The syndemic

Covid-19. Opioids. Poverty. Age. No public transport, few doctors, vaccine skepticism. But while multiple challenges make the pandemic worse, rural communities have strengths to build on


“Four hundred and eight thousand, six hundred and eighty-seven Americans are dead. Americans. Americans. Americans.”

Toni Young, founder and executive director of the Washington, D.C.-based Community Education Group, hammered it home like an accusation, or an angry reminder: “This conversation today is not about your political views,” she said. “It’s about preparing rural America to get vaccines.”

It’s a major challenge. Young and the other panelists outlined their experiences on a January webinar focused on COVID-19 preparedness in the country. The presentation was sponsored by the Rural Health Service Providers Network.

In recent weeks, the death toll has climbed, but these numbers haven’t changed: 19.3 percent of the population lives in a rural area. 134 rural hospitals have closed since 2010. (New York lost two hospitals; Pennsylvania lost three, according to Becker’s Hospital Review.) Twenty-one closed in 2020 alone. All this evidence suggests a rural health care infrastructure that would struggle—that is struggling—with the pandemic.

A vaccine would seem to be a no-brainer.

But the Kaiser Family Foundation found that rural Americans are vaccine-resistant, with 21 percent saying they “definitely would not” get the jab, eight percent saying they would only get it if required and 27 percent would “wait and see.”

It’s a question of “how do I get people to buy into this vaccine?” Young said. “I don’t need to affect their minds; I need to affect their hearts.”

Dr. Blanton Tolbert of Case Western Reserve University explained coronaviruses and the vaccine, providing the scientific underpinnings of the situation. The news of the week was full of the latest mutation in the virus, but, Dr. Tolbert said, this is normal. “Viruses mutate rapidly. This is just a part of their replication cycle.”

Dena Hughes, the CEO of TAN Healthcare in Beaumont, TX, talked about what she sees. Beaumont is a city of 118,000 but is adjacent to a large rural area. Hughes called it a “vaccine void.” They’ve been pouring energy into testing, but “that’s definitely a challenge,” she said, especially in communities of color.

The problem is that public health is not at the forefront, she said, “judges are,” and public health “is not at the table... coordination is lacking, and one county has no hospital.” Not having public health in a key role means that what they can do and leverage gets forgotten.

But, she added, even having it at the table doesn’t fix everything. “How many tables are there?” There’s an implication: Other players have their own goals, and just because you’re talking to important people doesn’t mean you’re getting anywhere.

Rural areas are not uniform, either. “There are different cultures two miles apart,” added Amber David from TAN. Educating people in science can be difficult. “There’s no trust behind the government.”

Rural communities, Young said, are in a syndemic—multiple conditions and crises, intertwined—of AIDS, opioids, poor health care infrastructure, COVID-19.

Which takes us back to the numbers.

Dr. Deborah Birx hopped on the call from Washington. “Twenty percent of those over 70 who get COVID go into the hospital,” she said. “The fatality rate is 10 percent. That’s why the decision to immunize the over-65s is so important.”

But how to get them on board?

Don’t despair—the solution could be as close as your nearest Dollar General

So the list of problems and roadblocks is long and formidable. How do you get people vaccinated, Dena Hughes asked, in such a skeptical environment?

Dr. Clay Marsh, West Virginia’s coronavirus coordinator, had some suggestions.

His state, famously rural, used over 100 percent of its available vaccine by getting an extra dose out of each vial, according to the West Virginia Metro News. They have the capacity to distribute more, the paper said, but there simply isn’t enough vaccine nationally.

So what worked?

Altruism, Dr. Marsh said. Putting different agencies in a room so they could work together. They prioritized. People over 80 were a majority of deaths; give them shots. Give frontline workers shots. First responders.

“Maintain control over the vaccine coming into West Virginia,” he said. Half of their pharmacies are independently owned; make sure they can get vaccines, because they’re close to their communities and people trust them. Work with the state nursing home association to make sure the fragile elderly, and their caregivers, get shots.

Technology can be a problem. Dr. Deborah Birx pointed out that “we’re asking 80-year-olds to register on... sites that are completely alien to them.” They might need someone to help them, a buddy, through the process to get them registered and to the appointment.

Easy, she said, is necessary. “You can’t make things super-complicated in a pandemic.

Focus on the local, panelists said. Local public health, local advocacy groups. Churches. Local government, local health care providers. Reach people through those they know and are more likely to trust.

Listeners and panelists had some great suggestions, too.

  • “Keep things simple. Override the red tape.”
  • Use a buddy system to help seniors, the disabled or those in poor health to get registered and vaccinated.
  • Call on professional organizations to get the word out and educate.
  • Do COVID-19 screening alongside regular health care.
  • “Move with agility and not be afraid to do things.”
  • “Focus on personal responsibility.”

Young had an idea: “Dollar Generals!”

The stores are ubiquitous, with 16,720 stores in 46 states, and you can find them in rural towns and in low-income areas. The parking lots could be used for socially distant registration. The stores could be used for reaching out and talking about the importance of vaccines? Why not?

It’s an example of agility. And rural people can do that really well.

“The outside world is getting to see the great nature of our people,” Dr. Marsh said. “We can all answer to a higher call and answer it together.”


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