Today, as with every third Thursday of November, the U.S. is celebrating National Rural Health Day, honoring the commitment of the health providers who steward the health of the one in five Americans who live in rural communities. At the same time, this occasion should remind us that over the past nearly 3 years, these hard-working professionals have been caring for rural communities in increasingly diminished health. Once a haven from cities devastated in the first months of the pandemic, rural areas have outpaced urban areas in COVID-19 mortality rates. And as the earlier surges of the pandemic recede, a new concern is emerging: a mismatch between the burden of long COVID in rural communities and the resources available to address this complex public health challenge.
According to U.S. Census Bureau data from October, approximately 7.5% of American adults report experiencing long COVID symptoms. Higher COVID-19 mortality and lower vaccination and booster coverage suggested rural Americans will face a greater burden of long COVID than their urban counterparts. We see this playing out, as many of the states with the largest percentage of patients suffering from long COVID — such as Kentucky, West Virginia, and Wyoming — are predominantly rural. However, the growing number of specialty clinics, research studies, and other resources for long COVID are currently concentrated in urban areas.
This is particularly concerning because even before the COVID-19 pandemic, rural health systems faced uphill battles in meeting the routine needs of their communities. In a 2019 survey, one in four rural residents reported not receiving the healthcare services that they needed. In rural areas over the last decade, hospitals, primary care practices, and pharmacies have closed at an accelerating rate — leaving many regions lacking access to basic healthcare. While one in five Americans live in rural areas, only about one in 10 physicians practice there.
These threadbare healthcare systems are particularly ill equipped to manage a growing number of patients with a novel complex chronic illness like long COVID. Specialists are in especially short supply in rural communities, and rural primary care physicians often treat a broader range of conditions with limited access to the support of specialists and advanced technology.
Even in cities with leading-edge clinics for long COVID treatment, many patients struggle to secure diagnoses and must navigate fragmented and overrun systems of care. Rural patients with a suspected or confirmed diagnosis of long COVID regularly relay to us their experiences with long journeys to locate providers who are familiar with long COVID. Many must wait for months for appointments at clinics that are located hours away. Even utilizing telehealth can be more difficult for long COVID patients in more remote areas, given factors like limited broadband coverage and lesser access to technology.
These structural obstacles are all the more significant given that many rural residents suffering from long COVID may not connect their symptoms to a prior infection. The actual prevalence of long COVID may be even higher than reported. Roughly half of rural adults do not believe they have had COVID at all, despite data showing that most Americans have been infected at least once. Low awareness of past infections, combined with misinformation and stigma, adds to the challenges confronting rural patients.
To address these gaps, policymakers, health systems, and funding institutions must invest in initiatives to deliver care and ensure equitable access to research opportunities for rural long COVID patients. Rural patients need access to specialty clinics and services, and the local capacity of rural health systems also needs to be enhanced. Virtual training and mentorship, through established platforms and programs such as Project ECHO, can support rural clinicians caring for long COVID patients. Telehealth can also bridge distances between specialists at long COVID clinics and rural providers. In parallel, public health and healthcare leaders must actively work to raise patient and community awareness around long COVID through community outreach and media campaigns. Most importantly, efforts to ensure rural equity in long COVID care, research, and support should be coupled with broader support for rural healthcare institutions.
Long COVID researchers continue to push the boundaries of science and clinical practice. Without serious efforts to close the geographic divides in access to knowledge and resources, we will see rural long COVID patients increasingly burdened by the pandemic’s enduring impacts on health and economic well-being. Now is the time to commit to driving rural equity in the long COVID response.
Anne Sosin, MPH, is a policy fellow and public health researcher focused on rural health equity at the Nelson A. Rockefeller Center at Dartmouth College. Krista Coombs is a long COVID patient advocate in rural Vermont and the Vermont state lead for the COVID-19 Longhauler Advocacy Project.