Indonesia’s current capital, Jakarta — now the world’s largest city — is polluted and overcrowded, and it’s sinking. So in 2019, Indonesia’s government announced a bold plan: to build Nusantara, a new capital, from scratch.

The site is located about a two-hour drive from the neighboring city of Balikpapan. Construction of Nusantara began in 2022, and the city’s core government district is nearly complete. The area features a sprawling green park surrounded by white office buildings with plants draping over their balconies, a bank that looks like a spaceship and the city’s centerpiece — a 250-foot-tall metal structure shaped like Garuda, an eagle-like mythical bird that is the country’s national emblem. Its 500-foot wingspan towers over the presidential palace.

But there are concerns that progress on this more than $30 billion project has been slow. Logistics, funding challenges and a presidential election have delayed the timeline. Local critics worry that construction could harm the environment and nearby Indigenous populations.

Today, the broader metro area includes around 150,000 people — a mix of construction workers and long‑established villages. The new city’s core is home to only about 10,000 residents, including roughly a thousand civil servants.

Nusantara was a signature project of former President Joko Widodo. Since the current leader, Prabowo Subianto, assumed office in October 2024, some critics of the project have questioned whether he shares the same enthusiasm. State funding for the project was cut in half for 2026 compared with the previous year. Prabowo made his first visit to the site in January 2026, more than a year after taking office.

The “political capital” by 2028

The uncertainty has fueled concerns, especially in the international press, that Nusantara could become a “ghost city.”

But Basuki Hadimuljono, the head of the Nusantara Capital City Authority, dismisses such concerns: “Don’t worry. It will be continued.”

Last year, Prabowo signed a presidential regulation that Nusantara will be designated Indonesia’s “political capital” by 2028 — different from previous language calling it the “national capital.” The shift confused other lawmakers and policy experts worried about a de-emphasis on the project.

For Basuki, the regulation was a symbol of support from the president. Once the legislative and judicial buildings are completed next year, he says, the president plans to finally move to Nusantara in 2028. Meanwhile, there are plans to move 4,100 more civil servants to the city this year.

Still, this goal is far from moving some 1.2 million residents here by 2029. Essential infrastructure such as schools, housing for married civil servants, malls and other places for entertainment are still missing.

“Silent victims”

And not everyone is happy with the development.

Local environmental groups like WALHI say that construction has already caused mangrove deforestation around Balikpapan Bay.

“The most impacted will be what we call silent victims — mangrove ecosystem and then proboscis monkey and owa Kalimantan,” says Fathur Roziqin Fen, executive director of WALHI East Kalimantan. The owa Kalimantan is an endangered primate living in the forest in East Kalimantan province.

Outside the city, a newly built dam and water treatment plant provide most of Nusantara with filtered drinking water — a luxury not found in other parts of Indonesia. But the plant was built on the edge of Sepaku Lama village, where many Indigenous people from the Balik tribe have lived for generations.

Part of the dam and flood mitigation — a concrete wall built along the Sepaku River — cuts off the village from using the water to bathe with and wash clothes as they used to. Alfian Brahmana Putra, the pump operator for the treatment plant, says the city provides free water for the village, but residents are responsible for having water pipes installed in their homes. Many families opt to use rainwater or buy tanks of water that are delivered to their houses.

Fifty-one-year-old Syamsiah and her husband, Pandi, who are both Balik and like many Indonesians have just one name, live in a concrete-block house on their farm in Sepaku Lama village. They’ve planted cassavas, bananas, green beans, fruit trees and many more crops. For them, this land is more than a livelihood — it’s their family history. Both Syamsiah’s parents and grandparents are buried in the village’s graveyard.

Nearby, a rhino-shaped rock in the river — a sacred site for Balik people called Batu Badok — now sits inside the water treatment compound, cut off from the community.

An enormous promise and an enormous question

Nusantara is planned to span nearly 1,000 square miles, an area about three times the size of New York City. As construction expands, the surrounding villages, including Syamsiah and Pandi’s, will eventually be absorbed. City officials have already told them that they will eventually have to sell their land.

But Pandi says he’s not interested in selling. “Maybe the government can compensate me for the plants or even the house. But my memories, my history, can the government replace that?” he says. He and his wife also say they don’t have anywhere else to go if they have to move. “They already have a capital city. Why build a new one? Why don’t they just leave us here peacefully?” Pandi adds.

Officials hope moving the capital will relieve some of Jakarta’s growing pains. Jakarta, with more than 40 million people in its metropolitan area, is polluted, overcrowded and sinking. But even as Indonesia grapples with the challenges of Jakarta, Nusantara is expected to be home to only 2 million people by 2045.

For now, Nusantara remains both an enormous promise — and an enormous question.

