maybe the state will offer help, or maybe that will come from the Texas A&M nursing school, as it sometimes has before. Maybe.

Ellis’s bedtime worries represent the sort of challenges facing state health officials as they prepare for the unparalleled logistical lift of a vaccination campaign expected to begin this month. Compared with many other states, Texas faces the additional complications of its sprawling geography and a chronic underfunding of public health that has left millions of uninsured residents both more vulnerable to the pandemic and less likely to get vaccinated. These problems are especially prevalent in rural areas and minority communities, where health-care providers are scarce.

“We have bigger populations, bigger diversity, bigger geographic areas that we need to cover. And we need a lot more providers in order to be able to cover our populations,” says Imelda Garcia, associate commissioner for the state health department’s division for laboratory and infectious disease services. “It’s similar challenges to other states but on a grander scale.”

Other difficulties are self-inflicted. Texas spends about $17 per person annually on public health, less than all but ten states and far less than other populous states like California ($72 per person) and other politically conservative states like Tennessee, which spent $51 per person on public health in 2019. Many hospitals have been understaffed during the pandemic, and there are no practicing doctors at all in 35 of Texas’s 254 counties. Legislators in Austin have also repeatedly refused to expand Medicaid eligibility, which contributes to the state’s having the highest rate of uninsured residents in the country, 18.4 percent. Inequities in health-care access are particularly pronounced in Black, Latino, and minority communities. The same is true in rural areas, where more than 3 million people, or about 11 percent of the state’s population, live in 170 rural counties that account for the majority of Texas’s more than 268,000 square miles. On top of all that, public transportation is absent throughout much of Texas, and often spotty where it does exist, making it more difficult for Texas’s poorest residents to obtain even routine health care.

“We’re doing ourselves no favors with any of this,” says Emily Brunson, a medical anthropologist at Texas State University who has studied vaccination efforts. Lack of access to health care is at least partly responsible for the virus disproportionately affecting low-income communities and people of color, experts say. Solving the logistical problems of getting vaccines to health-care providers means little to people in communities without those providers, or to people who are reluctant to get vaccinated because they don’t have health insurance and aren’t sure if they can afford to. It will be up to governmental health authorities to ensure that vaccines reach the Texans who live in such health care deserts.

The state has identified these communities as “critical populations” in its vaccine distribution plan, along with long-term care residents, the elderly, and people with underlying health conditions. After frontline health-care workers, they will be a high priority for vaccine distribution. But beyond identifying those priority groups and defining who actually qualifies as a health-care worker, many details of the state’s plan remain vague. In that respect, Texas is at least in good company. ProPublica has reported that most state plans, including those of states that contribute significantly more money than Texas to public health, haven’t yet addressed many particulars, especially when it comes to rural distribution. That’s at least partly a result of factors that remain in flux farther up the supply chain, as drugmakers prepare vaccines for shipment nationwide.

However, Brunson says more robust existing public health programs could have better prepared the state. “The whole goal of public health is to prevent health crises, whether they’re infectious or chronic,” she says. “The more emphasis placed on that, the better the population has done in general.” It’s too late to prevent the crisis and too soon to tell whether the state’s response will be adequate. What is clear is that there’s a lot riding on a successful COVID-19 vaccination campaign in Texas. Get it right, and it could help end the pandemic and focus public attention on Texas’s woefully underfunded public health efforts.

“There’s also the potential for things to go the other way,” Brunson warns. “That it goes poorly, that you undermine trust in public health, that you undermine trust in the entire vaccination program. And so then people stop vaccinating their kids.”

More money for public health could merit discussion when the Texas Legislature meets next year, but state health officials are hopeful the federal government will pick up most of the tab for COVID-19. The state has already received about $14 million from the Centers for Disease Control and Prevention, and Garcia expects millions more will be made available to states soon, although local governments still face costs of their own in distributing the vaccine. Insurance companies will pay for many individual vaccinations, but there will be additional federal money for vaccinations for the uninsured. While no Texan should have to pay to actually get vaccinated, state officials don’t know yet what the ultimate cost of the vaccination campaign will be to taxpayers.

Drugmakers Pfizer and Moderna have signaled a readiness to ship their vaccines as soon as they receive emergency FDA approval. When that happens, expected as early as mid-December for Pfizer and not much later for Moderna, the state health commissioner will decide who gets the vaccine and when, following guidelines developed by a state-appointed “Expert Vaccine Allocation Panel” comprising health officials, legislators, and infectious disease experts who will continue to meet regularly during the coming months.

Garcia, who chairs the panel, said distribution will be flexible and responsive to changing conditions, while prioritizing the protection of groups most vulnerable to the virus and ensuring that those in health-care deserts have access. The state health department is, for example, hiring temporary workers to help administer vaccines and will send specialized teams to areas where doctors and nurses are in short supply.

Stocking the Pfizer vaccine, which requires ultra-cold storage and is available only in relatively large shipments, will be an additional obstacle for providers without the expensive freezers necessary, but Moderna has developed a comparatively more stable vaccine that can be stored in a typical refrigerator for up to thirty days. It’ll be Moderna’s vaccine likely dispatched to places, especially rural areas, without the capacity to store Pfizer’s.

