Editor's note: The story was updated April 9, 2021, to correct the spelling of Brock Slabach's name.
CLARKSDALE, Miss. — In the early days of the pandemic, Greenwood, Mississippi, native Jackie Hawkins, a long-time rural public policy expert, expected that rural people of color would be hurt at higher rates than their urban and White counterparts.
As the pandemic set in, fear and hesitancy settled into Black communities relatively quickly, she said, because of the lack of information around the coronavirus, and because of years of fraught relationships with health care providers.
The Trump administration’s scant coronavirus prevention efforts alarmed Black communities, said Hawkins, who spent more than three decades working at the Mississippi State Department of Health.
Hawkins was asked questions such as “What happens if you don’t have insurance?” and “If I go to the hospital, will I be treated right?” she said. “In our mind, it was another thing to kill away Black people,” Hawkins told Stateline in a phone call.
Although deaths were initially higher in urban areas, since September death rates have been higher in rural communities.
Compared with their urban and suburban counterparts, the 60 million residents of rural America have limited access to health care. Rural hospital closures and a lack of affordable health insurance exacerbate the problem. Rural residents, on average, tend to be older, poorer and sicker or have underlying health conditions, all of which contribute to higher COVID-19 mortality rates.
The situation is especially dire for rural people of color, who have higher rates of premature deaths, poverty and chronic diseases and more often lack health insurance.
A recent report from management consultant firm McKinsey & Company shows just how dangerous the pandemic has been for rural people of color. From March 2020 through February, rural residents experienced 175 COVID-19 deaths per 100,000 people, compared with 151 deaths per 100,000 for urban communities. And in highly diverse rural counties where people of color made up at least a third of the population, 258 people died per 100,000.
In rural counties where the largest racial group was American Indian or Alaska Native, the overall death rate was 2.1 times that of White rural counties. In rural counties where Black people predominated, the overall death rate was 1.6 times that in White rural counties. And in largely Hispanic rural counties, the death rate was 1.5 times higher than the White rate.
Rural Americans with underlying health conditions—who are most likely to die from COVID-19—tend to live in areas with shoddy access to health care. Their states are more likely to have skipped out on Medicaid expansion under the Affordable Care Act, and they are more likely to have seen their hospitals shuttered in the past 15 years. Tackling those underlying access issues, public health experts say, could help rural people of color in the future.
The COVID-19 racial disparities in both urban and rural areas stem from “long-standing systemic inequalities and structural racism,” according to a March report by the planning and evaluation office of the U.S. Department of Health and Human Services.
“What we have seen through COVID is another example of the legacy of Jim Crow, the legacy of economic inequality, and the legacy of seeing these repeated patterns of disparities cyclically, but never really establishing the systems to create better outcomes,” said Dr. Jewel Mullen, associate dean for health equity at the University of Texas at Austin’s Dell Medical School.
The COVID-19 death rates in Mississippi and Texas, where more than a third of Black and Hispanic people live in rural counties, illustrate Mullen’s point. In Mississippi, that death rate among Black residents of rural counties has been 310 per 100,000 people. In Texas, the death rate among Hispanic residents of rural counties has been 331 per 100,000 people, according to McKinsey.
“This linkage of health and socioeconomic disparities drives higher rates of COVID-19 and cases of severe illness in already vulnerable populations,” the authors of the McKinsey report wrote. Because rural residents already experienced pronounced rates of food insecurity and poverty, among other issues, the report found, they were more vulnerable to COVID-19.
The pandemic has placed an additional strain on the already crumbling health infrastructure in rural areas, said Brock Slabach, senior vice president for member services for the National Rural Health Association. Sixty-five percent of rural counties nationally do not have a single ICU bed, according to McKinsey, and rural communities make up more than 61% of areas with shortages of medical health professionals, according to recent data from the U.S. Department of Health and Human Services.
Some 180 rural hospitals have closed since 2005, reports the Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill. Of the six that shuttered in Mississippi, all were in majority-Black towns. In Texas, 21% of the hospital closures were in areas with a large population of minorities. Both Texas and Mississippi are among the 12 states that opted out of Medicaid expansion under the Affordable Care Act.
Slabach and other population health experts say expanding Medicaid in Texas and Mississippi would make a huge difference for rural residents—especially those who are low-income and of color.
