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In Rural America, Dissatisfaction with COVID-19 Exclusions Faces Rising Number of Cases

As COVID-19 spreads in rural America, the number of new infections rises to peaks not seen during this pandemic and pushes hospitals to their limits. Many cities are experiencing their first major outbreaks, but this does not mean that rural communities have previously been spared the devastating effects of the pandemic.

The rate of infection in rural and border communities decreases and occurs during the first seven months, often appearing in pockets associated with meat packing plants, nursing homes or prisons.

Even if there were no cases, many rural areas were under state health orders, which left businesses closed and events canceled. And that has become part of the problem today. The early compassionate and cohesive responses of the COVID-1

9 community quickly gave way to growing anger and compliance fatigue, especially when some isolated cities did not see their first positive cases until the summer.

This resentment of public health recommendations, including the wearing of masks, is now in a crash course with a growing number of cases in the mountainous West, Midwest and Great Plains. For the fifth week in a row, rural districts are witnessing a sharp increase in cases to the point where more than 70% of the country’s non-metropolitan districts have earned the designation “red zone”, suggesting that the spread of viruses locally is out of control. The reality, however, is that COVID-19 has never been “controlled” in the United States

As professors of family medicine with experience in rural health policy and medical practice, we studied the barriers faced by rural communities during the pandemic and how they could address the challenges posed by COVID-19.

Understanding the drivers of the growing cases of COVID-19 in rural areas is crucial both to curb the current leap and to curb exacerbations in the future.

Why the cases in rural areas are increasing

Several factors have contributed to the increase in the number of cases in rural areas.

The politicization of the pandemic – and the wearing of masks – is hampering both public health efforts and cooperation between business, community organizations and health institutions. Political tensions have sparked misinformation on social media that can be difficult to reverse. If people do not take protective measures when COVID-19 does enter, it can spread quickly and easily.

In some communities, the resumption of activities in small towns, such as schools, churches and sporting events, has led to more infections. Experts cited social gatherings, including the nearly 500,000 Sturgis motorcycle rallies in South Dakota in August, as sources for the recent rise of COVID-19 in the upper Midwest.

Working from home is also almost impossible for many rural jobs. It can also be difficult to get paid sick leave, which makes some people choose between working while sick and being isolated at home for free. Meat and poultry processing plants and other agricultural industries often employ immigrants, whose realities of life and commuting can make social distancing difficult. Many rural areas are highly dependent on the leisure industry and services. When visitors arrive outside the city, they can bring COVID-19 with them.

A man partially dressed in a mask is waiting for a job interview in Imperial County, California.
Unemployed workers are waiting to fill out job applications in a region severely affected by the COVID-19 pandemic.
Mario Tama / Getty images

Local health care is already in short supply

Accurately identifying COVID-19 outbreaks and stopping the spread may also be more difficult in rural areas.

Funding for rural public health departments has long been anemic, crippling their ability to test, share data and track contacts. Limited resources also limit education and promotion efforts.

Many rural hospitals and primary care practices have entered the pandemic in financial difficulties and chronic staff shortages. They are located at the end of the supply chain, which makes it difficult to acquire the necessary personal protective equipment and test consumables. Rural hospitals have fewer beds per capita for resuscitation than their urban counterparts. The lack of consistent broadband coverage can also hamper access to telehealth.

These factors, combined with caring for a population that is relatively older, sicker and poorer, leave rural communities extremely vulnerable as cases continue to rise.

How to reverse the wave of growing cases

The intervention can now slow the rate of increase in COVID-19 cases in rural hotspots, while building a more stable long-term response.

To be most effective, the unique demographics, economies and prospects of each rural area must be taken into account in policy development.

For example, allowing rural communities to control their opening and closing decisions based on local dynamics of disease transmission would allow them to better balance disease mitigation with economic impact. Some states allow rural communities with little or no application for exemption from public health orders. These applications usually look at local infection data, containment measures and health options.

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Changing the nature of the conversation about COVID-19 in the community can also help implement simple, effective measures such as wearing masks. When communications are personal, they can be more accepted. For example, a public service message may remind people that wearing a mask keeps your favorite business open and your grandmother healthy. Defining risk levels in understandable terms for different types of activities can also help, such as how to exercise or socialize safely. Working with trusted local envoys, such as business owners and religious leaders, can help convey evidence-based information.

A cafe owner wears a protective face mask in Stillwater, Oklahoma.
Stillwater, Oklahoma, withdrew the requirement for people to wear masks in stores last spring after employees said some customers were threatening store employees.
Johannes Eisele / AFP through Getty

Planning is also essential. Communities need to be prepared to receive supplies, tests and treatment when needed; protection of the most vulnerable members of the community; educate the community; and to support people in isolation and quarantine. The regional approach in rural areas for testing and tracking contacts, sharing supplies and exchanging staff can help address some of the gaps. Bringing test results closer to home can reduce waiting times and courier costs. Sharing resources between healthcare organizations can also minimize the severity of the reaction.

3 ways to strengthen systems for the future

COVID-19 is unlikely to be the last pandemic to see rural America. Here are three ways to strengthen rural systems in the future.

  • Through partnerships with universities and local and state agencies, communities can incorporate their unique sensitivity into dynamic epidemiological models that could better inform local health and economic decisions.

  • Aligning public health and health care can help governments better balance pandemic responses and ensure that all parts of the community move toward the same goal.

  • Increasing broadband access and internet speed in rural and border communities can also help. During the pandemic, people everywhere appreciate the need for internet connectivity for education, teleworking and the purchase of goods, as well as virtual healthcare.

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