Although we in the U.S. were clearly not sufficiently nor effectively prepared for the onslaught of the coronavirus in our metropolitan areas across the nation, we need to begin our immediate preparations for the impact of this virus on the rural areas of our nation. This crucial planning requires the recognition that the risks, issues of prevention and treatment opportunities are substantially different in rural communities than in metropolitan areas.
In rural communities, as opposed to urban or suburban areas, there is a substantially higher number of at-risk individuals. In general, these individuals are older and have a higher percentage of chronic diseases, including diabetes mellitus, heart disease, chronic obstructive lung disease and cancer, among others. Individuals who live in rural communities, on average, have a substantially lower social determinant of health parameters. They are less wealthy and live in poorer communities, impacting the quality of systems and services available. There have fewer economic opportunities. Health care is less accessible. Mortality rates are higher. For instance, one analysis revealed that there is a 60% higher death rate for the flu than in the large metropolitan areas due to these factors as well as less-accessible health care.
Even before the pandemic hit, there was an existential crisis occurring among rural hospitals. Rural hospitals serve around 60 million people (about a fifth of Americans), but 119 rural hospitals have closed since 2010. Eighteen closed last year and eight have closed so far this year. Several factors are contributing, including the trend to care for patients as outpatients rather than inpatients, increasing costs and decreasing reimbursements among others. This obviously results in even fewer hospitals to serve this vital population. These rural hospitals are more dispersed, less equipped and with substantially less funding available than other parts of our country — and with much more limited supplies, including beds, personal protective equipment and ventilators to name a few. Indeed, the loss of elective procedures at these sites during our current crisis, one of their main profit centers, has further handicapped their funding streams and ability to prepare.
Due to the broad geographic similarities and remarkable health care disparities facing rural areas across the nation, focusing on a state-by-state response would promote a poorly orchestrated and haphazard approach to the coming tsunami of COVID-19 cases in rural areas. The distance between rural homes and communities will likely cause a delay in the impact in rural populations compared with metropolitan areas. This will likely result in the most deadly and impactful time for our rural neighbors occurring while the national curves of impact are declining. As the numbers impacted in our rural areas will be smaller, they could be lost in the declining curves, despite a significantly higher percentage of serious infections and deaths in rural areas.
Perhaps with the exception of relatively few successful gaming tribes, we may have even greater potential for devastation among rural American Indian reservations. Chronic neglect and underfunding of Native American health care services has resulted in poorly prepared systems to handle such a pandemic. The public health infrastructure is minimal, and the communities are often quite poor. One in six households on reservations are overcrowded, making social distancing an unapproachable ideal. The vast majority of these reservation-based hospitals and health centers were developed to provide only primary care services, generally without the resources or capacity to provide more than initial basic emergency care and immediate transportation to larger hospitals for acutely ill patients. Chronic shortages of health care providers, personal protective equipment and supplies further limit the capacity of these facilities. Indeed, it is reported that the Indian Health Service has only 81 ventilators across their national network.
This is an urgent crisis. We are in need of broad national leadership now to begin a focus on our rural area preparations. I urge the immediate implementation of a national task force — made up of rural and tribal leaders, rural hospital executives, medical and public health experts, state and federal representatives — to meet this urgent need for planning and implementation of appropriate funding and public health measures.
Dr. James Galloway, former medical director of two rural hospitals, was assistant U.S. surgeon general, a rear admiral in the U.S. Public Health Service and health administrator in the Chicago region for the Department of Health and Human Services under Presidents George W. Bush and Barack Obama.