Michelle A. Williams is dean of the Harvard T.H. Chan School of Public Health. Bizu Gelaye is an assistant professor at Harvard and Massachusetts General Hospital. Emily M. Broad Leib is a law professor, director of the Harvard Law School Food Law and Policy Clinic and deputy director of the Harvard Law School Center for Health Law and Policy Innovation.
Over the past few weeks, our urban centers have scrambled to mobilize in response to the mounting covid-19 cases. But be forewarned: It’s only a matter of time before the virus attacks small, often forgotten towns and rural counties. And that’s where this disease will hit hardest.
Covid-19 is infiltrating more of the country with each passing day. Colorado, Utah and Idaho are grappling with sudden clusters in counties popular with out-of-state tourists. Cases are also skyrocketing in Southern states such as Georgia, Florida and Louisiana. So far, sparsely populated communities have been better insulated from the spread. But since no place in the United States is truly isolated, there’s simply no outrunning this virus. Every community is at imminent risk.
Rural communities could fare far worse than their urban and suburban counterparts. Rural populations are older on average, with more than 20 percent above the age of 65. Rural populations also tend to have poorer overall health, suffering from higher rates of chronic illnesses such as heart disease, diabetes and lung conditions, all of which put them at greater risk of becoming severely ill — or even dying — should they become infected.
Rural areas also already suffer from a rural mortality penalty, with a disparity in mortality rates between urban and rural areas that has been climbing since the 1980s. Chronic financial strain and the erosion of opportunity have contributed to “deaths of despair” as well as a rise in conditions such as heart disease, Type 2 diabetes and stroke. Add in prolonged social distancing and the economic downturn, and these trends will surely worsen.
Long before the novel coronavirus emerged as a threat, America’s rural hospitals were already in dire financial straits. About 1 in 4 are vulnerable to being shuttered, with 120 having closed in the past decade. With the pandemic looming, many of these health systems have been forced to cancel elective procedures and non-urgent services such as physical therapy and lab tests, which in some cases account for half of their revenue. As cash flow wanes, the American Hospital Association warns that even more hospitals could be forced to shut their doors exactly when patients need them most.
Rural counties have just 5,600 intensive care beds total, compared with more than 50,000 in urban counties. In fact, half of U.S. counties do not have any ICU beds at all. And even if these counties are somehow able to scale up their infrastructure, experts are afraid there will not be enough health-care workers to staff them. The time to prepare rural America is now. Fortunately, rural health systems will get some relief from the stimulus bill, which allocated $100 billion to health-care providers. But it is critical that we find additional ways to alleviate the burden on these health systems to the greatest extent possible.
One way to do that is by expanding telemedicine capabilities, which will allow millions of Americans to be seen by care providers even if there’s no room for them in hospitals. The Centers for Medicare & Medicaid Services recently issued guidelines that expand access to telemedicine for Americans on Medicare. That directive now includes federally qualified health centers, rural health clinics and hospices, so they, too, can be reimbursed for serving patients remotely.
Of course, telemedicine is far from a panacea, as broadband access remains limited in so much of rural America. The stimulus included an additional $100 million for rural broadband access, but this will not be enough. In the long term, policymakers must continue to close the “digital divide,” recognizing that Internet access is both an economic and health necessity. In the short term, Internet service providers should consider rolling out mobile Internet units and providing WiFi hotspot access to temporarily increase connectivity.
More importantly, we must expand the social safety net, especially the Supplemental Nutrition Assistance Program, child nutrition programs, Supplemental Security Income, housing assistance and Medicaid. Lawmakers must also ensure the availability of these programs to rural residents. For example, unlike their urban counterparts, many rural children cannot come to schools each day to pick up meals. The Agriculture Department launched a pilot program to deliver meals to rural children in some regions, but initiatives such as this should be more widespread.
It is clear the battle against covid-19 will look vastly different in the heartland than in our cities. The U.S. Navy won’t be docking a floating hospital in Nuckolls County, Neb. But if what’s happened in America’s coastal cities can teach us anything, it’s that the coming weeks will determine the trajectory of this virus. And we don’t have a moment to waste.