Rural Health Amid the Coronavirus

How has COVID-19 affected healthcare in rural areas? People in rural communities are typically spread out by distance already—but some could be more at risk for certain conditions because of that (reduced access to care, unwillingness or inability to travel to the doctor, etc.).

By Nan Sloan, Vice President of Compliance, Medecision

The COVID-19 pandemic has hit cities across the United States hard, taking more than 100,000 lives, stretching hospitals and healthcare workers to the breaking point, and leaving millions unemployed after months of economic shutdown. But in the remote towns and communities of rural America, where farms and factories continue to keep the nation’s food and manufacturing supply chain humming, many people feel immune to COVID-19 and its devastating effects.

After all, rural residents don’t live on top of one another like people in cities do, nor do they share public transit. They often live miles away from their nearest neighbors or the closest store, school or hospital. Social distancing is a way of life in sparsely populated communities like these that are already spread out by distance.

But though rural counties still have fewer COVID-19 cases than large metro areas, infection rates are now hitting rural America with a vengeance and outpacing their urban counterparts, according to an analysis of COVID-19 data by the Kaiser Family Foundation. While metro areas have nearly three times as many cases and deaths per 100,000 residents as rural counties, the mortality rate from the virus is essentially the same across these populations (4.2% for metro populations and 3.8% for rural populations).

I’ve watched this statistic play out firsthand in the rural Virginia town where I live. Our county has gone from zero to 48 cases of COVID-19 in a little over a month, with positive cases doubling every nine days. Though we’re lucky enough to have a hospital in our county of 10,000-plus, it has just seven ICU beds and supports two adjoining counties whose COVID-19 cases are also rising, along with two state prisons across the Rappahannock River. An outbreak at one of these facilities, the Haynesville Correctional Center, has already led to over 200 cases among inmates and staff and five deaths.

In my corner of Tappahannock, Virginia, we have yet to hit our peak—and a similar scenario is unfolding across rural America, from the cattle ranches of Nebraska and the reservations of Oklahoma to the bayous of Louisiana and the migrant farms stretching from Florida to California. These communities may not have the population density of epicenters like New York, Los Angeles and New Orleans, but they do have a higher percentage of older poorer residents, many of whom have underlying conditions like hypertension or diabetes that make them more vulnerable to the virus and its severity.

When they do get sick, they also have fewer resources for getting care. More than 120 rural hospitals have closed over the past decade, and hundreds more are on the verge of shuttering, according to a February study by Chicago’s Chartis Center for Rural Health. Instead of driving 20 miles or more to the nearest clinic or hospital, many rural residents find it easier to self-medicate at home or ignore their symptoms altogether. Some lack the transportation they need to get to a healthcare facility in places where there are no bus lines or Lyft or Uber drivers.

Even if they have coronavirus-like symptoms, they may have trouble getting tested. In my community, the closest testing site is more than an hour away in Richmond. Not only does our local hospital have a limited number of beds, but also it has a shortage of ventilators and personal protective equipment (PPE) needed to handle an outbreak. The surplus equipment it did have was picked up by its parent hospital months ago and sent to larger hospitals in Richmond and Norfolk to prepare for the pandemic. Why? People assumed the isolation of rural communities would protect these areas from the coronavirus. While that may have been true initially, this is no longer the case, especially in rural areas in the mountains and along the coast that double as escapes for city dwellers.

Our town of 2,000 swells to about 6,000 in the summer with tourists from New York, Philadelphia, Baltimore and Washington, D.C., who come down to spend weekends on the river. When these cities started locking down in early March, we saw an influx of out-of-state visitors who came here to get away, but they weren’t self-quarantining or taking precautions. Since then, we’ve had a hundred bikers ride through our town—none of whom were wearing masks—and the river has been packed with dozens of people who continue to party and congregate in large groups. Even the locals are hesitant to wear masks and follow social distancing rules when out in public, because they believe their isolated lifestyle makes them immune. Even if they did contract the virus, many doubt they would receive the same quality of care as people in cities. Many already have a deep-seated distrust of the government, and they don’t want to be told what to do.

Getting proper access to healthcare was already challenging for rural residents before the pandemic hit. Now with local providers focused on fighting COVID-19, it’s becoming increasingly difficult for them to get the routine and preventive care they need for other ailments. Few have telehealth or know how to use it. Some can’t get to a doctor without someone else taking them. As the coronavirus bears down on rural America, sheriff’s deputies in some counties have started making rounds to check on residents who haven’t been seen in a while, and community hospitals run by large healthcare systems are rotating clinicians in from bigger facilities. But these efforts alone won’t be enough to protect residents as the outbreak escalates.

Healthcare leaders need to expand their focus beyond the cities that have been affected by COVID-19 to the rural communities that will soon bear the brunt of the virus. How can we equip them with the resources they need to flatten their curve?

This will take providers and payers working together to boost access to medical care, equipment and testing in these communities and to determine how best to educate residents about the risks of COVID-19 and the precautions they need to take. It could mean recruiting retired physicians to work at rural hospitals for a few weeks or teaming up with nursing and medical schools to provide students with real-world experience in exchange for helping out in these facilities. It might require case managers reaching out to homebound patients (or their next of kin) regularly by phone, partnering with churches to provide rides to the doctor, or setting up weekend mobile health clinics in a school or community center, where high-speed internet is more readily available for telehealth visits.

Rural America runs the farms, fisheries and factories that our country depends on to keep grocery store shelves stocked and our nation’s supply chain going. As a country, we owe it to these communities to treat them as part of our society, not like outcasts, and to ensure they are getting the help they need to weather this pandemic.