COVID-19 Highlights Vulnerabilities of Rural Hawaii
by Joyce Lee-Ibarra, JLI Consulting LLC
At the outset of COVID-19’s appearance in the United States, rural areas seemed insulated from the disease’s impacts. Urban centers like New York, Chicago, and New Orleans were clearly bearing the brunt of the pandemic, while less densely populated rural areas showed little effect.
In recent weeks, that’s all changed. After an initial delay, cases in rural communities have climbed throughout the country. On March 6, COVID-19 first emerged in Hawaii on its most densely populated island of Oahu. Cases followed in mid-March and early April on the state’s neighbor islands, home to the Hawaii’s more rural areas. As of April 19, 2020, Hawaii Island reported 62 COVID-19 cases; Maui (including Molokai), 106 cases; and Kauai, 21 cases, compared to Oahu’s 385. Although the majority of cases in the state remain on Oahu, the slow and steady growth of confirmed COVID-19 infections on neighbor islands confirms that they are susceptible to the disease as well.
As Hawaii remains under shelter-in-place orders, we consider a few questions specific to our state’s rural communities.
How much more rural are the neighbor islands than Oahu?
It helps to first define what we mean by “rural.” Using 2010 US Census data from CountyHealthRankings.org, a program of the Robert Wood Johnson Foundation, rurality is measured as a percentage of a county with census tract-area populations of less than 2,500. Overall, 8.1 percent of Hawaii’s population lives in rural areas; however, wide variation exists across the islands. On Kauai, 12.9 percent of the population is considered rural; on Maui, 14.6 percent; and on Hawaii Island, more than a third—38.0 percent—live in rural areas.
If COVID-19 is spread through close physical contact with people infected by the disease, does living in more rural areas offer some protection against infection?
Some initially argued that the rurality of some neighbor island communities would serve to minimize the spread of the COVID-19. Although their residents are presumably better able to practice social distancing, rural communities often lack medical capacity—in terms of personnel, facilities, and equipment— leaving them less able to respond to outbreaks than urban areas.
Graphic Credit: New York Times, Hawaii Coronavirus Map and Case Count, April 18, 2020.
COVID-19 cases in Molokai, East Maui, and Kauai raised early concerns about rural areas’ ability to contain the disease. State legislators serving communities in East Maui, noting the risk the coronavirus poses to rural areas, even sought assistance from the National Guard to help enforce travel restrictions and enhance community policing efforts in an effort to proactively stem the disease’s spread. Analyses (table, above) show that the COVID-19 case growth rate has slowed across all Hawaii counties recently. Overall, fundamental guidelines for slowing transmission of coronavirus apply equally to residents of urban and rural areas: wash your hands well and often, avoid close physical contact with others, and cover your nose and mouth with a cloth face covering when in public.
What other risk factors for COVID-19 are heightened among people living in rural communities?
About 15 percent of Americans—nearly 46 million people—live in rural areas and tend, on average, to be older and at greater risk for certain conditions such as heart disease and obesity. In addition, residents of rural communities are more likely to possess certain demographic characteristics such as lower income and lower employment than their urban counterparts, which places them at greater risk for poor health outcomes. Combined with more limited health care access, rural residents experience greater overall vulnerability for acute diseases such as COVID-19.
Although nationally people living in rural areas have higher percentages of uninsured than urban areas, Hawaii’s overall uninsured percentages are relatively low. 2017 data shows the percentage of uninsured ranging from 4.1 percent in Honolulu County to 6.4 percent in Hawaii County, offering a bright spot locally in the typical relationship between rural residence and poorer health.
How can decision makers address the vulnerabilities of rural communities in Hawaii going forward?
A study published last week by The Pew Charitable Trusts notes that the rural response to COVID-19 has been hampered by ongoing declines in rural populations, which undermine the available health care workforce as well as the tax base for funding health care services. Policy makers and community leaders can keep this demographic trend—one which began prior to the current pandemic—in mind when planning for long-term economic and health system recovery.
Investments in infrastructure for rural communities will need to be part of the long-term strategy for future public health emergencies as well as economic recovery plans. While virtual health care and telemedicine seem obvious solutions for addressing rural health needs, many rural communities lack broadband internet or even reliable cellular phone service required to make these options viable. Shoring up these entry points to technology and communication will be critical for the long-term health—both physical and financial—of Hawaii’s rural communities.
Joyce Lee-Ibarra is principal of JLI Consulting LLC and a consultant to the Hawaii Data Collaborative.