Vaccine shipments will be sent directly to designated health-care providers, rather than the state health department. Garcia hopes this will make distribution much more streamlined than when, early in the pandemic, supply chain difficulties and garbled coordination between federal, state, and local authorities resulted in shortages in personal protective equipment and COVID-19 tests.

And after testing backlogs and software problems dogged its COVID-19 tracking system over the summer, the state health department is emphasizing the importance of the system it will use to track immunizations. Providers will be required to report every vaccination to the state. That anonymized data, which will be shared with the federal government, is important for several reasons, not least of which is that almost every vaccine coming to market, including Pfizer’s and Moderna’s, will require two separate doses administered weeks apart. Reminding people to return for the second shot will be crucial.

As of Tuesday morning, a little more than 4,100 health care providers—including hospitals, health clinics, and nursing homes—had enrolled directly with the state to administer vaccines. Another 2,470 Texas locations of national pharmacy chains Walgreens and CVS had enrolled with the federal government, a spokesman for the state health department said.

Because of the Pfizer vaccine’s stringent storage and transportation requirements, health officials anticipate that the first vaccine doses will go to providers—mostly research hospitals and other major health centers treating COVID-19 patients—with the space and equipment needed to store them. Regardless, Texans will be among the first in the nation to receive the vaccine, with Pfizer announcing recently that Texas is one of three states taking part in its pilot delivery program.

Pfizer and Moderna have said they’ll collectively be able to make enough doses to vaccinate up to 30 million Americans by the end of the year. With the initial 1.4 million dose allotment for Texas that the governor announced this week, and as supplies remain limited—the state’s plan describes this as “Phase 1,” running through at least the end of this year—vaccines will go to health-care workers directly interacting with COVID-19 patients, as well as to long-term care staffers, EMS providers, and home health-care workers for vulnerable and high-risk patients. Outpatient care workers, pharmacy workers who vaccinate or test patients who may have COVID-19, and urgent care clinic workers make up a “second tier” the state has identified among those being prioritized in Phase 1.

As supplies increase next year, the plan next focuses on “critical populations,” including people 65 and older, people with underlying medical conditions, and people in racial and ethnic groups that have been disproportionately at risk of getting COVID-19. That’s Phase 2, running through July of next year, and it’s also when the state would send its “specialized vaccine teams, as needed” into rural and other underserved communities. Vaccine availability would gradually expand throughout the first half of the year and by Phase 3, from July through October, there should in theory be enough vaccine for all Texans. It’s worth noting also that the state laid out this potential timeline back in October, and on Wednesday the New York Times spoke to public health experts in projecting a timeline that expects all Americans to have access to the vaccine by early next summer. Of course, uncertainty abounds.

State and federal plans are liable to shift, and it’s important that local authorities prepare now, says Philip Keiser, the health authority for Galveston County and cochair of the vaccine distribution task force at the University of Texas Medical Branch. Galveston County, for example, is developing a local information technology system that can interact with the state’s tracking system. Tarrant County this week spent nearly $100,000 on large freezers to store the vaccine.

“If we sit and wait for the state or the federal government to tell us exactly what to do, we’re going to be behind the ball,” Keiser says. “And that’s I think one of the things that happened early on. Nobody knew what to do, and [they] were like, ‘Well, what should we do? Well, what do the folks from Austin say? They say they’re waiting for the federal government. What’s the federal government say? Well, the CDC says this, and the FDA says that.’ So what I think works better is that we get a plan, and we are best equipped to execute that plan.”

Don’t expect drive-through immunization sites or long lines for vaccinations, if officials can help it, even in major urban centers. Appointments will be required in most cases. “We’re looking at each one of our physician offices for how they can [manage] the flow of traffic,” says Roberta Schwartz, executive vice president of Houston Methodist Hospital. “You still want to physically distance people. We will not have walk-up clinics. We can schedule those appointments far enough apart to ensure physical distancing and safe delivery, and not cause a crisis while we’re trying to solve a crisis.”

The COVID-19 vaccines that will soon be available have been shown to be both safe and effective, but they are also voluntary. Persuading people to actually get vaccinated will go hand in hand with distributing vaccines. “Whenever we look at surveys specifically on this vaccine, about two thirds of people want to go get it,” says Marc Boom, president and CEO of Houston Methodist. “And that’s good news, because that’s probably about the percentage we want to get at to develop herd immunity.”

To spread the good news of vaccination, says Brunson, the medical anthropologist, the state will need to dispel any skepticism that may exist. A multimedia advertising campaign will encourage vaccination, although details on its rollout were unavailable. Whatever that messaging ultimately looks like, it should be consistent and apolitical, but localized, Brunson says. What plays in Austin might not play in Bedias.

We should also keep in mind what we all have in common, and what we owe to each other. “We’re literally in this situation together. And we’re literally living or dying with each other. We’re spreading the disease to each other,” Brunson says. “So it’s very important that we start to think about these things this way, to have conversations with our families, with our neighbors, with our communities, about what’s going on and about what we can do to get out of it.”