The pandemic death rate in rural America is two times higher than the metropolitan rate, primarily because rural Americans have been slower to get vaccinated against Covid-19, health experts say. But a combination of other complex factors is also part of the equation.

Since June 2021, about 42,000 rural Americans have died from Covid-19. If rural Americans were dying at the same rate as metropolitan communities during that same period, 21,000 fewer people would have died.

So why has the rural death rate been higher than the urban rate, especially in the second half of 2021?

The biggest reason is that rural areas have lower vaccination rates, said Carrie Henning-Smith, deputy director of the University of Minnesota Rural Health Research Center. People who are not vaccinated are at greater risk of infection, hospitalization, and death from Covid-19, she said.

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“I think the higher rates of vaccinations among urban residents have helped us see a decrease in deaths of urban residents, but we haven't had the same rate of vaccination uptake in rural areas, which is why we see this divergence in death,” she said. 

The rural vaccination rate is currently about 20% lower than the metropolitan vaccination rate. As of December 9, 46.4% of the total rural population was completely vaccinated, versus 58.8% of people living in metropolitan counties.

Raising the rural vaccination rate to the metropolitan rate would have resulted in 5.7 million additional completed vaccinations in rural America. The CDC estimates that unvaccinated Americans are dying of Covid-19 at a rate 14 times higher than vaccinated Americans.

But lower vaccination rates aren’t the only factor in rural America’s Covid-19 deaths. Behavioral factors are also part of the cause, Henning-Smith said.

“We know that rural residents have been, for a variety of reasons, less likely to adhere to preventive measures,” she said. “They’re less likely to wear masks or socially distance.”

A study earlier this year found that rural residents were less likely to observe public health measures to combat Covid-19. They were less likely to limit the number of people they allow in their homes, less likely to wear a mask in indoor public places, and less likely to maintain social distancing, according to a report from McKinsey, a management consulting firm.

Another factor is pre-existing conditions. Rural populations tend to be older and have higher rates of chronic conditions like type 2 diabetes and cardio-pulmonary disease, which can cause complications for Covid-19 patients.

“We saw higher death rates among rural residents and that had a lot to do with the health conditions that were already in the population,” Henning-Smith said.

The amount and type of healthcare available in rural areas can also be a factor.

“You have this issue of healthcare capacity,” Henning-Smith said. “We know that healthcare everywhere is absolutely stretched to the max. Healthcare workforce shortages seem to be most pronounced in rural areas. And rural facilities are less likely to have ICUs and ventilators.”

Because healthcare systems across the country are strained, she said, urban facilities don’t necessarily have room to accept patient transfers from rural areas.

Rural transportation issues also affect access to healthcare, said Michael Urban, senior lecturer at the School of Health Sciences at the University of New Haven in Connecticut. In some cases, he said, long drives into town can hinder residents’ willingness to get tested or cause them to put off care for too long.

As early as November of last year, the National Institute of Allergy and Infectious Diseases (NIAID) found that treating Covid patients early speeds up recovery and reduces the likelihood of complications. That, in turn, reduces the demand on the healthcare system.

The highly contagious Omicron variant is now in the United States. Current vaccines offer some protection against the variant, but the National Institutes of Health report that a booster shot offers 25 times more protection than the initial immunization alone. The CDC recommends that people 16 and up get a booster shot.

Urban said the winter months could be difficult.

“We're going up into our next wave (of Covid),” he said. “The question I would have is how big of a wave will it be? Will be like last winter, or is it going to be milder?”

Tim Marema provided additional reporting for this article.

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