Rural America Could Be the Region Hardest Hit by the COVID-19 Outbreak

As the COVID-19 pandemic sweeps through cities and urban centers, cases in more rural areas have generally been few and far between.

However, it appears an infectious prairie fire may be burning its way toward these less populated areas in the Midwest and other regions of the United States.

“Many rural communities aren’t seeing anything. They’re simply having to prepare for what they know is coming,” said Dr. Randall Longenecker, the assistant dean for rural and underserved programs in Heritage College of Osteopathic Medicine at Ohio University. “[But] it will come, no matter what.”

Indeed, both Montana and North Dakota reported their first COVID-19 related deaths on Friday.

It was also reported that rural counties in Colorado, Utah, and Idaho that rely on tourism are experiencing some of the highest rate of COVID-19 cases per capita in the nation.

And as the new coronavirus-caused illness expands into all areas of the United States, rural areas may be among the hardest hit due to their demographics and lack of resources.

The 15 percent of people in the United States who live in rural areas are largely a higher-risk population that is particularly vulnerable to serious outcomes with COVID-19.

In addition, many people in rural areas live 30 or more miles away from the nearest hospital.

“Systems that are under stress during routine times will be more stressed during disasters and times of crisis. Sometimes we forget those systems that are at the brink,” said Tricia Wachtendorf, PhD, director of the Disaster Research Center at the University of Delaware.

Rural health systems already stretched financially are therefore particularly vulnerable, but so are rural areas that don’t have as deep a bench of resources to tap when times get tough.

“When you start thinking about recovery trajectories and impacts, the extent to which there is community functioning before a disaster has strong implications in that recovery trajectory post-disaster,” Wachtendorf told Healthline. “That goes right down the spectrum: transportation systems, employment support, hospitals and public health, food security — all the key systems. If those are low pre-disaster, those are going to have substantial effects on what communities experience during the disaster, as well as their post-disaster recovery.”

Older and less healthy

Rural populations tend to be older and face a higher risk of death from heart disease, cancer, lower respiratory disease, stroke, and unintentional injuries.

More than 20 percent of the population in completely rural counties are ages 65 and older, according to U.S. census data, compared to around 15 percent in mostly urban centers.

Americans living in rural areas also tend to have higher rates of cigarette smoking, high blood pressure, and obesity compared to their urban counterparts.

Both older age and cigarette smoking are two factors tied to a higher risk of severe illness or death from COVID-19.

Despite these statistics, there is a sense among some experts that some people in rural communities, as well as political leaders in these states, aren’t taking the threat of COVID-19 seriously enough.

Initially, “Less dense areas might be at an advantage compared to geographic areas that are more densely populated, and they may also be less connected to some areas where there’s a concentrated case,” Wachtendorf said.

But once these communities do start to see cases, they might struggle to fill basic public safety and administrative roles, especially if people such as police officers and firefighters get sick and have to self-quarantine.

Despite this potential threat, Mississippi Gov. Tate Reeves, Missouri Gov. Mike Parson, and Alabama Gov. Kay Ivey have all rejected calls to issue shelter-in-place orders that are becoming increasingly common in other states to try to slow the spread of the disease and help flatten the curve.

Doctors in Tennessee are also urging that state’s governor to issue a shelter-in-place order.

In addition, Reeves issued an executive order this past week that seemed to exempt most businesses in Mississippi from closures, muddying the public’s understanding of how to respond to the crisis.

That could be particularly damaging, as neighboring Louisiana has seen its COVID-19 cases soar, recording the highest growth rate in the world in the first 2 weeks since its first confirmed case.

But even there, with Louisiana Gov. John Bel Edwards urging residents to stay home, some are defying those recommendations.

In the town of Central, Louisiana, for instance, the Life Tabernacle Church has continued to host gatherings of 1,000 people or more as COVID-19 cases mount.

These religious services have come as President Donald Trump calls for businesses to reopen and for people to “pack” churches on Easter Sunday.

Experts say these types of acts could have ripple effects that overwhelm rural hospitals and disrupt essential services down the line.

