COVID‐19 is laying bare inequities in health and health care that have existed for centuries in the United States. Individuals and communities already more likely to experience health disparities are the same people at highest risk for both the health and economic impact of this pandemic: low wage workers, people without health insurance, people with underlying health conditions, people of color, and Indigenous people. 1 Already, COVID‐19 cases are disproportionately more common among those groups, and mortality rates are higher. 2 , 3 , 4 , 5
Rural residents also face unique risks related to COVID‐19. On average, compared to urban dwellers, rural residents are older, more likely to have underlying health conditions, and less likely to have health insurance or financial resources to weather this sustained storm. Challenges to accessing health care in rural areas, even in the best of times, are well documented in this journal and elsewhere. More than 125 rural hospitals have closed in the past decade; nearly half of those that remain teeter on the edge of making it, operating in the red. 6 In rural communities, shortages of health care providers are widespread and people have longer distances to travel to access care. Especially relevant for COVID‐19, rural areas have a disproportionately small percentage of ICU beds, ventilators, and respiratory treatment, and many rural residents live far from an emergency room, making care difficult to access should they have an onset of severe COVID‐19 symptoms. 7 , 8 , 9
Further, just as COVID‐19 risk is not equally distributed across the general population, neither is it equally distributed within rural areas. Within‐rural disparities in health and health care access by race and ethnicity existed long before this current crisis, with non‐Hispanic black and Indigenous rural residents facing higher rates of mortality 10 , 11 and Hispanic rural residents facing poorer access to care, 12 relative to their non‐Hispanic white counterparts. People of color and Indigenous people living in rural areas are also less likely to have health insurance and financial resources, 11 making it both more difficult to access health care and to endure the economic impact of this pandemic.
Differences in health and health care access by race and ethnicity among rural residents are direct results of historical and current structural racism. 13 That is, policies, systems, and institutions have long advantaged some groups at the expense of others. The legacy of structural racism plays out in where people live (eg, tribal lands), access to resources, historical trauma, and experiences of discrimination and injustice. 13 , 14 COVID‐19 is an especially cruel spotlight on racial inequities that were already baked into a flawed system.
None of that is to say that non‐Hispanic white rural residents are not suffering from COVID‐19. They are, and will continue to. However, risks and resources are inequitably distributed by race and ethnicity, and changes are required to address it. The pandemic response provides an opportunity to do so. Policy intervention to address COVID‐related suffering in rural America should prioritize those places that already have the fewest resources and the poorest health outcomes, namely black and Indigenous rural residents and racially diverse rural communities. Approximately 1 in 5 rural residents is a person of color or Indigenous, 15 , 16 and 11% of rural US counties are majority nonwhite. 11
Both media coverage and research should focus on the experiences of people of color and Indigenous people in rural America in order to understand the unique challenges they face related to the health and economic impacts of COVID‐19. Without deliberately centering on their voices, there is a risk of portraying rural areas as monolithically white, which they are not, 15 , 16 or of losing sight of the deepest tragedies because averages can mask disparities, especially for minority populations.
In order to effectively design and target policies to address inequities by both race and geography, these data must be separately reported. This is made abundantly clear in the COVID‐19 crisis, when there have been clear calls to disaggregate data by rurality and by race and ethnicity, but not necessarily paying attention to the intersection of these. Given the aforementioned issues, there is a particular need for data on racial inequities among rural residents. States and municipalities that are tracking the epidemic have access to this data and should plan to release it in order to make transparent which communities are hardest hit. Such information can—and should—inform current relief efforts, as well as longer‐term structural changes.
Change is already happening, and rural communities are leading the way. One powerful example comes from the Yurok Reservation in Northern California. 17 In that remote, rural location, messaging around COVID‐19 has been informed by tribal leadership to ensure that it is culturally relevant and resonant. Tribal leadership has also worked hard to ensure that basic needs of elders with underlying health conditions are being met, and that important social and cultural events continue, albeit in a different, virtual format. 17
The rapid transformation of our health and economic landscape in the wake of COVID‐19 has the power to correct longstanding inequities that are particularly evident now, and to ensure that rural communities—especially majority nonwhite rural communities—have sufficient access to health care services, infrastructure, broadband, education, and economic opportunity. May the legacy of our COVID‐19 response be to repair the neglect faced by diverse rural communities across America.
Funding
Research reported in this publication was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health Award Number UL1TR002494. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
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