The above graph details the COVID-19 Impact Score, developed at the F. Marie Hall Institute of Rural and Community Health, Department of Research, Reporting, and Data Management at Texas Tech University Health Sciences Center. This score is a composite that describes how much the virus has impacted a set of communities in regards to both per capita deaths and cases. This analysis looked at all United States counties which were subdivided by rural and urban.

From what is shown above, from the start of the COVID-19 pandemic in March 2020 until October 2020, urban counties had a slightly higher COVID-19 Impact Score, meaning COVID-19 was affecting these counties more severely in regards to both confirmed deaths and confirmed cases.

One exemplary case can be seen in New York City, an early pandemic epicenter, where both cases and deaths increased at an intense rate during the first 3 months of the pandemic. Spread started in the United States’ urban centers before it arrived in rural America. Unfortunately, once COVID-19 hit the rural areas of the United States during fall 2020, it acquired a strong foothold, and death and cases dramatically increased. The virus’ grasp in rural America is still present at the time of writing in the fall of 2021. The difference between the rural and urban COVID-19 Impact Scores appears to be growing across time as well, starting from when rural eclipsed urban in fall 2020 to present day.

The issues facing rural America are multi-faceted with no single solution. One reason for the rural-urban disparity is the lack of adequate financial, labor, and equipment resources that rural healthcare systems need to combat this pandemic effectively. Relative to urban areas, rural areas also tend to contain more residents who are older or possess pre-existing conditions that may make it more difficult to ward against the virus’ strongest ailments. Further, a lack of reliable transportation to a healthcare facility or a lack of healthcare facility entirely is a reality for many in rural areas. The lack of disposable income and insurance may be a factor for some who want treatment but feel as if they are unable to afford it.

Many hospitals, both rural and urban, are so full of patients in regular and ICU beds that they are transporting COVID-19 patients to faraway facilities, relying on another key logistic input that is also stretched thin, ambulance services.

Currently, in early fall 2021, with the Delta variant surging, especially among the unvaccinated, many rural hospitals are struggling with staffing shortages and increased employee fatigue and burnout. Traumatized, many healthcare workers are quitting at record rates. A situation that we as a society swore to protect against in the early days of the pandemic. Additionally, a demographic group unable to get vaccinated, young children, are also experiencing high rates of hospitalizations due to the Delta variant. Many hospitals, both rural and urban, are so full of patients in regular and ICU beds that they are transporting COVID-19 patients to faraway facilities, relying on another key logistic input that is also stretched thin, ambulance services. Services are being rationed and medical professionals are making tough decisions. The aggregate of this comes at a cost of increased wait times for other types of patients who need to visit the emergency or other healthcare departments across the nation.

Misinformation too plays a role. For example, some COVID-19 positive rural residents or those looking to safeguard against the virus’ effects are so desperate they are turning to unproven treatments, such as the livestock anti-parasitic Ivermectin. The chief reason that the scientists who discovered Ivermectin won awards for human health is that it is effective against parasites, especially those that affect the food supply. There is no substantiated evidence that it impacts the COVID-19 virus in humans, and there is no emergency use authorization for Ivermectin in regards to treating or preventing COVID-19. On the other hand, safe and effective COVID-19 vaccines are available and the Food and Drug Administration just recently approved the Pfizer COVID-19 vaccine in late summer 2021.

Going forward, targeted education efforts using trusted community individuals and strong advocacy for proven public health behaviors such as social distancing, mask-wearing, avoiding large gatherings, and hand hygiene, will be key in helping rural areas lessen the impact of COVID-19 on their communities and combat misinformation, especially misinformation regarding both the virus and the readily available and free vaccines. Using the phrase that united many early in the pandemic, if we work together we can all flatten the curve once again.

Methodology. Data sources for this analysis were publicly available. All data was at the county level. COVID-19 deaths and cases were collected from The New York Times’ GitHub repository. The range of data was from March 2020 to August 2021. County population was collected from the County Health Rankings & Roadmaps, a program of the University of Wisconsin Population Health Institute. The US Department of Agriculture, Economic Research Service provided the Rural-Urban Continuum codes which was used to divide counties into rural or urban.

COVID-19 confirmed cases and deaths were calculated at a per capita rate, i.e., a per 100k rate, for all counties. The data was then normalized on a 0 to 1 scale. These per 100k rates were then weighted to create the COVID-19 Impact Score. Cases per capita are weighted at 30% and deaths per capita at 70%. These two weighted scores were then added together to create the composite, COVID-19 Impact Score.

Michael Penuliar, MA, MBA, MA is the director for Research, Reporting, and Data Management at the F. Marie Hall Institute for Rural and Community Health, Texas Tech University Health Sciences Center. He enjoys his family and lifting heavy objects in his free time.