Lives and Livelihoods, a Rural NNE Perspective: There’s been a lot said about lives and livelihoods in the aftermath of the election and in anticipation of a pandemic reset. I would like to comment on this based on our research on COVID-19 and rural health equity in NH/VT.

Context: NNE is the oldest region in the US, and rural regions have significant underlying social vulnerability. Rural NH/VT are more politically purple than most would believe. Shared borders with NY/MA and an influx of out of state residents represented areas of concern.

Rural communities across NH and VT mobilized to protect each other early in the response. They formed mutual aid groups, divided towns, identified vulnerable members of the population, and provided support to protect them. https://www.healthaffairs.org/do/10.1377/hblog20200722.490817/full/

The NNE region was able to avert the expected surge and many rural communities did not register a single case. Some rural communities have no direct experience of COVID-19 infection or death; however, they have now experienced the deep economic impacts of the response.

LIVES: Some rural communities in NH/VT now see their rural isolation and distance from regional urban centers as protective and their social networks as safe. That said, they do fear tourists and COVID-19 “refugees.” This low perception of local threat may represent a risk now.

I worry that early success may represent a risk for this NNE region; however, I do not find support, for the notion that lower compliance with public health measures here reflects a lack of concern for neighbor or community or a choice of livelihoods over lives.

LIVELIHOODS: Many in rural NH/VT voice concerns related to loss of businesses and employment and housing and food insecurity. They worry about the impact of quarantine policies on seasonal economies dependent on tourists from counties requiring 14 day quarantines.

Many believe that state leadership has been sensitive to these impacts. Both NH/VT governors have explicitly recognized impacts and used CARES Act funding to target hard-hit sectors of the economy. Stakeholders suggested that this has increased tolerance of ongoing measures.

What does this mean? First, I think this points to the need to reject the false dichotomy of lives and livelihoods. Public health measures are needed to protect lives but work better when paired with policy responses to mitigate inequities and offset social and economic impacts.

Second, this points to the need to understand how early experiences—success, distance from hard-hit areas—shape perceptions of risk and responses. Public health measures and messaging need to be tailored not only to local context but also to their varied pandemic experiences.

Third, we need to give voice to the concerns of communities and enable productive mechanisms for input. Public health expertise is important; however, people are the experts of their own lives and losses. Listening to them strengthens, rather than undermines responses.

It is not the job of public health experts to attend personally to all of these concerns. Rather, I would like to encourage everyone to advocate for the the enabling policies, strategies, research, and partnerships necessary to enable public health measures to work better.

Finally, I hope that others will share their perspectives and experiences, both from this region and others. These discussions benefit from many voices, and we need to learn from each other and our communities.