Rural America is more vulnerable to COVID-19 than cities are, and it's starting to show
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Via: dignitatem-societatis • 4 years ago • 10 commentsBy: David J. Peters (The Conversation)
S E E D E D C O N T E N T
Rural areas seemed immune as the coronavirus spread through cities earlier this year. Few rural cases were reported, and attention focused on the surge of illnesses and deaths in the big metro areas. But that false sense of safety is now falling apart as infection rates explode in rural areas across the country.
Of the top 25 COVID-19 hot spots that popped up in the last two weeks, 18 were in non-metropolitan counties. Arkansas, North Carolina and Texas all set records in mid-June for the number of people entering hospitals for COVID-19. Georgia’s daily reported death toll from COVID-19 was up 35% compared to three weeks earlier.
As a professor of rural sociology, I have been studying the challenges rural America faces in responding to this pandemic to improve how communities prepare and respond.
Being able to identify communities that are susceptible to the pandemic before people become ill would allow officials to target public health interventions to slow the spread of the infection and avoid deaths. To do this, I developed a COVID-19 susceptibility scale to assess every county in the Lower 48 states. Susceptibility does not mean an outbreak of COVID-19 will happen, but it means conditions are right for one to occur if the virus is carried in and takes hold.
Why rural populations are at high risk
When you look at the factors that make a population more susceptible to the coronavirus, small communities and rural areas have higher risk factors, as a share of the population, than major cities do.
Rural areas tend to have older populations than the national average, with more chronic health conditions that raise the risk of developing more severe cases of COVID-19. They have fewer health care providers and more uninsured residents, meaning residents often wait longer before seeking medical help. They also tend to be home to large group facilities, such as prisons, meatpacking plants and nursing homes, where the virus can quickly spread to residents and employees can carry it back into the community.
In Iowa, for example, the Tyson plant in Storm Lake drove a 68% increase in confirmed coronavirus cases during the past two weeks. In New Mexico, where new cases rose 42% in the first week of June, about half the new cases were at the rural Otero County Prison. Anderson County, Texas, posted a 10-fold increase in cases when state officials counted infections in five prisons there.
The COVID-19 susceptibility scale uses 11 indicators of the disease based on initial reports from the Centers for Disease Control and Prevention. Those fall into seven distinct risk components: population density; people aged 65 and older; people living in group quarters such as colleges, prisons and military bases; employment in nursing homes; employment in meat processing facilities; people with compromised health; and the prevalence of diabetes. Among people hospitalized with COVID-19, more than 70% have some underlying medical condition, often diabetes or lung or cardiovascular diseases.
Where the high-risk populations are
Looking across the rural-urban continuum, the scale shows that populations in non-metropolitan counties are more susceptible to COVID-19 than in metropolitan ones. That susceptibility increases when going from big cities to rural areas.
Why were big cities overrun with COVID-19 cases? While only 6% of metropolitan counties are at high risk according to my scale, they tend to be our nation’s very large global cities. A small number of COVID-19 cases in densely populated cities can spread rapidly causing numerically large outbreaks. This can quickly overwhelm the health care system, even in large cities. This is what happened in New York City, causing cases to spread across the northeastern U.S.
About one-third of the most rural counties have susceptibility scores in the 80th percentile or higher, as do 29% of semi-rural counties and 19% of micropolitan counties, those with a city of 50,000 people or less. A map of these susceptibility scores shows high-risk communities are concentrated in the Great Plains, Midwest, around the Great Lakes and in some parts of the South.
Some counties are at high risk on just one factor, but have low overall susceptibility. Apache County in northeast Arizona, home to the Navajo Nation, is one example. High rates of diabetes mortality make this group highly susceptible to COVID-19. However, the lower percentage of senior citizens and other risk factors lowers the overall score.
In analyzing the data, some trends stand out.
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Rural counties are primarily susceptible due to their large senior populations. COVID-19 outbreaks are likely to originate in care facilities for the elderly, posing risks for residents and workers alike.
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In semi-rural places, institutions like prisons and military bases add to the risk, as do high numbers of residents who are older or whose health is already compromised.
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Micropolitans are at above average susceptibility due to residents’ health issues, large numbers of meat processing plant workers and care facilities. Semi-rural and micropolitan counties typically provide employment and social services for a region, likely attracting higher-risk populations.
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By contrast, the populations of metropolitan counties have lower susceptibility, though the largest ones face a risk of community spread of the virus because of their high population densities. Cities have lower percentages of older residents and people living in institutional settings. However, a small number of cases in densely populated cities can trigger large outbreaks, driving national cases and deaths.
Researchers at Princeton came to similar conclusions about the high susceptibility of rural counties in a study published June 16 that modeled the impact if 20% of the population in every U.S. county became infected.
Tailoring responses to a pandemic
By knowing how populations are susceptible to severe outbreaks, communities can tailor their responses.
In large metropolitan cities, susceptibility is clearly driven by high population densities, making business closures and shelter-in-place orders essential to slow community spread of COVID-19.
