DENVER – Last month, Glen Mays was having dinner at a rural mountaintop restaurant west of the city when a fellow diner collapsed with a heart attack.

Mays, a college professor, leaped into action, clearing a space and giving the 60-ish woman CPR.

For 35 minutes.

"It was exhausting," he said. "I knew as soon as it happened that it would be 30 minutes or more until we got an ambulance up there."

An ambulance racing up a nearby canyon from the outskirts of Denver finally reached the woman, and the EMTs got her heart beating again before rushing her to a hospital. Mays doesn't know if she survived.

He does know her chances of survival are significantly lower than if she'd been in Denver.

"Incidents that are survivable in urban areas are often not in rural areas," said Mays, the chair of the department of health systems and policy at the Colorado School of Public Health.

A new study from the National Center for Health Statistics confirms what Mays and other experts have long known: Rural Americans are up to 20% more likely than their urban counterparts to die from illnesses such as cancer, heart disease and lower respiratory infections. Lack of access to health care, poverty, smoking and heavy drinking all play a role in driving up the disparity between rural and urban residents – a gap probably exacerbated by the COVID-19 pandemic and closure of rural hospitals.

The federal study examined the 10 leading causes of death nationally from 2009 through 2019. It found people in cities live longer than their rural counterparts, and the health disparities are increasing.

Rural Americans die from COVID-19 infections at about twice the rate of urban Americans, based on data analyzed by the Center for Rural Health Policy Analysis at the University of Iowa. Public health experts said rural Americans are less likely to have gotten vaccinated, driving up their coronavirus death rates.

Such choices, along with unhealthy eating and lack of exercise, contribute to the widening health divide between rural residents and those living in cities, said Dr. Varinder Singh, chair of the cardiology department at New York City's Lenox Hill Hospital.

"People continue to do things that are not good for them. But that's human nature and you have to deal with that," he said.

Singh said health care disparities exist in urban areas too, especially within communities of color. He said the federal study raises important questions about the growing urban-rural divide and should prompt discussions about how to effectively reach rural populations with public health messages.

How long does the ambulance take to arrive?

Singh said another major factor in rural health is the time it takes for an ambulance to arrive, as was the case for the woman Mays helped.

Though high-volume urban hospitals have more practice at some complicated procedures, Singh said, health care is otherwise surprisingly consistent, given national benchmarks, federal regulations and insurer oversight.

"Once you get into the system, you're essentially going to get the same treatment in the same timing," Singh said. "But how quickly you get to the emergency room matters. In New York City, the farthest you're going is 20 blocks."

A federal study posted by the JAMA Network shows that ambulances nationally take an average of seven minutes to arrive after someone calls 911. That time doubles to 14 minutes in rural areas, and 10% of rural 911 calls aren't answered for almost 30 minutes.

Though relatively few Americans live in rural areas – about one in five – they live on 80% of the country's land, primarily where food, oil, gas and other critical supplies come from, said Brock Slabach, chief operations officer for the National Rural Health Association.

If the people who make our country's gasoline and raise our meat and milk our cows get sick, that can have rapid impacts on city dwellers 1,000 miles away, Slabach said, and the supply chain problems caused by the pandemic have driven that point home.

"People think the chickens just magically show up on their plate. They don't understand that comes from a rural place, and that takes people and resources to happen," said Slabach, a former rural hospital administrator based in Kansas. "The virus exploits all of the weakness in the rural health care structure."

The country's rural health care structure is shrinking: More than 130 rural hospitals closed in the past decade as health care costs rose, rural populations aged, federal reimbursements stagnated and younger, healthier people left for better jobs and higher pay in cities, Slabach said.

The nation's approximately 1,800 rural hospitals cover nearly 97% of the land area but provide only 1% of intensive care unit beds, according to an analysis by doctors from the National Institutes of Health.

As more unvaccinated Americans struggle with COVID-19, Slabach worries the effects will be felt disproportionately in rural areas. He predicted rural Latinos, Black people and Native Americans would fare worse, because those groups are unhealthier than their white counterparts, and the Centers for Disease Control and Prevention reported those three groups will continue to have COVID-19 death rates at least twice that of white Americans.

In the last two weeks of September, the COVID-19 death rate in rural counties had grown an average of 6.1% compared with 2.5% in large urban ones, according to a USA TODAY analysis.

"They have a geographic disparity, and then you add in a racial or ethnic disparity, and it becomes an even bigger factor," Slabach said. "Rural populations are older, poorer and sicker than their urban counterparts."

COVID-19 exploits weaknesses

In rural western Gove County, Kansas, new hospital administrator Conner Fiscarelli said he struggles to attract and retain staff when big urban hospitals pay nurses thousands of dollars a week to manage crowded COVID-19 wards. The Gove County Medical Center has 22 beds but no ICU, so patients who need complicated or specialized care, such as cardiac interventions, must travel several hours to a bigger town for those procedures, exhausting the town's all-volunteer ambulance service.

"The biggest challenge in rural health care is staffing. There are shortages everywhere, and it's exacerbated in rural areas right now," he said.

For several months last fall, Gove County had the highest per capita COVID-19 death rate in the country, as the virus killed dozens of mostly elderly people in the hospital's nursing home, along with some of their relatives.

Like many rural hospital administrators, Fiscarelli is worried about how to manage the health challenges of "long COVID," in which patients don't fully recover from the virus and symptoms such as fatigue and shortness of breath persist. It's a new complication for a population that is older, unhealthier and less likely to seek care. Several of the hospital's doctors held an open-air forum at the town park to answer questions from dozens of residents who attended, he said.

"Having a strong primary care model in a rural community to address those chronic concerns is really important," he said. "On the plus side, you can see the difference in the community when you're providing a good quality of care. You know that you've made a real difference in their life."

Mays, the public health professor, said the new federal report on rural care is an important step in addressing health care disparities nationally. In general, people living in cities are better educated, earn more money and make better health care decisions, he said.

"Increasingly, people without a college education, they're concentrated in rural areas because they're not being drawn to urban areas where the good jobs are, where the good pay is," Mays said. "Those rural populations are being left behind. And that cuts across both gender and race."

Contributing: Jayme Fraser

This article originally appeared on USA TODAY: COVID-19, heart attacks and cancer: Rural Americans die at higher rates