“This administration has ground fair housing enforcement to a halt,” reads one letter posted at DearAmericaletters.org. “Worse, they’re picking and choosing which protected classes count.” Other letters include: “I pray for justice for every person unfairly denied a safe place to live,” and, from “a tired HUD employee,” “Months later, I still think about the people impacted by the work I was forced to abandon.”

Last fall, two HUD civil rights lawyers were fired after raising concerns with Congress that the agency was unlawfully restricting fair housing enforcement. One of them, Paul Osadebe, who helped launch the site and spoke to NPR in his personal capacity and as an AFGE Local 476 union steward, says the practices continue. “We’re not being allowed to help the people that we’re supposed to be serving,” he said. “If it’s something to do with race, if it’s anything to do with gender, you’re just not allowed to touch that anymore.” NPR has asked HUD for comment.

Under the 1968 Fair Housing Act, HUD must investigate complaints of housing discrimination based on race, national origin, religion, sex, family status or disability, and pursue legal action or settlements when discrimination is found. But HUD Secretary Scott Turner, in a video message for Fair Housing Month, said the law had been distorted to advance “radical ideologies” tied to diversity, equity and inclusion (DEI). He accused the Biden administration of “weaponiz[ing] the Fair Housing Act” and said the current administration seeks “to restore sanity to enforcement.”

Turner pointed to a proposed rule to end liability for unintentional discrimination (the disparate impact standard), which advocates say is crucial for addressing hidden bias in housing and other areas. He also highlighted HUD reviews of housing efforts in Boston, Minneapolis and Washington state that aim to address historical racial disparities, suggesting those programs may discriminate against white people.

Internal HUD memos last year directed staff to reduce compliance burdens and listed “priorities and practices that must be eliminated,” including cases involving gender identity, environmental justice, and some race-based cases focused on protecting a group rather than an individual. HUD has told states it will not reimburse them for certain discrimination cases tied to sexual orientation, gender identity, criminal record, voucher use or English-language proficiency. Fifteen Democratic-led states and the District of Columbia have sued, calling the shift arbitrary and unconstitutional.

“They’ve turned [civil rights law] on its head,” said Sara Pratt, a former head of HUD’s fair housing office. While states can have stronger laws, she said the federal government is now restricting what states can pursue.

Employees who posted on the site say the policy changes have caused harm. They resent portrayals of civil rights staff as lazy, and describe mass firings, forced resignations and reassignments that have thinned experienced ranks and made it harder to do their jobs. They worry many victims — including homeless people, families with disabled children and survivors of domestic violence — will not get remedies.

One anonymous writer told NPR that broad executive orders on DEI and ideology have left HUD attorneys unable to offer legal interpretation as they normally would, making investigators overly cautious. That, the writer said, can lead to treating sex as no longer inclusive of LGBTQ people. Osadebe added that HUD has directed staff to speak only English with clients after a Trump order designating English the country’s official language. “Imagine that you are a U.S. citizen in Puerto Rico — you speak only Spanish,” he said. “That’s absurd.”

Employees say an atmosphere of repression discourages speaking out for fear of being silenced, attacked or losing their jobs. Osadebe said he hopes the anonymous letters prompt Congressional action and encourage federal workers across agencies to speak up. “We’re all experiencing the same things,” he said.

Jet fuel prices have roughly doubled since the start of the war in Iran, a rise even sharper than spikes seen in gasoline and diesel. In response, airlines worldwide are cutting routes, raising fares, adding fuel surcharges and boosting baggage fees.

In Asia, some countries are rationing fuel and restricting exports to cope with the shock to supplies and to jet fuel in particular. “This is an Asian crisis,” says George Shaw, an analyst at trade analytics firm Kpler. “They’re in a worse position than anyone else.”

In Europe, Airports Council International Europe — a group representing airport operators — warned the European Commission that if “significant and stable” passage doesn’t resume through the Strait of Hormuz by the end of April, “systemic jet fuel shortage is set to become a reality for the EU.” Some analysts are skeptical that shortages would set in that quickly.

The world’s three top jet fuel producers have been knocked out

Traffic of ships through the Strait of Hormuz remains at a trickle, which affects jet fuel in two ways. First, the Persian Gulf hosts many refineries that make jet fuel and export it around the world; the disruption is blocking that finished product from reaching markets. Second, crude oil from the Gulf — used as feedstock for refineries worldwide, including major jet-fuel producers in Asia — is also being blocked. The finished product and the raw material are both experiencing supply shocks. “It’s really a double whammy,” Shaw says.

To illustrate the scale: the top three global exporters of jet fuel are China, South Korea and Kuwait. China has banned exports of jet fuel and South Korea has cut back production because it can’t get enough crude. Kuwait can produce jet fuel but can’t send it out. In effect, the three top global suppliers of aviation fuel are all essentially knocked out at once.

