In the United States, there is a renewed campaign to vaccinate rural Americans due to the stark difference in Covid-19 cases and deaths among those living in less-populated areas compared with towns and cities.
Rural residents are now twice as likely to die from Covid-19 as Americans in metropolitan areas. Yet rural areas tend to lag at least 10% behind metropolitan areas when it comes to vaccination – and this hesitancy is exacerbating already existing health issues.
“Rural populations are older, they’re sicker and they’re poorer,” said Fred Ullrich, research analyst at the RUPRI Center for Rural Health Policy Analysis and co-author of a report on Covid’s disproportionate burden on rural communities.
Residents of rural areas also tend to have lower rates of insurance, or the insurance they have doesn’t cover as much, which means they may put off seeking care until it’s too late. And they have worse access to healthcare itself – all of which can lead to worse Covid outcomes.
At the same time, rural residents have some of the lowest vaccination rates and the highest opposition rates to vaccination, a September survey by the Kaiser Family Foundation found. Urban residents, in comparison, were flipped, with one of the highest vaccination rates and the least opposition to getting vaccinated.
As of early October, 42.6% of rural residents were fully vaccinated, compared with 54.5% in metropolitan areas, according to an analysis by the rural-news publication the Daily Yonder. In September, rural areas saw their biggest leap in vaccinations since June before declining again in recent weeks. Even as new cases of Covid have begun falling, rural areas still have an infection rate that is 80% higher than metropolitan areas – and the death rate is still twice as high.
Now, several initiatives are focused on working with rural communities to lower Covid cases and increase vaccination.
The National Rural Health Association (NRHA) recently launched an initiative to address vaccine hesitancy and to recast vaccination as a community endeavor vital for being a good neighbor and keeping schools and businesses open.
“In rural communities, there is a lack of trust in national and even regional sources of information,” Brock Slabach, chief operations officer of the NRHA, told the Guardian. “Local trusted leaders have more influence on the confidence of people to receive the vaccine.”
This campaign is reaching out to trusted sources – including physicians, leaders in community organizations and religious leaders like priests, pastors, imams and rabbis – to help them answer questions about why the vaccine is needed.
A new series of public service messages has also been launched by the Ad Council and the Covid Collaborative, relaying the stories of everyday rural Americans and their reasons for getting vaccinated. And governors are also urged to establish trust and confidence in vaccines and to clear the way for better access in rural communities.
It’s also important to understand that many people have received contradictory messages about Covid and the vaccine from trusted sources, Ullrich told the Guardian. “Getting people to change their minds is very, very difficult.”
There are many reasons why the pandemic has hit rural residents hard.
More than 180 rural hospitals have closed since 2005, and people living in rural areas had a 20% greater death rate before the pandemic. Hospitals and medical centers were short-staffed to begin with, but burnout – and the temptation of higher pay in cities – has led to an exodus of experienced health workers. Smaller hospitals often don’t have the budget to hire expensive travel nurses.
The remaining hospitals are often far away and don’t offer higher levels of care like intensive care units, but many of the larger hospitals are full and can’t accept transfers. And it’s hard for rural residents to seek early treatments like monoclonal antibodies, which are typically offered at specialized infusion centers. Other types of health access have also worsened during the pandemic, with rural residents lacking access to high-speed internet for telehealth visits and vaccine appointments.
There are also disparities within the urban-rural divide. Across the US, people of color are more likely to get very sick and die from the virus than white people. But these disparities are even more pronounced in rural areas, according to a recent study. Living in a rural area as a person of color is a “double whammy”, said Kwadwo Boakye, co-author of the study.
At the start of the pandemic in the US, the coronavirus was often seen as an issue facing cities. For the first four months, as major metropolitan centers like New York and Los Angeles called in refrigerated trucks to handle the overwhelming crush of deaths, the virus mainly spread in the close quarters of metropolitan areas.
But by July, it was spreading in rural America, too – and when rates in cities began to decline, many rural areas continued adding new cases. By the fall, Covid was more common in rural areas than in cities.
Yet “it’s hard to get rid of that earlier notion that this really was not a rural problem,” Ullrich said.
“Rural is not a refuge. It’s clear that the disease has sought out every corner of the country, and it doesn’t make any difference where you live,” Ullrich said. And while cases are falling for now, “who’s to say that we won’t see yet another climb up the rollercoaster?”
Ullrich compared vaccination campaigns to painting a house. “Painting the big walls is not a problem, but getting into the little nooks and crannies, finishing this, retouching up that – that always takes forever, right? It’s always that last little bit,” he said.
“We got the bulk of the population vaccinated in a relatively timely fashion, but we’re down to the details now.”
