In rural counties, UI research shows higher rates of COVID-19 cases, deaths

Updated research from the University of Iowa College of Public Health shows disparities throughout the summer between rates of COVID-19 cases and deaths in metropolitan and nonmetropolitan areas.

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Raquele Decker

Fred Ullrich poses for a portrait in his office located at the College of Public Health building on Wednesday, Oct. 27, 2021.

Ryan Hansen, News Reporter


Cases and deaths from COVID-19 are much higher in rural counties than in urban counties, according to research from the University of Iowa College of Public Health.

Data trends show nonmetropolitan areas have much higher death rates because of COVID-19 than metropolitan areas across the country, including in Iowa.

The current data set is updated through Oct. 15 and shows a seven-day rate of 23.86 cases and 0.38 deaths per 100,000 people in metropolitan areas, while there are 39.79 cases and 0.84 deaths per 100,000 in nonmetropolitan areas.

Fred Ullrich, program director for research in the UI Department of Health Management and Policy and researchers on the project, said his interest in researching the topic began at the outset of the COVID-19 pandemic. The research has been updated multiple times throughout the past 20 months to reflect the changing trends of the pandemic, he said.

“Early on in the pandemic, in what might be referred to as the first surge, there wasn’t a lot going on in nonmetropolitan areas,” Ullrich said. “It was largely a metropolitan phenomenon.”

During the second surge, which Ullrich said was in the summer of 2020, rural cases of COVID-19 picked up and by the third surge, in the late fall and early winter of 2021, cases and deaths in nonmetropolitan areas surged past those of urban spaces.

“Paralleling the introduction of vaccines, we saw a sharp decline in incidence and mortality,” Ullrich said. “The mortality rates and incidence rates have largely been parallel. They haven’t always been superimposable, but they have always run in the same general direction.”

Ullrich said there was an especially noticeable disparity between the rate of COVID-19 cases and deaths in metropolitan and nonmetropolitan populations last month.

“The metropolitan rate then sort of tapered off in September, but the nonmetropolitan people kept going,” Ullrich said. “That’s when we saw some really sharp differences in the rates between the two populations.”

Ullrich said he was cautious to speculate as to why rural COVID-19 mortality and incidence rates were higher.

He said higher death rates within rural areas can be the result of lower vaccination rates, but that does not necessarily explain why COVID-19 cases are higher.

“The rural population is older, sicker, and poorer,” Ullrich said. “All of those things will contribute, not necessarily to the spread of the disease, but they certainly contribute to poorer outcomes. If I don’t have a lot of money or I don’t have insurance, I’m less likely to go to the physician, and so therefore I’m less likely to get the appropriate treatment that I need.”

Incidence is the rate of occurrence of a condition and in the case of COVID-19, represents on a rate basis how often people have tested positive in the population, Keith Mueller, director of the Rural Policy Research Institute Center for Rural Health Policy Analysis.

Mueller has co-authored the research with Ullrich from the beginning and said additional factors have contributed to the high mortality rates from COVID-19 in rural areas.

“We know that around the country since 2010, over 130 rural hospitals have closed,” Mueller said. “In many places, that was the cornerstone of care in the community.”

Mueller said health care disparities in rural areas are compounded by struggles to recruit and retain medical professionals. He said hospitals have worked together to move patients and make sure they get the best treatment possible during the pandemic.

Mueller said he has worked in the field of rural health for nearly 30 years, so when he and Ullrich found a data set that allowed them to do this analysis, he was deeply interested in researching, analyzing, and compiling that data to inform the public.

“We’re not happy to do it because we’re not happy there’s a pandemic,” Mueller said. “But we’re certainly happy to be a resource that can help people understand what is happening.”

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