Connecticut National Guard members wait to check-in vehicles for Connecticut's largest Covid-19 Vaccination Drive-Through Clinic in East Hartford, Connecticut. But many in rural America may be reluctant to get the vaccine, even if it's available, exposing serious issues burdening U.S. healthcare systems.(AP Photo/Jessica Hill)

This story was originally published on Eyal Kedar’s Rural America and Covid-19 blog. 

Any good system requires upkeep. There is regular maintenance. There is a constant investment in success. This investment must be both thorough and sustained. If done correctly, the result is a system that is flexible and strong.

The Covid-19 pandemic has revealed many truths about the American healthcare system. One of the most important is that, like any system, it functions as a set of parts. Another is that when critical parts fail the system breaks down. 

Rural healthcare has long been a failing and yet critical part within this larger system. The result today is a virus that has spread particularly well in rural areas and which, in turn, is likely to keep the pandemic going long after it should be gone. This is the part of the failure that is easy for all of us to see. But the danger in having a weak rural healthcare system is complex, and there is more to it than meets the eye. 

Take, as just one example, vaccines. With the very infectious B.1.1.7 variant of the coronavirus now spreading in the U.S., the percentage of people who will need to receive the SARS-CoV-2  vaccine series to achieve herd immunity is going to be even higher than previously expected.

The science behind this is straightforward. The R number, which is the average number of people who become infected by an infectious person, will be higher for B.1.1.7 than it has been for prior, less infectious coronavirus strains. 

To prevent a very infectious virus from spreading, it has to have very few vulnerable people to infect. The way to achieve this condition is to have as many people as possible in a community vaccinated. However, a recent Kaiser Family Foundation poll showed that, even after correcting for variables such as political affiliation, rural Americans remain more reluctant than urban and suburban Americans to receive the SARS-CoV-2 vaccine series. 

Other historically disadvantaged groups such as African Americans are also more reluctant to receive the vaccine series, according to the report. What’s more, rural Americans were also much more likely to trust their own physicians in this poll than they were to trust any federal health organizations or officials in giving vaccine advice. So what is this all saying? 

At the risk of sounding like a reductionist, and with the acknowledgement that this is a very complex issue, I believe it says the following:

When there is insufficient investment in a group or a person, there will be insufficient trust. When there is insufficient trust in an important part of a larger system, that larger system will likely fail. We need the cooperation of all Americans to fight this pandemic, and so the rise of Covid-19 in rural America has done more than just hurt rural Americans. It has made us all more vulnerable.

In a recent radio interview, I mentioned that “we’re not seeing the cracks in the walls of the system” in rural America. “We’re seeing the absence of walls.” 

I believe that this states the problem correctly, which is that rural healthcare systems are in some areas simply weak, and in other areas non-existent. To move forward properly we will need to strengthen rural healthcare systems where they exist and build new systems where there are none. We will also, for the sake of being more prepared for the next pandemic, need to make these repairs with both a rural and a national view. If we do it right, we can begin to build the trust in our larger healthcare system that will be necessary to keep us strong.

To do this, however, will require a new approach. For one, any building should be done with the goal of integration in mind. Rural America is home to 60 million people (using the Census definition), and for a solution to be all encompassing, it will need to include national, regional and, above all, local participation. 

As I noted, rural Americans tend to trust their own physicians most in giving medical advice. I’ve written before about what I believe has been an ineffective national messaging campaign to rural Americans about the Covid-19 pandemic. I’ll also state in a different way something else I’ve written about, which is that without rural representation in any rebuilding or communication effort there is likely to be a continued sense in rural places that our largest institutions in healthcare simply do not see us. The result will be more of the same theme – a failing system, a lack of trust, and a weaker nation.

Another important point is that there is no substitute for the building effort that I’m proposing. Ideas for how to convince reluctant Americans to accept the SARS-CoV-2 vaccine series have ranged from the punitive (i.e., fire people from their jobs if they don’t accept the vaccine) to the exhortative (i.e., give them an incentive, such as a gift card or a check). However, these ideas will at best have a short term impact and at worst (if they feel coercive or demeaning) may even further erode the trust of medically disadvantaged groups in the American healthcare system.

The message of this essay is simple. It is a call for awareness and for larger and more concerted action. It is a call to eliminate a longstanding double standard in American medicine. How many urban or suburban Americans would be willing to move to a place where there are no subspecialists, or no doctors at all? How many Americans would trust the advice of their national healthcare leaders if their own communities felt ignored and left behind? The answer, for the many Americans (both rural and non-rural) in this situation, is likely few. 

Abraham Lincoln famously said, “A house divided against itself cannot stand.” Today, this line rings as true as ever. America’s healthcare system remains deeply divided between haves and have-nots, and we can never be truly strong if our rural places are left behind.  Rural America is simply too important. It is where we get, as just a very small list, most of our food, much of our energy, and all of our wide-open spaces. It is also where, in the event of a pandemic, we get contagion and also a lack of trust that divides and threatens us all. 

This lack of trust comes, to a significant extent, from an ongoing underinvestment by our government and by the American medical establishment in rural healthcare. Again, the same rule is here. Every system requires the right amount and the right kind of investment. This is what builds trust, and when there is not enough trust a healthcare system is bound to fail. 

With the right attention and planning, we can build a national rural health network that is connected, flexible and strong. This network will need to have the right parts and it will need to have enough of them. It is something that can be done, and in a time of great fragmentation and pain for the American people it may be a way to help bring us back together and make us stronger once again.

Eyal Kedar, M.D., is a rural rheumatologist who developed an interstitial lung disease clinic in the North Country of New York. He is a leader in the region’s medical-care response to Covid-19. One of his chief interests is in developing strategies for improving healthcare delivery to rural communities. More information is available on his website.   

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