Rural America has borne a disproportionately large share of the deaths caused by Covid-19 in the past three years. But after months and years of sharply divergent death rates, rural and urban America have reached a tentative equilibrium, of sorts, in the rate at which their residents are succumbing to Covid-19.

Over the course of the pandemic, about 37% more rural Americans than urban Americans have died from Covid-19, when deaths are adjusted for population size. If the rural death rate were as low as the metropolitan rate, 138,437 fewer people would have died.

The large gap between the cumulative death rates in rural and urban areas are primarily the result of large surges, when the rural death rate accelerated compared to the urban rate.

Earlier in the pandemic, the weekly rural death rate has been more than two times higher than the urban rate for months at a time. In the last year, however, the gap – while still significant – has stabilized. Since July 2022, the weekly rural death rate has been on average about a third higher than the urban rate. For the past three months, it’s been about 25% higher.

The disproportionately higher rate is still disturbing, but it’s not accelerating the urban-rural gap the way surges in the past did.

For now, health experts say, the smaller gap between urban and rural death rates is reassuring because it means the nationwide death rate is relatively stable.

The Pandemic’s First Impact: Major Cities

At the start of the pandemic in early 2020, the epicenter of the public health crisis was New York City. Four months into the pandemic, in May 2020, urban Americans were dying at a rate three times higher than rural Americans (21.95 vs. 5.46 deaths per 100,000).

But that began to change as the summer of 2020 approached. 

The graph above tells that story. It compares the weekly death rate in metropolitan counties to the weekly death rate in nonmetro (rural) counties. When the line is below 0%, as it was at the start of the pandemic, the urban rate is higher than the rural rate. And when the line is above 0%, rural America’s weekly death rate is higher.

By August 1, 2020, rural and urban areas had equivalent death rates. From there, the weekly rural death rate soared relative to the weekly urban death rate, and it has remained higher than the metro rate for 118  out of the last 126 weeks.

Rural Death Rates Soar

Weekly death rates give only a snapshot of the pandemic. To see the crisis’ longer-term impact, we can use the cumulative death rates. The cumulative death rate continually rises as more people die from Covid-19. The steeper the increase of the line, the more the weekly death rate is increasing. When the number of deaths decline, the cumulative death rate lines are more horizontal.

In December 2020, cumulative rural deaths rates went through the first of what would be two periods of rapid acceleration over metropolitan rates. On the cumulative death-rates graph, these are periods when the blue line (rural) is steeper than the black line (metro).

By the first week of December 2020, rural and metropolitan counties had about the same number of cumulative deaths proportionately (91.78 deaths per 100,000 in rural areas and  89.29 deaths per 100,000 in metro areas).

But rural America quickly got much worse. That shows up in the graph when the blue line crosses the black line and soon surpases the black line. By February of 2021, for example, the rural cumulative death rate was 16% higher than the urban cumulative rate. Rural weekly death rates have exceeded urban rates for 119 out of the 135 weeks that the Daily Yonder has been tracking deaths.

The gap in cumulative death rates between urban and rural America continued to grow until February of 2021, when vaccines started to come online and, shortly thereafter, warmer temperatures allowed better social distancing. Throughout the summer, the rural weekly death rate was closer to the urban weekly death rates – shown where the blue and black lines increase at a roughly parallel rate. 

From March to July 2021, right before the next big surge, the cumulative rural death rate was a steady 15% higher than the cumulative urban death rate. 

After a Period of Stability, Rural Death Rates Grow Faster than Urban Rates for the Second Time

That equilibrium continued until late summer 2021, when weekly rural death rates accelerated again during the Omicron surge. For the rest of 2021, the weekly rural death rate was as much as two times higher than the urban weekly death rate. 

By the end of the Omicron surge in January 2022, the rural cumulative death rate grew to 35% higher than the urban rate. 

Since the initial coronavirus surge, which concentrated in New York, the rural death rate has been higher than the metro death rate during every single surge, including the current small surge.

In March of 2022, the gap between rural and urban cumulative death rates reached a second plateau. Since then, the rural cumulative death rate has remained about 37% higher than the urban rate for 40 consecutive weeks. 

A Combination of Factors Make Rural Death Rates Higher

Lower vaccination rates explain part of the reason rural death rates have tended to be higher than urban death rates.  Only 56% of rural residents are fully vaccinated today, compared to 67% of their urban counterparts. 

But vaccination rates alone don’t tell the whole story.

Rural areas have greater health challenges that pre-existed Covid-19. Rural areas are, on average, poorer, older, and sicker than their urban counterparts. These demographic factors are what public health experts call social determinants of health, or the environmental conditions that can affect someone’s health status. Populations that fare worse on social determinants of health tend to have worse health outcomes.

Rural health expert Carrie Henning-Smith, PhD, of the University of Minnesota said things like access to health care services and underlying conditions can make rural death rates worse.

“Rural areas with high poverty and high rates of uninsured individuals are some of the most likely to have lost hospitals and other health care services,” Henning-Smith said in a Daily Yonder interview.

From 2010 to 2021, there were 136 hospital closures, 103 of which occurred in rural counties, and 35 of which occurred in rural counties with poverty rates higher than 20%. 

What Happens Next?

“For two years we saw massive spikes [in infections and deaths]. But for the last 10 months, we haven’t,” said Randy Wykoff,  M.D., dean of the College of Public Health at East Tennessee State University. “The question everybody is asking is, are we going to keep seeing the spikes?”

Wykoff said in an email to the Daily Yonder that the plateau in death rates over the past 10 months has been reassuring. 

“I would say that the plateau is related to a combination of advancements in our treatments of Covid, growing immunity in the population (from vaccines and infections), and decreased severity of some of the more recent strains,” said Smith.

But even health experts can’t predict the future. 

“What is the virus going to do? Are we going to see mutations that are more lethal?” Wykoff said. “If the next version of the virus is more lethal, that’s sort of a game-changer.”

Wykoff said national preparedness to prevent Covid-19 may include the development of annual vaccinations that are targeted at the currently dominant strains of the coronavirus, similar to the way flu vaccines are developed.

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