In North Carolina, a dreadful headline met our eyes and dealt yet another devastating blow to our already battered hearts, “Child dies of coronavirus, becoming the first pediatric death in North Carolina.” Aurea Soto Morales died June 1, 2020, due to COVID-19 associated complications – she was 8-years-old. She passed one week before North Carolina’s highest one-day increase in cases and patient hospitalizations. One week before North Carolina Department of Health and Human Services Secretary Dr. Mandy Cohen stated, “I am concerned,” given the continued increase in key coronavirus metrics.
Rural regions of North Carolina are disproportionately affected by coronavirus.
Dr. Cohen is correct; the increase of cases, hospitalizations, and deaths is very concerning. The current trends are signals that we need to take seriously, especially in the rural regions of North Carolina. Throughout the pandemic, reports often emphasize metropolitan areas as they are more densely populated. Although rural areas have fewer cases than metropolitan areas, they are disproportionately impacted by COVID-19. Rural counties exceed per-capita coronavirus rates for both metropolitan areas and the state on average.
Rural North Carolina has a higher proportion of people at high risk or vulnerable to severe illness from COVID-19.
The higher per-capita rates of coronavirus in rural areas are of concern because individuals that live in rural communities are older and sicker than those in metropolitan communities. Recent census data indicates that more rural residents are unemployed, live in poverty, and are uninsured compared to metropolitan communities. Given rural North Carolinians are at an increased risk of severe illness from COVID-19, due to older age and certain underlying health conditions, they are likely to require more intensive hospital care and are at an increased risk of mortality.
North Carolina’s rural regions will have difficulty responding to an outbreak.
Before the pandemic, rural areas in North Carolina already lacked adequate access to health care compared to their metropolitan counterparts. Access to health care is a barrier as residents tend to live further from hospitals, have limited access to primary care, make less money, and are less likely to be insured. Due to North Carolina’s rural economies being weaker and less diverse, the economic impacts of the pandemic have been pronounced. In some of the most impoverished counties, unemployment doubled from March to April. The significant loss of jobs and job-based health insurance in rural communities will further strain the rural health care system. According to the Foundation for Health Leadership & Innovation, of the 80 rural counties, 63 are designated as health professional shortage areas, with 11 rural hospital closures since 2005, and an additional 8 in financial distress as of 2017. The continued loss of jobs and health insurance will continue to exacerbate the difficulty rural hospitals have to stay afloat and respond to the pandemic.
Approximately 45% of rural households don’t have broadband, roughly 15% more households than their metropolitan counterparts. As telehealth has become more critical to care while sheltering in place, the poor broadband infrastructure in rural communities makes it difficult to serve patients remotely and mitigate the spread of COVID-19. Having such poor broadband infrastructure and access means an increased possibility of COVID-19 exposures, spread, and reduced in-person care seeking to avoid possible exposures.
Possible compounded impact of COVID-19 in rural North Carolina to communities of color.
The COVID-19 pandemic has made the health disparities experienced by people of color, especially African Americans, more apparent in recent months. Although rural communities tend to be less diverse than metropolitan communities, racial health disparities are still present. African Americans make up the largest rural minority as an artifact of slavery in the Deep South. African Americans have higher rates of morbidity, mortality, and comorbid conditions, than other rural residents. In a report by the AAMC, many of the rural hospitals that closed in 2010 were in communities with significant populations of color – leaving communities of color with even more pronounced disparities in health care access.
State appropriations may not be enough to bolster the rural health care system.
House Bill 1043 titled, Act to Provide Aid to North Carolinians in Response to the Coronavirus Disease 2019 (COVID-19) Crisis, has several line items appropriating millions of dollars to bolster rural North Carolina’s ability to respond to the pandemic. Although the state is making an effort to improve, monitoring, transportation, broadband, and the health care system in rural communities, it may be too little too late. The longstanding disparities of health care and broadband access will require time and additional resources to be resolved in rural communities. In the meanwhile, the state is in Phase 2 of re-opening, and as we have seen, there has been an associated increase in cases, hospitalizations, and deaths. It is important that as the state continues efforts to re-open that they emphasize activities to protect at-risk communities and vulnerable populations through the intentional allocation of resources for screening, treatment, and tracing in rural North Carolina.