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The coronavirus pandemic walloped rural America last year, precipitating a surge of deaths among white residents as the virus inflamed longstanding health deficits there.
But across the small towns and farmlands, new research has found, Covid killed Black and Hispanic people at considerably higher rates than it did their white neighbors. Even at the end of the pandemic’s second year, in February 2022, overstretched health systems, poverty, chronic illnesses and lower vaccination rates were forcing nonwhite people to bear the burden of the virus.
Black and Hispanic people in rural areas suffered an exceptionally high toll, dying at far higher rates than in cities during that second year of the pandemic.
In towns and cities of every size, racial gaps in Covid deaths have narrowed. That has been especially true recently, when major gains in populationwide immunity have tempered the kind of pressure on health systems that appears to hurt nonwhite Americans the most.
With coronavirus deaths climbing, though, and health officials bracing for an even deadlier winter, scientists warned that efforts so far to close the racial gap in vaccination rates had not been enough to insulate nonwhite people from the ravages of major Covid waves.
Nowhere were those difficulties more pronounced than in rural areas. Black, Hispanic and Native American people in those places recorded the deadliest second year of the pandemic of any large racial or ethnic groups anywhere in the United States, according to the new research, which was led by Andrew Stokes, an assistant professor of global health at Boston University.
In those communities, the Biden administration’s reassurances that every Covid death is now preventable jar with the difficulties of obtaining medical care.
Rural pharmacies are often few and far between, making it difficult for poorer and less mobile residents to receive critical antiviral pills.
Doctors said that some Black patients, especially those who are uninsured or far from hospitals, wait too long before seeking help to benefit from new treatments.
And Black and Hispanic people have received booster shots at lower rates, a consequence of what some physicians describe as a lack of awareness stemming from cutbacks to public messaging, especially in conservative states.
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“The national vibe is that everyone should now be in a position to do what they need to protect themselves from the virus,” said Bobby Jenkins, the mayor of Cuthbert, Ga., a mostly Black town whose only hospital closed six months into the pandemic. “But not everyone’s in a position to do that yet.”
Racial disparities in Covid deaths have narrowed for several reasons, scientists said. The early vaccine rollout prioritized older Americans, who are disproportionately white. But over the last year, primary vaccinations for Black and Hispanic people climbed at roughly double the pace of white rates.
The rate for Hispanic people, 54 percent, now exceeds that for white people, which is 50 percent. The Black vaccination rate, 43 percent, still lags, but the gap has diminished.
The virus also infected and killed Black and Hispanic people at such greater rates in the pandemic’s first year — at one point in 2020, Black rural dwellers were dying at roughly six times the rate of white dwellers — that it may have had fewer targets by Year 2.
Those changes have been so profound that among the oldest Americans, white Covid death rates have recently exceeded those of Black people, according to Centers for Disease Control and Prevention data.
But the shrinking of the racial gap is partly because of a worsening of the pandemic for white people rather than serious advances for Black or Hispanic Americans. White Covid death rates climbed by 35 percent from the first to second year of the pandemic, the C.D.C. found. Over that period, death rates fell by only 1 percent in Hispanic people and 6 percent in Black people.
“It’s not a movement toward equity,” said Alicia Riley, a sociologist at the University of California, Santa Cruz. “It’s that white people started getting and dying of Covid more.”
The national picture has also disguised a shift that has as much to do with geography as with race, Dr. Stokes said. As the brunt of the pandemic shifted in late 2020 from big cities to rural areas, which have a bigger share of white residents, the national tally of Covid deaths naturally came to include more white people.
But within rural areas, Covid deaths were apportioned at greater rates to nonwhite people, just as they were in big cities and in small or medium ones, Dr. Stokes’s team found. He used C.D.C. counts of Covid death certificates up until February, avoiding more recent and potentially incomplete data, and took into account the older age of the white population.
At the worst of the Omicron wave this winter, Black and Hispanic death rates exceeded those of white people in towns and cities of every size, just as they had at the peak of every previous virus outbreak.
Black death rates at this winter’s peak were greater than those of white people by 34 percent in rural areas, 40 percent in small or medium cities and 57 percent in big cities and their suburbs. The racial gap was so large in cities because white urbanites have died from Covid at vastly lower rates than white people in rural areas for most of the pandemic.
Dr. Stokes said that the findings demonstrated that whether people lived in a big city or small town sometimes had as much to do with their experience of Covid as the part of the country where they lived. In the pandemic’s second year, ending in February 2022, rural parts of the West, South and Northeast all experienced surging white Covid deaths, despite stark differences in those regions’ containment strategies.
