This story was published with the assistance of the Journalism & Women Symposium (JAWS) Health Journalism Fellowship, supported by The Commonwealth Fund.
For a pediatrician, Mark Tomsho is surprisingly calm when talking about the decline of childhood vaccination rates.
“Pendulums swing, pendulums swing,” he mused, Zen-like, in his office between seeing patients one April evening. “Nothing stays the same. And I find that truth and reality usually win out.”
Tomsho has spent the last 40 years practicing medicine in the small town of Summersville, West Virginia, population less than 5,000. Nestled in the rolling hills of Nicholas County, Summersville has voted for President Donald Trump three times. It has an annual potato festival. It’s best known for coal mining and the large, man-made lake ringed with white cliffs that poaches tourists from New River Gorge National Park, a 30 minutes’ drive south.
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It’s also known for its high vaccination rates. Local health officials credit Tomsho for that.
“I have seen the difference in cervical cancer rates based on who the health care provider was, because I know they were vaccinated if they saw Mark,” said Anita Stewart, health officer of the Nicholas County Health Department and a practicing OB-GYN.
West Virginia has some of the highest childhood vaccine rates of any state in the U.S., and Nicholas County routinely rivals the more populous counties that surround it in the number of vaccines distributed.
That all feels under threat now. A national movement pushing distrust in the medical establishment has ascended to the highest echelons of public health. Historic measles outbreaks have cropped up in unvaccinated communities. And the local figures like Tomsho who have long served as the backstop to that kind of pervasive politics are dwindling in numbers.
The pendulum is swinging.
Small private practices are closing at a rapid rate, making way for big hospital groups that can afford to be in rural areas like Summersville. That shift has had to happen to maintain health coverage in the often forgotten parts of the country. But it’s also created a facelessness to medicine that many fear could undercut the herd immunity doctors have worked for decades to establish in their hometowns.
Without established relationships with doctors, patients are more likely to believe misinformation.
In a KFF poll, nearly 40% of people who didn’t have a trusted health care provider said they believed it is “definitely” or “probably” true that the measles-mumps-rubella vaccine causes autism in children, a claim that isn’t backed up by scientific evidence. When people did have a trusted provider, that percentage dropped to about 25%.
“People know you, and they know that you’ve extended yourself into the community, and you’ve been there and your practice has been there, both for their well-child visits and when their children are ill. They tend to trust you,” Tomsho said.
Tomsho is soft-spoken and bespectacled, with close-cropped white hair and a more-than-passing resemblance to Anthony Fauci. His desk and office are as full and busy as his schedule; on the ground, piles of papers and medical files sit beside two framed diplomas that are unlikely, from the looks of it, to ever find a home on the wall.
“A name everyone in the county knows,” one father said of Tomsho while sitting next to his son in the waiting room. Rainbow letters above read, “The Future of the World is in This Room.”
Tomsho has practiced medicine in Summersville since July 1986. He’s treated families for generations, watching them grow and shrink. Some families said they drove more than 45 minutes to see him that day.
“Trust helps them to agree with what we recommend,” Tomsho continued. “As corporate medicine takes over, I think we’ll see less of that.”
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Across the street from Tomsho’s office is a regional hospital where he, until recently, had admitting privileges so he could follow his young patients there if necessary. He had to stop due to health issues of his own.
The state’s largest health system, WVU Medicine, purchased the hospital in 2018.
The hospital is a physical reminder that Tomsho, who is 70 and reluctantly considering retirement — it “crosses my wife’s mind a lot” — is a vestige of a waning kind of health care.
Tomsho’s practice doesn’t have a website; he is elusive via email. His waiting room feels almost quaint in an age where doctors are Amazon employees and AI agents. An intermittent beeping noise, like one from an AOL dial-up modem, constantly emits from behind the check-in desk.
That’s our fax machine, the receptionist tells a young parent confused by the noise. It’s “either trying to receive or send a fax.”