“It’s seeking appropriate levels of care, so being able to be seen in a clinic for a chronic disease rather than having to go to the emergency room, for example,” Slabach said. “That’s why we need to make sure that coverage is a priority.”
Rodney Washington, associate professor of population health science at the University of Mississippi Medical Center, teamed up with trusted community leaders such as Hawkins to try to counter the distrust and misinformation that is prevalent in the rural communities of color in the Mississippi Delta.
Washington has studied the Delta for years and knows each town is unique. He hosted Zoom sessions with residents of Holmes, Leflore and Washington counties to hear their concerns, using grant money from the CDC Foundation, an independent nonprofit that mobilizes philanthropic and private-sector resources to support the public health work of the federal Centers for Disease Control and Prevention.
Washington led a research team that assessed the available resources and enlisted some residents—political leaders, community organizers and church members—as liaisons to distribute COVID-19-related information and ask for residents’ reactions.
“Some people have mistrust at the local level. Some people have mistrust at the state level. There’s this mistrust in the health care field altogether,” Washington said. “Then there’s not the best perception of universities coming in to collect data. … Residents don’t see any meaningful impact in their own communities.”
But Washington said the outreach efforts bore fruit. Those who were a “hard no” to getting a vaccine last fall were searching for sites to make an appointment by February, Washington said. He added that residents said they felt vaccines were inequitably distributed in their towns.
Leaders across the three counties in which Washington is working want to partner with barber and beauty shops, host events in local parks and invite health care professionals to ease people’s vaccination concerns.
After addressing hesitancy, access became the next challenge.
The Biden administration last month announced that it will spend $10 billion, much of it from the latest COVID-19 relief package, to expand access to vaccines for communities of color, rural residents and low-income people. The administration also will funnel $6 billion to community health centers so they can ratchet up vaccinations and testing, and spend another $3 billion to boost local efforts to increase equitable vaccine distribution.
Rural communities have created partnerships to combat inequity in the vaccine rollout. In Baton Rouge, Louisiana, Black churches became vaccination sites only weeks after leaders questioned city leadership about the lack of sites in predominantly Black areas. The Community Foundation of Northwest Mississippi, a nonprofit that connects Delta counties with financial resources, collaborated with prominent Delta leaders to create a vaccine transportation initiative that rents buses to transport residents to vaccine appointments.
Vaccine hesitancy lingers among people of color despite these improvements. A recent survey of people in the San Francisco Bay Area published in the Journal of the American Medical Association showed Black, Asian and Hispanic respondents were less likely to get a COVID-19 vaccine. Their reasons included low confidence in coronavirus prevention, mistrust of vaccine producers and a lack of faith in the government’s approval process. Transportation difficulties, low vaccine supply, language barriers and technological hurdles are other rural challenges, Hawkins said.
For example, for residents of the tiny city of Itta Bena in Leflore County, Mississippi, the closest vaccination site is the Wal-Mart pharmacy about 10 miles away in Greenwood. With no public transit, a car is required to get there. And internet connectivity issues or a lack of broadband access can make it difficult for people to schedule a vaccination appointment online.
In recent weeks, however, Mississippi has made significant strides in getting vaccines to people of color.
As of Feb. 1, Black Mississippians made up just 17% of the state residents who had received vaccines, even though they are 38% of the state’s total population. As of this week, however, Black residents accounted for 32% of vaccinated Mississippians. Jefferson, a county of about 7,000, leads the state with 37% of residents vaccinated. But most predominantly Black rural counties in the Delta lag Jefferson, with 23% or less of their populations fully vaccinated. Issaquena County, the least populous county in the state, ranks last, with only 8% of its residents vaccinated.
Statewide progress has been slower in Texas, where Black people are 12% of the total population. Black Texans received 7% of the vaccinations on Feb. 1 and were still only 8% of the total vaccinations as of this week. Hispanics are 40% of the total population in Texas but made up just 28% of the vaccinations.
Despite the recent progress in Mississippi, Hawkins said the state still has “a long way to go.”
“We need resources accessible to all people and not just one side of the tracks,” Hawkins said. “People just need to understand our story. Don’t dress it up. Be transparent.”