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Health inequities in rural communities across the South are continuing to determine who is most vulnerable to Covid-19 now that the Delta variant is bringing a new surge in deaths.

Several states, including Florida and Georgia, have experienced the highest levels of hospitalizations to date in recent months, as the highly contagious variant sweeps through the country, and within those states, rural areas are especially hard-hit.

“Delta has been brutal on our community,” said Tammy Jackson-Moore, co-founder of the Guardians of the Glades nonprofit, who has been working to improve vaccination rates in Pahokee and other predominantly Black or Hispanic cities in Palm Beach County, Fla. “We knew Covid was bad, but Delta showed us it was worse than what we anticipated.”

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The Glades, an agricultural area bordering the Everglades, is one of a number of rural communities with large Black populations that STAT visited early this year to report on the pandemic’s impact.

In Pahokee, where STAT previously exposed vaccines intended for local Black and Hispanic local residents instead going to white people who drove there from out of town, there have been more deaths since Delta hit than at any other time in the pandemic, according to Jackson-Moore.

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Nationally, the racial gap in deaths appears to have narrowed significantly in recent months, according to government data, though Black people are still dying at slightly higher rates than white individuals across the U.S. since the summer, according to the CDC. The differences are small: There were 0.3 deaths per 100,000 Black people compared to 0.2 per 100,000 white people in May, and 1.3 Black deaths versus 1.2 white deaths in August.

These numbers don’t tell the whole story, however, as a lower percentage of Black people than white people reach old age, when Covid-19 is most lethal. “People of color in the U.S. tend to skew younger and are dying at younger ages,” said Keisha Leanne Bentley-Edwards, a professor of medicine at Duke University School of Medicine who studies racial determinants of health. The overall data obscure the level of disparity, she added.

Within the United States, there are considerable variations in worst-hit communities, with some white rural areas with low vaccination rates suffering deaths from Delta where they’d previously experienced minimal impact. Elsewhere, the lack of health care infrastructure that contributed to deaths early in the pandemic is compounding the effects of Delta.

“The contagion now is worse than ever. … Every time we turn around, there’s another case,” said Paul Langford, the mayor of Shellman in Randolph County, Ga., which lost its hospital during the pandemic, as STAT reported earlier this year, and only has one ambulance in the county. “Because of not having a hospital, a lot of people can be in the middle of a severe case before they finally go to another hospital.”

He knows two people who have died in the past two weeks, and he regularly calls the Albany hospital to ask after a Shellman resident who’s been on a ventilator for weeks.

Georgia reached its highest rate of hospitalization during the pandemic in early September, and Randolph County has been particularly badly hit, with 84 hospitalizations per 100,000 people as of Sept. 13, according to the CDC, compared to 59 per 100,000 in the state overall. “We need a hospital and a second ambulance something awful,” said Langford.

Florida is no longer reporting county-level data on Covid-19 deaths, but Palm Beach County Covid hospitalizations were at 987 in mid-August, roughly double their previous peak, according to the U.S. Department of Health and Human Services.

In Pahokee, several local families were devastated by Delta, Jackson-Moore said, with everyone getting sick and multiple people dying of Covid-19 within one household. “With the community so close-knit, everybody knows somebody,” she said.

The local hospital ran out of intensive care unit beds during the summer, she said, meaning some had to go outside of the community for care and in some cases, relatives didn’t have transportation to easily get to those hospitals. “Some of these family members couldn’t be with their loved ones. They had to get a phone call that they didn’t make it through the night,” Jackson-Moore said.

The same factors that contributed to racial disparities during earlier waves of Covid, such as comorbidities and access to health care and transportation, have been relevant during the Delta surge, said Bentley-Edwards. The loosening of social distancing rules restrictions also likely hurt Black and Latino people, who are more likely to work in service industries, she said.

Overall, the demographic differences in Covid-19 deaths come down to structural racism, said Michael Siegel, physician and researcher in the Department of Public Health and Community Medicine at Tufts University School of Medicine, who has studied racial inequity throughout the pandemic. “It’s pervasive. It’s differences in economic status, housing, education level, incarceration rates, types of occupations which affects level of exposure, preexisting conditions, population density,” he said.

Even when he controlled for these individual factors, Siegel still found a difference in the number of deaths between Black and white populations: “They really all stem from structural processes implemented over time, which is structural racism.”

Covid-19 vaccines are incredibly effective at preventing hospitalization and death. But the Delta variant, with the rise of breakthrough cases in people who had gotten shots, forced vaccine educators to change their message. “Delta came about and people were testing positive even though they had been vaccinated, so we had that challenge to deal with,” said Jackson-Moore.

Guardians of the Glades came up with a new slogan to attempt to overcome vaccine hesitancy: “Some protection is better than no protection.” Finally, she said, the devastation of Delta is pushing some people who resisted vaccination to heed her warning.

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