For a long time, West Virginia’s approach to rural health looked more like Tomsho’s office than not. In the 1800s, the state opened three local hospitals to treat miners and other industrial workers — “not something that you’re going to see in other states” at that time, said Katie Thompson, a historian at the William A. Neal Museum of the Health Sciences at West Virginia University.
“Things in West Virginia are very community based,” Thompson said. “A lot of the health care is set up in West Virginia with access in mind.”
West Virginia was one of the first states to offer community polio vaccination events in the 1950s, and doctors in the state were still doing house calls even into the 1960s, long after that practice was discontinued elsewhere.
The state passed a no-exceptions school vaccine requirement in 1937. It took until 1980 for all 50 states to pass vaccination mandates for school children. West Virginia is the only state that has, since the inception of vaccine mandates, always required all of its public school students to receive all of their shots.
The strengths of such a system were on display during the rollout of the COVID-19 vaccine, when West Virginia outpaced other states in how quickly it distributed its allocated shots.
Unlike other states, West Virginia declined to distribute the vaccine through pharmacy chains like Walgreens and CVS. Instead, it created its own network of local, independently-owned pharmacies and long-term care facilities to distribute the vaccine. The National Guard helped.
“There’s nothing like being able to help your neighbor,” one local pharmacy owner told NBC News at the time.
Like elsewhere in the country, West Virginia has faced attempts to change its pro-vaccination policies. Gov. Patrick Morrisey is a staunch Robert F. Kennedy Jr. ally who’s pushed to align his state with the vaccine-skeptical Make America Healthy Again movement. He’s tried to weaken the state’s childhood vaccine mandates.
Public health officials say they’re fielding more questions from West Virginians about vaccines and diseases, like measles, hepatitis B and RSV.
“I think it’s certainly highlighted the importance of listening to patients and community members and others about the questions that they have related to immunization, and being able to answer them,” said Elaine Darling, who co-runs The Center for Rural Health Development.
As of spring 2026, the majority of West Virginians supported vaccines and vaccination requirements for school-aged children.
“West Virginians have a tendency to try to protect each other,” Darling said. “I think that probably does factor in quite a bit to why we’re able to maintain high vaccination rates.”
Still, the state isn’t immune to the financial challenges of maintaining a localized rural health system. A report last year found that of West Virginia’s 33 rural hospitals, 13 are in danger of closing; five could close in the next two to three years.
WVU Medicine and Vandalia Health System now own 70% of the hospitals across the state, according to the West Virginia Center on Budget and Policy.
The change has happened rapidly. Three health systems merged to form Vandalia in 2022 and 2023. WVU Medicine has doubled the number of hospitals it owns over the last four years.
In some respects, these health giants have saved struggling rural hospitals from the brink of closure. When WVU Medicine announced that it would take over the operations of the medical center in Fairmont, a town close to Morgantown, where West Virginia University is located, and reopen it while it built a new, 100-bed hospital next door, the community was happy.
“That’s a pretty big deal for people who need care in that area,” Thompson said. “I haven’t heard a lot of negative.”
But that change comes with a cost. New health providers can mean new faces, new systems and new challenges with insurance.
“That erodes the long-term trust,” Tomsho said.
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Study after study have reached the same conclusion: The more time people spend with their doctors, the more they know them, and feel known, the more they trust the system.
Big health systems don’t always work that way. More advanced scheduling systems limit providers’ down time and result in shorter visits with patients. There’s less time to learn about their lives and build a relationship with them.
At smaller practices in more rural areas, doctors are “known as community members,” said Richard Frankel, who studies clinician-patient relationships at the Indiana University School of Medicine. “They know their patients’ families.”
“In larger communities, it’s much more anonymous, and there may well be a feeling on the patient’s part of being just a cog in a wheel,” he said.
