People living in America’s rural communities are dying at twice the rate of people living in American cities, a new study shows. And all of the rural areas are in … guess what? That’s right, Republican states. States, we might add, with low vaccination rates, supported by conservative politicians selling anti-vax sentiment and hoax cures under the guise of “personal freedom.”

Health disparities in rural communities aren’t new. Greater levels of poverty combined with limited access to medical care and systemic racism create a natural recipe for disaster. But, add in existing co-morbidities such as age, obesity, and diabetes, and throw on this pervasive misinformation about vaccines—which also drives low vaccine rates and staffing shortages—and now the recipe is deadly. 

“For those of us that work in public rural health care, that’s not entirely surprising. Because, there’s this phrase we used to describe rural populations, and that is they are older, sicker, and poorer,” University of Iowa’s Fred Ullrich, who co-authored the report tells CBS News.

According to the study, 20% of rural residents said they would “definitely not” get a COVID-19 vaccine, compared to 7% of urban residents and 14% of suburban dwellers. Given what we know about vaccines—that they save lives—the compounding issue is that people who live in rural areas have a higher risk of poor outcomes if they’re struck by COVID-19. 

In rural northeastern Texas, Titus Regional Medical Center has a 39% vaccination rate, CEO of the hospital Terry Scoggin tells The Oklahoman. 

Adam Willmann, board chairman of the Texas Organization of Rural and Community Hospitals, believes the political divide and misinformation has made it difficult.

“It’s more about politics now than it is about health or health care,” Willmann tells KXXV-15, ABC news in Central Texas. 

In southwestern Missouri, only 26% of Newton County’s residents are fully vaccinated. The Oklahoman reports that the health department held raffles, offered vaccine clinics, advertised in local newspapers, and even brought vaccines to remote areas. But vaccine numbers only increased after a community member died or got seriously ill. 

In rural Washington, since the delta variant struck, death rates have begun to soar–stoaked by conservatives across the state decrying mandates, honing in on those ordered by Gov. Jay Inslee–back to the old standby motto of the government infringing on the rights of the people. 

“COVID’s bad, but the issue that we need to rally about has more to do with constitutional governance than it has to do with the immediate issues of public health,” Rep. Jim Walsh, a Republican from Aberdeen, Washington told The Seattle Times. Walsh is anti-mandate, but swears he’s not anti-vaccine. Let’s not forget that, in June, Walsh was forced to apologize for wearing a yellow Star of David to protest vaccine rules. “It’s an echo from history,” Walsh wrote on a Facebook page at the time. “In the current context, we’re all Jews.” 

Hospitals in rural communities from Texas to Alaska have all been forced to activate “crisis standards” of care, rationing resources as they attempt to handle the tidal wave of hospitalizations.

“There is a national disconnect between perception and reality when it comes to COVID in rural America,” Alan Morgan, head of the National Rural Health Association tells KHN.  “We’ve turned many rural communities into kill boxes. And there’s no movement toward addressing what we’re seeing in many of these communities, either among the public or among governing officials.”

Again, in so many ways, these deaths are preventable.