Experts on Camera

COVID-19 in rural America: a perfect storm?

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SciLine interviewed: Dr. Carrie Henning-Smith, deputy director of the University of Minnesota Rural Health Research Center and an assistant professor in the Division of Health Policy and Management at the University of Minnesota School of Public Health. Her research focuses on health equity, with a particular emphasis on rural residents, older adults, and historically marginalized populations.

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Interview with SciLine


What are the trends in coronavirus prevalence in rural areas?  


[00:00:27] 

CARRIE HENNING-SMITH: By and large, coronavirus in rural areas is steadily going up. There are still some rural places with no cases at all. There are some rural places where the case numbers have plateaued or started going down. But there are a lot of places where the case numbers are going up. And we saw in the month of May, three-quarters of the 100 counties with the highest increase in case rates were in rural places. This is shifting from being a very urban issue to being a very rural issue. At this point, more than 90% of all rural counties across the country have at least one COVID case, and more than 40% of rural counties have at least one death from COVID.  


Why is the case prevalence or caseload trajectory different than in urban areas?  


[00:01:19] 

CARRIE HENNING-SMITH: It’s different for a few reasons. For one, it started more slowly. This very much started as an urban issue in the United States. We first saw hot spots in Seattle and New York and New Orleans, places where people were densely concentrated and lived together, lived close to each other. And things have started to slowly spread into rural areas to the point where now nearly every rural place is affected. But there are some things that make addressing COVID and make counteracting COVID in rural areas more challenging. Rural areas are older on average than urban areas. Rural residents have more underlying health conditions, higher rates of disability. These are risk factors that put people at greater risk for COVID and the most severe impacts of COVID. Rural residents also have lower incomes, higher poverty rates, higher rates of uninsurance and unemployment. All of those things make it more difficult for rural folks to get the resources they need to get access to the care that they need if they are experiencing symptoms of COVID or any other health problem. And then rural hospitals and rural health care capacity is more limited. Rural areas have experienced rural hospital closures for the past couple of decades. In 2020 alone, 12 rural hospitals have already closed. Many, many more are on the verge of closing or operate on the red on an annual basis. Rural hospitals are less likely to have ICU beds and ventilators available. They’re more likely to have workforce shortages. So just maintaining the capacity that you need to treat COVID in a rural area is especially tricky, especially difficult to do.  


Why are rural residents likelier to suffer severe effects of COVID-19?  


[00:03:20] 

CARRIE HENNING-SMITH: Rural residents have more risk factors for COVID-19. They’re older on average. They have more underlying health conditions. They have higher rates of disability. All of those put people at greater risk of severe impacts of COVID. Rural areas also have higher poverty rates, lower income rates, lower insurance rates and higher unemployment rates even before any of the economic impacts of COVID started to hit. That makes it more difficult for rural residents to access the care they need. It also means that many rural residents need to show up for work to get their much-needed paycheck, even if they’re not feeling well, even if it might not be the safest condition to be in. And then rural health care capacity is more limited. Rural hospitals have been closing for the past couple of decades at least. And in 2020 alone, we’ve seen 12 rural hospitals close already this year. Some of those have closed as a direct result of COVID because they weren’t able to perform routine procedures or elective procedures, and so they didn’t have that revenue coming in the door. For those rural hospitals that remain open, many of them operate in the red on an annual basis. It’s difficult to simply keep the lights on and pay their staff, let alone ramp up capacity for a crisis like this. Rural hospitals are less likely to have ICU beds, less likely to have ventilators, more likely to have workforce shortages, all of which makes it difficult for them to have the capacity that they need to handle COVID when it hits their community.  


What are some of the challenges rural residents face in accessing health care?  


[00:05:10] 

CARRIE HENNING-SMITH: There are a number of challenges rural residents face in accessing health care. One of the ones that might be the most obvious is simply geographic distance. People usually have to travel further to get to the health care because people live further from one another and resources in rural communities. Rural areas also have serious workforce shortages as it relates to health care. Eighty percent of all rural areas are designated as medically underserved, meaning they don’t have enough health care workforce to provide the care that they need. Rural hospitals have been closing around the country. Rural health care facilities, including hospitals and clinics, are seriously underresourced. And so it’s difficult for them to have the capacity they need to serve the population in the best of times, let alone during a pandemic.  


Can you speak to how COVID-19 is impacting any particular communities in rural areas?  


[00:06:08]  

CARRIE HENNING-SMITH: Yeah. It’s important to recognize rural areas are not monolithic. The risk for COVID is not uniformly distributed across rural places. There are some rural places that have no COVID cases still today, other places where COVID rates have started to go down and many rural places where the COVID rate is still high and rising. And part of this is because the risk factors and the hot spots for COVID are not uniformly distributed across rural areas. We’re seeing a lot of hot spots pop up in rural places where there are prisons, meatpacking plants or long-term care facilities or deep, chronic poverty and structural racism, places like the Navajo Nation, where it’s difficult to have the capacity to spread – to slow the spread and to treat the virus once it gets into the community. I think it’s also important to recognize that many of the places that we’re hearing a lot about, like prisons and meatpacking plants, are disproportionately located in rural communities. And they don’t only impact the people who live in the prison or the people who work in the meatpacking plant, but they impact all of the other community members as employees of those institutions come in and out, go home to their families at night, interact with other community members. It becomes really difficult to slow the spread once it gets into one of those places. 


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Dr. Carrie Henning-Smith

Division of Health Policy and Management, University of Minnesota

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