“It’s like showing up at church and suddenly there’s a different preacher,” said Mark Hall, a professor emeritus at Wake Forest University who’s studied patient-provider relationships and health care consolidation. “It doesn’t matter that they’re a perfectly good preacher. ‘Wait, where’s my preacher?’”
A 2020 study in Pittsburgh, Pennsylvania, found that patients saw big hospital groups as “less navigable, accountable, and transparent to outsiders” — even if they also recognized that they needed these big health systems to come in and save their health institutions. They were “mostly beneficial for the long-term viability.”
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When Tomsho first arrived in Summersville, his new neighbors weren’t so sure he’d last.
“‘Are you just going to be here a year or two and then leave like everybody else?’” he recounted being asked.
Tomsho grew up in California, started his pediatrics residency in Colorado, then transferred to Pittsburgh when his mother got sick. He came to Summersville as part of the National Health Service Corps, a program that sends doctors to rural, underserved areas. He joined because it “aligned with his ethics” and helped pay for medical school.
“I came here, visited. There was no pediatrician. So I said, ‘This is just what I want to do,’” Tomsho said. “I was starting out just fresh, and I was still young and enthusiastic.”
It’s easy to see why Summersville would entice a young doctor: It’s in a beautiful area, and the people are friendly. Every fall, the Army Corps of Engineers releases millions of gallons of water from Summersville Lake into the Gauley River; the ensuing “Gauley Season” of temporary whitewater rapids draws rafters from across the country. The town is quiet the rest of the year.
It was just him, a nurse and a receptionist at first. They set up in a “little tin building” that now serves as the town’s pharmacy. The original “Top Gun” was in theaters.
Tomsho had to prove himself. He wrote a column in the newspaper for a while, which helped. Word of mouth did, too. He’s given talks at the local schools and participated in local health fairs, sports physical clinics. At some point it became clear that he wasn’t going anywhere. In 2022, he was even chosen to serve as the 52nd grand marshal of the Nicholas County Potato Festival.
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Forty years after Tomsho first started practicing medicine, West Virginia is still a place that draws a certain kind of person. A certain kind of doctor.
Kara Piechowski, a clinical pharmacist and recently-graduated physician from West Virginia, took a personal interest in the state’s vaccine policy when Morrisey pushed legislation to weaken it in 2025.
“I created a website, just a personal Google website, and coded it to where I could put all of our West Virginia legislators’ emails in one link, and then did a draft email that you could tailor,” Piechowski said. “And that link was used, like, 7,500 times to contact our state legislators.”
Piechowski said she plans to return to the state after she completes her residency. (She recently matched into a combined internal medicine and pediatrics residency program at the Ohio State University.)
The trust providers form with patients in West Virginia is “unmatched” compared to the other states where she’s worked, Piechowski said.
“You just don’t get to know patients on a level that you do here in West Virginia in a lot of, if not most, other places,” she said. “I think people say, or think at least, ‘This is someone who’s like me and has my best interests at heart, so maybe I’ll trust them.’ But that’s just a guess.”
When asked what he’d do if West Virginia stopped requiring vaccines for public school attendance, Tomsho remained characteristically calm.
“We’ll just have to do as much of an in-office campaign, maybe a little bit in local media, about the importance of vaccines and our experience with prevention of these vaccine-preventable diseases,” he said.
Tomsho shrugs off suggestions that he personally has some kind of especially effective approach to getting people vaccinated. It’s just how it is in West Virginia. The American Academy of Pediatrics is very strong in the state, he said, and they encourage it. There’s a nonprofit rural health network that focuses on vaccinations. The insurance companies still encourage it, and Medicaid still encourages it.
Pendulums swing, pendulums swing.
But he allowed that it might also have something to do with the fact that he is simply there.
“It’s their ability to decide that empowers them, and I think that’s important to them,” Tomsho said of his vaccine-hesitant families. “We do not exclude them from the practice in any way. I just tell them, ‘I will ask you about it every visit to make sure you haven’t changed your mind.’”
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