The COVID-19 death rate in rural America is now more than twice the death rate of urban areas, according to a new study .

The first surge of COVID-19 in the spring of 2020 initially hit urban areas hardest, with high rates of infections and deaths, according to the study for the Rural Policy Research Center published in September. At the time, many rural communities were largely untouched.

But subsequent waves of the pandemic tore through rural areas, where many people are older, in poorer health, unvaccinated, more likely to live in poverty and where medical facilities are often inadequate or overcrowded. Rural rates of infections and deaths began pulling ahead of metropolitan areas at the beginning of summer 2020, the study noted.

Infection and death rates were higher in nonmetropolitan areas during the third surge until its peak in January 2021, the study said. Incidence and mortality rates are currently much higher in nonmetropolitan counties than those in metropolitan counties.

Since the pandemic began, about 1 in 434 rural Americans have died from COVID, compared with roughly 1 in 513 urban Americans. But as of mid-September, metropolitan areas were experiencing a seven-day average death rate of 0.41 per 100,000 people, while rural communities had an average death rate of 0.85 .

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, told NBC News.

Weve turned many rural communities into kill boxes , Morgan added. And theres no movement towards addressing what were seeing in many of these communities, either among the public, or among governing officials.

COVID incidence rates in September were roughly 54% higher in rural areas than elsewhere , according to Fred Ullrich, a research analyst from the University of Iowa College of Public Health who co-wrote the new study. Rural counties had higher rates of COVID than urban counties In 39 states, he noted.

The Washington Post reported earlier this month that COVID cases and deaths were notably higher in Republican states than in Democratic states.

Of the 23 states that had new per capita case totals higher than the U.S. average, 21 voted for Donald Trump in November, the Post noted. Sixteen of them were among the 17 states with the lowest rates of vaccination.

The newspaper called it an inescapable overlap of pandemic and politics as Republicans battle against mask and vaccine mandates.