But since rural areas are more sparsely populated, general shelter-in-place orders may be less effective. Instead, rural and micropolitan communities will need to isolate members of specific vulnerable populations quickly. This includes people in poor health, older residents, people living in institutional settings and workers in large meat processing facilities.
To accomplish this, local agencies and providers will need to provide essential services, including food and health care. In many areas, the monumental task of providing these services to a dispersed population will require volunteers and civic groups.
Lack of health care and social services makes rural communities particularly vulnerable. Any state or national response will be hindered by logistical barriers to deploying health providers and supplies over a large geographic area. Limited broadband access means health planners cannot rely solely on telemedicine to fill the gaps in rural areas.
Communities may also see social issues surface. In micropolitan and small metro communities, susceptibility is linked to large meat packing plants whose workforces are predominately Hispanic. Outbreaks may lead to people being treated as coronavirus carriers based solely on their ethnicity and may worsen the marginalization of people based on race.
Different communities have different vulnerabilities to COVID-19, requiring distinctly different strategies to respond effectively to the pandemic across the rural-urban continuum. Such strategies should be developed now to prepare for the next COVID-19 wave.
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People in my rural area seem to care less about it than they did before, even though the numbers are actually starting to grow now (albeit slowly), and they weren't before.
Right when it starts to matter, nobody cares.
I suppose I shouldn't say that nobody cares, but sometimes it feels that way.
The susceptibility study does not support that contention. What the study indicates is that the responses used in metropolitan areas aren't going to be as effective in rural areas. So, comparing the response in rural areas to the response in metropolitan areas would be inappropriate.
When it starts to matter in rural areas, people stop paying attention. Simply expecting rural areas to do what New York has done elevates other types of risks. Rural areas aren't the same and a knee jerk metropolitan response can cause long lasting and irreparable damage in rural areas.
What the susceptibility study indicates is that the needs in rural areas are different and the response should be tailored to those different needs. The CDC is tailoring its guidelines and requirements for high density populations. Those CDC guidelines and requirements won't necessarily be as effective in rural areas and, in some cases, may actually create greater problems elsewhere.
As an example, rural areas rely more on churches for community support and services. Banning church services adversely impacts community support in rural areas.
Huh? I said people where I live seem to care less about it than they did before. What does my own lived experience about the attitude of people in my own local area regarding the threat have to do with the study? I doubt very many are even aware of it.
My point was that people generally acted concerned before, and many wore face coverings and stayed clear of others in stores. Now you hardly ever see face coverings at all, and stores are full of people acting like the threat is completely over, just as regional numbers are finally starting to tick upwards, after being nearly flat before.
I'm not sure what you mean by that. What people? People in rural areas? What's that supposed to mean?
What are you talking about? The response now mostly has to do with face coverings in public areas, testing, contact tracing, and protective isolation of high-risk populations like those in nursing homes. Those things apply everywhere.
Well, that's what this author says (the susceptibility study itself doesn't), but who said anything about city vs. rural responses? I certainly didn't, and it's just you and me here at the moment.
Are you just making stuff up to argue about?
I'm not religious, and I have no idea if church services in my area are literally banned or not at the moment, but I seriously doubt that peoples' interpersonal, church-based relationships around here would just evaporate if they couldn't cram together inside of a church for a while, singing and potentially breathing virus all over each other. People do have phones.
I agree. It seems I cannot flag my own comment so you will need to flag it to remove it.
My mistake. Sorry.
As of 5 PM yesterday, my rural county had 540 known cases, and 27 deaths. That's a 5% fatality rate among known cases. Not as bad as we'd originally feared, but bad enough.
The number of new cases per day is slowing, and seems to be staying low, so that's a positive. Masks are mandated here, but the only company enforcing the mandate so far is Costco. I went there Friday for the first time in months, and there were only 2 people not wearing masks. When I go to Walmart, Food Lion, or Lowe's, half or fewer are wearing masks. So, yeah, people don't seem to care as much as they did back in March/April.
We've had several outbreaks at poultry-processing plants. A few weeks ago, I saw a van from the local poultry processing place at a stop light. The company provides transportation for many of its employees. The van was full, and I didn't see masks on any of the passengers. It seems there are some lessons we need to learn.
I have a feeling that is probably an inflated fatality rate based on the percentage of positive tests and not the more accurate way of measuring fatalities through antibody test results. In my area we had a large antibody testing study that revealed only a .15% fatality rate in this area. The antibody testing is key to getting accurate fatality rates and helping the individual to accurately assess his risk of death.
Possibly. But antibody testing at present is not especially accurate, either.
I thought dead, was dead...
I get what Dean is saying. We don't know the denominator.
It still doesn't look good for our county, though. Our fatality rate among known cases is higher than the same rate in many places, in part because of the reasons given in the article. A large percentage of our population is elderly, and therefore more susceptible. It is difficult to shelter in place here - there is no grocery delivery, and few restaurants that deliver will go everywhere in the county. If you want to eat, you have to leave the house. And some people just don't follow common-sense guidelines. If you're working in a plant where there's an outbreak, it's probably not wise for you and your coworkers to pile into a van all together with no masks.