Rurality Versus Readiness: The Relationship Between State-Level Connection and Capacity Variables and the Management of Medical Stockpiles for a Public Health Emergency

• Date: 01 December 2021
• Published date: 01 December 2021
• Author: Nathan Myers
• DOI: 10.1177/0160323X211061352
• Subject Matter: Research Articles

Rurality Versus Readiness:

The Relationship Between

State-Level Connection and

Capacity Variables and the

Management of Medical

Stockpiles for a Public

Health Emergency

Nathan Myers

1

Abstract

This study investigates what factors contributed to the score a state received for managing its med-

ical countermeasures stockpile pre-COVID-19. It is particularly interested in the relationship

between a state’s level of rural population and its countermeasure management capacity. A fixed-

effects regression analysis was run using data from 2016 to 2019 to test for a relationship between

the percentage of rural population in a state and the states’countermeasures management score,

while controlling for other relevant social, economic, and political variables such as level of social

associations, the segregation index, and the level of income inequality. Rurality and physicians per

capita proved to be significant and negative. A subsequent analysis found that states with higher lev-

els of rural populations have lower levels of COVID-19 vaccinations, even accounting for effective

countermeasure management. This points to rural states having challenges in regard to medical

countermeasures that cannot be completely solved with technocratic solutions.

Keywords

social capital, rural states, housing segregation, income inequality, medical countermeasures, public

health emergency preparedness, pandemic response

Introduction

The emergence of a novel coronavirus at the

dawning of a new decade indicates that infec-

tious diseases will continue to be an impor-

tant agenda item in regard to both national

security and public health. Although these

policy areas are certainly interconnected, they

can sometimes be treated as separate issues.

The Strategic National Stockpile, a federally

1

Political Science and Public Administration, Indiana State

University, Terre Haute, IN, USA

Corresponding Author:

Nathan Myers, Political Science and Public Administration,

Indiana State University, Terre Haute, IN 47803, USA.

Email: nathan.myers@indstate.edu

Original Research General Interest Article

State and Local Government Review

2021, Vol. 53(4) 281-297

© The Author(s) 2021

Article reuse guidelines:

sagepub.com/journals-permissions

DOI: 10.1177/0160323X211061352

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funded reserve of medical resources, including

vaccines and countermeasures, was established

in the 1990s in anticipation of potential bioter-

rorism events (Nicholson et al. 2016). States

and local governments are assessed by the

federal government in regard to their ability to

effectively manage these resources (CDC

2021). At the same time, the ability to immunize

as much of the population as possible against

influenza and other vaccine-preventable ill-

nesses is a metric by which the public health

establishment is evaluated. The media has doc-

umented the manner in which vaccination rates

have fallen in some parts of the United States,

due to mobilization of anti-vaccination advo-

cates (Brumfiel 2021) coupled with distrust of

government (Enten 2021, July 10) and distrust

of the pharmaceutical industry (Grimes 2021).

Medical countermeasures are definedbythe

Food and Drug Administration as “FDA-regulated

products (biologics, drugs, devices) that may be

used in the event of a potential public health emer-

gency”(FDA 2021). Countermeasures can be

used to “diagnose, prevent, protect from, or treat

conditions”associated with a range of threats,

including emerging infectious diseases (FDA

2021). So at a time when the federal government,

as well as state and local partners, are making

strides in regard to the professionalization of coun-

termeasures management prior to and during an

emergency, a growing percentage of the public

may be disinclined to accept such resources from

the government. Both of these facets of govern-

ment performance in regard to medical counter-

measures are captured by National Health

Security Preparedness Index. The year 2020

brought not only the emergence of COVID-19

but also the beginning of the largest vaccination

effort in the history of the U.S. When considering

the success of this effort and the potential for

improvement in the future, it is useful to look at

what factors have affected state performance in

regard to the management of medical countermea-

sures in the past.

This study will focus on the NHSPI data

regarding the management of medical counter-

measures as the dependent variable, with most

of the independent variables derived from the

County Health Rankings data set. Of particular

concern for this paper are variables measuring

the percentage of rural area in the state, as

well as the level of social associations, residen-

tial segregation, and income inequality in the

state. The model also includes variables with

which to measure health system capacity, edu-

cation level, quality of health outcomes,

overall economic strength, and overall state

administrative capacity.

Rural Areas and Public Health

Challenges

Rural areas confront technical, financial, and

social-behavioral barriers to policy change, as

Bagchi (2020) recently outlined in the context

of expanding telehealth services. Leider et al.

(2020) noted the disparities in regard to prema-

ture mortality between urban and rural areas.

Mortalities decreased less in low-income rural

areas than in comparable urban areas since

2005. Higher income urban areas have seen a

decline in premature mortality since 2005,

while higher income rural areas have seen

increases in premature mortality. Melvin et al.

(2020) note that states with a higher percentage

of rural areas also tend to be less healthy. As

noted by Melvin et al. rural areas have a dispro-

portionate level of “older, poor, and underin-

sured residents”as well as “high rates of

chronic illness”(p. 1). Cosby et al. (2019)

describe a “rural mortality penalty”which has

increased over the last three decades. The

authors found the urban–rural disparity to be

“persistent, growing, and large”from the

1970s to 2016 (p. 155). Santibañez et al.

(2019) note that between 2004 and 2016 infec-

tious disease threats that are a particular threat

to rural areas, including those borne by mosqui-

toes, fleas, and ticks, tripled in the United

States. In addition, rural areas must confront

public health challenges from agriculture and

livestock, forests, and outdoor recreation. The

fact that rural populations are spread over

such large areas also creates challenges for car-

rying out public health activities.

This is attributed in part to slower economic

recovery from the Great Recession in rural areas

compared to urban areas. Rural areas have

282 State and Local Government Review 53(4)