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North Carolina's rural counties are hit disproportionately by COVID-19. Here's why.

Underfunded and understaffed public health infrastructure, along with older and sicker populations, contributed to rural North Carolina counties being disproportionately affected by COVID-19.

According to data from the N.C. Department of Health and Human Services and the N.C. Rural Center, the 10 counties with the highest rates of deaths per 100,000 residents, as well as nine of the 10 with the highest rates of cases per 100,000 residents, are rural counties. 

Dr. Paul Bolin, department chairperson at East Carolina University’s Department of Internal Medicine, said while these counties aren’t as densely populated as urban ones, their industries and rates of poverty contributed to rapid community spread. He said the populations in these counties also tend to be older, sicker and are less likely to have health insurance — so when the virus does spread in their community, they’re more vulnerable to its impacts.

Bolin said these impacts, combined with the already underfunded and understaffed public health infrastructure seen in a lot of rural counties, are leaving a trail of damages that will likely reverberate throughout rural North Carolina for years to come. 

“Rural health is just a different animal,” Bolin said. “And a lot of these counties have had just an incredibly difficult time during the pandemic.” 

Community spread

The first cases of COVID-19 in North Carolina originated in urban areas, such as Wake County, before eventually trickling into rural counties.  

Although rural counties have a lower population density than urban ones, they still faced periods of critical community spread. From September through November, nearly twice as many new cases were reported in rural counties than urban and suburban ones, according to the NCDHHS. 

Bolin said population density is a key variable when looking at the pandemic, but there are several other factors in rural counties that explain why they can see periods of critical spread. 

One of these factors is poverty, Bolin said. According to a study by the University of Wisconsin-Madison, a larger proportion of residents in rural areas experience poverty and experience it for longer periods of time than those in urban counties. 

“Living in poverty may require more people to sleep together, travel together, eat together  — all of which can contribute to community spread,” Bolin said. 

Misty Herget, vice president of programs and strategic partnerships at the N.C. Rural Center, said rural populations tend to work in industries, such as manufacturing and agriculture, where working from home isn’t an option. Additionally, she said even if it is an option, it may not be possible in certain areas due to poor internet access. 

Facilities that are considered hot spots for spread are more often located in rural counties, Herget said. These include prisons, long-term care facilities, meatpacking and processing plants, and migrant farmworker camps. 

“You don't have those exponential growth curves like you saw in New York City last spring,” Bolin said. “But you do have significant spread, and it is because of these factors.” 

A vulnerable population

Bolin said a main area of concern when it comes to rural counties is what actually happens to the residents when they get infected with the virus. 

According to the CDC, residents in rural counties tend to be older and sicker than residents in urban counties. They are also more prone to cigarette smoking, high blood pressure and obesity — all of which can worsen COVID-19 when contracted. 

“When we look at some of these counties from a health perspective, they may be already predisposed because they may be part of a historically marginalized population or have comorbidities like diabetes or cardiovascular disease,” Douglas Urland, director of the North Carolina Institute for Public Health, said. “So when they're exposed to COVID, that can become more of a problem for them in terms of severe illness or hospitalization.”

Mark Holmes, a professor in the UNC Gillings School of Global Public Health and director of the Cecil G. Sheps Center for Health Services Research, said residents in rural counties can also face barriers to accessing health insurance. He said this is a large reason why they’re more prone to having pre-existing conditions and may not be able to get the help they need if they get COVID-19.

Residents in rural counties are less likely to have insurance available through an employer, Holmes said, and sometimes can’t afford the price of a private policy. He also said since rural counties tend to be older, they’re more likely to qualify for Medicare but can still face barriers to actually getting a policy.

“Even if they’re eligible and they qualify, it can be challenging for them to actually sign up and get enrolled in that program,” he said. 

Bolin said he saw residents face other barriers to getting health care in addition to a lack of insurance: a distrust for the health care system, an inability to drive to health care facilities and an inability or unwillingness to take time off from work to get health care. Herget said these populations can also struggle to access any telehealth services that are available due to poor broadband service. 

Lisa Chestnutt, a retired teacher and resident of Hyde County, said she has seen residents in her county not only struggle to access health care, but also basic necessities due to the financial strain brought on by the pandemic. 

“Our bank and grocery store in Engelhard have closed forcing us to travel in either direction for banking needs and groceries,” she said. “Funding is definitely needed to help rural areas like ours. Most people can't imagine having to travel an hour to shop at Food Lion, but we do this once a week.” 

All of these factors, Holmes said, contribute to the vulnerability rural counties face to COVID-19, and the severity of the cases they contract. 

“People in rural counties are more likely to test positive for COVID, and they are also more likely to die from it,” he said. 

Underfunded infrastructure

The ability of health care facilities in these counties to respond to COVID-19 has also been a point of concern. 

North Carolina’s health care system is decentralized, Urland explained, meaning local health departments have autonomy over their own operations. He said in rural counties, health departments are generally underfunded and understaffed, especially since the 2008 recession.

“During that recession, many health departments faced decreased funding and staffing,” he said. “And many of them have not built that back up in the years following, even as the economy in many sectors has gotten better.”  

These departments have received spurts of funding since then, due to events like H1N1 and Ebola, Urland said. But he said this one-time, limited funding hasn’t allowed the departments to build and sustain the public health infrastructure they need. 

In Hyde County, for example, Chestnutt said there is no hospital — only a medical center and the local health department. 

But infrastructure doesn’t just refer to buildings and technology, Urland said. It also includes staffing. Holmes and Urland both emphasized that staffing issues have been a huge problem during the pandemic, including both recruiting and retaining staff members. 

“If you only have so many people to try to deal with the overwhelming amount of calls that you're getting, in addition to things like contact tracing, it gets extremely, extremely hectic,” Urland said. “It becomes increasingly difficult to deal with something like this pandemic, and you can't respond as quickly as you want, and it’s just very difficult to manage.” 

Urland said moving forward, building back public health infrastructure in rural counties that is strong and sustainable should be a priority at all levels. Herget agreed, saying she hopes to see investments that will help rural communities become more resilient to disaster. 

“Rural communities are made up of very resilient people,” Herget said. “Strong, innovative, resourceful people. And you need those people, but you also need infrastructure and financial resources. It’s a both-and situation.”


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