“If someone gets sick in those areas or an agency or department gets sick, there may be fewer people within those agencies to continue operations, leaving that particular community more vulnerable,” Wachtendorf said.

A lack of hospitals

Medical facilities known as critical access hospitals, which have 25 beds or fewer and are 35 miles away from the closest facility, are among the ones that have closed at the highest rates in the past two decades, even as their closure rate slowed somewhat thanks to provisions in the Affordable Care Act.

“Rural hospitals, on the whole, they’re going to see their curve, whether it’s flat or not, start a whole lot later, maybe 3 weeks, 6 weeks,” Longenecker told Healthline.

In the meantime, however, “Rural hospitals right now are seeing a steep decline in activity, empty beds, and empty practices, so for right now there’s a steep loss of revenue.”

For those rural hospitals — ones that remain after more than 80 have closed since 2010 and nearly 700 more found themselves on the brink of closure — that loss of revenue illuminates a dangerous teetering in our health system, as administrators try to balance the costs of staying afloat against the predicted flood of eventual COVID-19 cases.

In the meantime, many of these critical access hospitals are operating with bare-bones staff.

“What’s happening is the wave hasn’t come yet here,” said Jane, a travel nurse working at a critical access hospital in Wisconsin. “We’re down to two teams working here per day, which is OK most days because procedures keep getting canceled and falling off, but yesterday, we were working our (tails) off and I’m wondering why are we down to a skeleton crew? It’s because they’re trying to save money for when the s— really hits the fan.”

By then, supply shortages and other issues may have already rocked the system, Longenecker says.

“Hopefully some things will be worked out, like the supply of testing and supply of personal protective equipment — or not. They may have already sent them to the city,” he said.

Jane agreed.

“What scares me is that, because there’s not confirmed cases up here yet and there’s only two in the county. I’m just worried that we’re going to get overlooked when it happens and we’re going to be up a creek,” she told Healthline. “I think a hospital is not a place you want to be right now unless you absolutely have to be.”

System shock

Part of the reason rural areas are so vulnerable to the COVID-19 health crisis is that they were vulnerable to begin with.

Rural zip codes lost almost 20 percent of their hospital beds between 2006 and 2017, according to a study from the Economic Innovation Group (EIG), a bipartisan public policy organization.

But that doesn’t tell the whole story. Within this study, EIG found that economically distressed rural areas were especially affected.

Put another way, “There are fewer than half as many hospital beds per capita reasonably accessible from the average rural distressed zip code as are from the average rural prosperous one,” the report says.

Wachtendorf noted the example of hospital closures funneling people from a wide geographic radius into central, overburdened regional health centers, as well as local clinics that aren’t full hospitals, as potential points of strain in the system in a crisis.

Rural areas that rely on farming as a main source of income might also find themselves in a particular bind.

“It’s not like you could just take 2 weeks off and think the crops will still be there,” Wachtendorf said. “Some of that seasonal work is very much dependent on timing. And it’s not just a matter of pushing off that production for 2 weeks or a month. It’s either done now or it’s not done at all.”

Is telemedicine the answer?

One way in which hospitals and doctors are dealing with this ongoing crisis both in rural and urban centers is through telemedicine.

Not every patient is a COVID-19 patient, so those who can receive care from their homes and thus stay out of overburdened hospitals is a benefit to the system at large.

“Prior to COVID-19, we were seeing much more of a demand for telehealth in rural areas,” said Pamela Ograbisz, DNP, FNP-BC, director of telehealth at LocumTenens.com, a healthcare staffing agency. “In a way, COVID-19 leveled the playing field in healthcare by erasing the boundaries between rural areas and large cities. It doesn’t matter where patients are located; they need care.

“Because of this and because clinicians are overwhelmed, demand for telehealth has gone up across the board,” Ograbisz told Healthline.

But telemedicine can only go so far, and won’t fix the fragmentary nature of the American healthcare system, Longenecker said.

“It’s hard, as individualistic as we are as Americans, for us to think about the good of the community or think epidemiologically, which is a very different way of thinking than just thinking about me and my family,” he said. “But anything we could do to be less fragmented and to be more systemic (as a healthcare system) would be really, really good.”

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