“It’s not enough to look at Massachusetts versus Texas,” Dr. Stokes said. “You have to look at rural Massachusetts versus rural Texas.”
Heading into a critical fall booster campaign, Dr. Stokes said, the results spoke to a need for much more proactive vaccination plans tailored to Black Americans, especially rural ones. “Adopting equitable vaccine strategies requires us to go above and beyond simply making them available,” he said.
In small and medium cities and rural areas across the South, where protective policies were rare, Black people suffered among the highest Covid death rates of any racial or ethnic group in any region in the second year of the pandemic, Dr. Stokes found.
Among those killed was Jackqueline Lowery, 28, a middle school science teacher and single mother of two in Darlington, S.C., a mostly Black city of 6,000. Having just given birth to a son, Ms. Lowery hesitated to be inoculated because she worried — without needing to — that the vaccine would contaminate her breast milk.
When she called a cousin, Jessica Brigman, a nurse, in September to say that she had fallen ill, Ms. Brigman urged her to see a doctor. But Ms. Lowery, who had obesity and gestational diabetes, had another priority: She had not yet tested positive for the virus, and she needed to before she could qualify for Covid pay from her employer. In the meantime, she was using up valuable sick days.
“She was the sole provider, and she had to pay bills, and she wasn’t going to get paid because she’d missed a solid week of school,” Mrs. Brigman said of her cousin’s worries. “They kept telling her she needed proof of positive Covid status.”
By the time she got a positive Covid result, Ms. Lowery was hospitalized, Mrs. Brigman said. About a week later, with blood clotting near her lungs, she died from Covid as she was being transported to a better-equipped North Carolina hospital. Mrs. Brigman remembered her cousin’s anxiety about qualifying for Covid-related time off as she weakened.
“She was like, ‘I need to get a positive test, I need to get a test,’” Mrs. Brigman said. “She never was focused on anything else.”
Dr. Morris Brown III, who practices primary care nearby, said that financial worries often kept patients from seeking care in a state that has refused to expand Medicaid coverage for low-income people.
Even deciding to seek treatment, though, does not guarantee finding it. Dr. Toney Graham III, a South Carolina hospitalist, said that his orders for Paxlovid antiviral pills were rejected until he found the single rural pharmacy nearby that stocked it. Whatever Covid-related public education campaigns once existed have dried up, he said, leaving people in the dark about boosters and treatments.
“There’s been a big drop-off in communication,” Dr. Graham said.
Nonwhite people have generally faced the most severe disadvantages in surviving Covid at young and middle ages, partly because of differences in the burden of chronic illness and workplace risks.
A return to workplaces by white people may be helping to diminish the racial gap in infections across age groups, said Theresa Andrasfay, a postdoctoral scholar at the University of Southern California. But as long as nonwhite workers are in closer contact with customers and colleagues and can less afford to stay home sick, she said, workplace-related disparities will persist.
Black people have also kept masking at greater rates, national polls indicate, a split that rural residents said was still on sharp display. “It’s more the Black who wear their masks,” said Roy Lee McKenzie, 78, of South Carolina, who is still recovering from a 2020 Covid case.
In rural areas, hospital closures, job losses, low vaccination rates and health problems stemming from poorer medical access have all exacerbated the effects of the pandemic. Inoculation rates were much lower in rural counties that voted more for Donald Trump, research has shown, but also in rural areas with health worker shortages and with more Black residents.
Janice Probst, who studies rural health at the University of South Carolina, said that the state’s strategy of funneling vaccines first through hospitals, and then through large chain pharmacies, had the effect of leaving behind more disadvantaged rural residents whose towns had neither.
In some places, though, even progress in vaccinating nonwhite communities has not been enough.
In Minnesota, Black, Hispanic and Asian adults under 65 were more highly vaccinated than white residents during the first Omicron wave, according to research led by Elizabeth Wrigley-Field, an assistant professor of sociology at the University of Minnesota. But middle-aged nonwhite people were killed more often by Covid anyway. Black people suffered double the death rate of white people.
“The whole way that the pandemic is framed now from political leaders is very much that people can choose their level of risk,” Dr. Wrigley-Field said. But, she said, “the risk that social groups have does not fall in lock step with their vaccination. It’s decoupled from that because of all the other things in our society that put some people at more risk than others.”