The U.S. can’t fully escape the global crisis

Europe and Asia are especially affected because they rely directly on crude oil and refined products shipped out of the Persian Gulf. But even the U.S. — the world’s largest oil producer and a net exporter of jet fuel — is interconnected with this global system.

California has been importing some jet fuel from Asia “for quite a while,” says David Ruisard, head of U.S. products assessment at commodities intelligence group Argus. Refineries have been shutting down in California, with companies citing state environmental regulations as a factor. Meanwhile, the U.S. produces abundant jet fuel in refineries in Louisiana and Texas, but that fuel would have to travel through the Panama Canal to reach Los Angeles; it’s often cheaper and easier to bring a tanker from South Korea, which is currently in a crunch. “It could be a problem for imports reaching that market” on the U.S. West Coast, Ruisard says.

Delta says the spike will cost an additional $2 billion this quarter

U.S. carriers largely stopped fuel hedging — using financial contracts to lock in future fuel prices — after hedging proved expensive when prices later fell. That leaves airlines exposed to sudden price spikes. Delta recently told investors it expects higher fuel prices to cost an additional $2 billion this quarter. Delta is relatively better off because it owns a refinery.

“We woke up this morning with a very different set of fuel assumptions than we had when we went to bed,” Delta CEO Ed Bastian said, describing the dramatic shift in prices since the war began. He said Delta is cutting unprofitable flights and recapturing higher fuel costs by raising ticket prices — and that customers still seem to be buying. Delta isn’t worried about shortages in the near term, Bastian said. Shaw of Kpler adds that raising ticket prices and cutting unprofitable routes should be enough to prevent shortages in the U.S. and Europe, though Asia may face different risks.

Prices expected to remain elevated

Even if ship traffic through the Strait of Hormuz resumed immediately, prices would stay high for weeks. Restarting production in Middle East oil fields that shut down takes time; refineries require complex processes to be brought back online, and some facilities may be damaged. Rystad Energy has estimated oil and gas facilities in the Middle East have suffered as much as $50 billion in damage from the war.

Once production resumes, tankers still take weeks to travel to buyers, creating further delays before markets see relief. According to Argus, the last shipment of jet fuel to pass through the Strait of Hormuz arrived in Europe; it had been loaded on Feb. 28, before the war began, and took weeks to complete its journey. No more deliveries are en route now. Even if the strait reopened and a tanker left today, it would still be weeks before arrival.

“The market’s effectively seized up,” Shaw says. “It will take a long time for it to get back to a semblance of normality, even in the most optimistic scenario.”

When asked how the conflict makes them feel, a group of 13 voters used words like “afraid,” “angry,” “concerned,” “sad” and “despair.” Many said they’re worried the war is being mishandled and will keep creating economic pressures at home.

The voters took part in two online focus groups Tuesday night run by messaging and market research firms Engagious and Sago as part of the Swing Voter Project. NPR is a partner on the project and observed both sessions.

All 13 live in Georgia and voted for Joe Biden in 2020, then supported President Trump in 2024. Seven identified as independents, five as Republicans and one as a Democrat.

Not a single participant described the military action in Iran as going well so far, despite Trump’s claims that the U.S. has decimated Iran and that the war is “very close to over.”

“They are very anxious, some angry, upset when they hear about the war,” said Rich Thau, president of Engagious, who moderated the groups. “They are not happy that we are there.”

Focus groups aren’t statistically representative, but they can illuminate how certain voters are thinking. In this case, they reflect how some key voters view U.S. military action in Iran, which polls show is broadly unpopular with Americans.

Nick H., a 28-year-old independent, said Trump miscalculated how the war would unfold. “It’s about calculation, his inability to calculate,” Nick said. “It’s clear that he completely underestimated the opponent here.” He noted Iran has bombed U.S. bases and seized the Strait of Hormuz, a critical route for global energy, and worried Iran could use drones similarly to tactics seen in the Ukraine war.

Bryan M., a 24-year-old independent, said he’s concerned the U.S. has lost expensive, advanced military equipment. “They’re destroying our most advanced weapons,” he said. “And our weapons shouldn’t be destroyed that easily because they’re more advanced than Iran’s.”

Most participants said they disapprove of Trump’s performance in his second term so far. A central complaint is a perceived gap between the voters’ priorities and those of the president.

“It seems like he’s prioritizing taking over as much of the world as possible,” said Corey W., a 55-year-old independent.

Howard R., 31 and an independent, accused the president of focusing on personal gain, pointing to things like “crypto scams.” Xaveria T., a 44-year-old Republican, said Trump is prioritizing “his own personal gain” over Americans’ economic needs. “How is he going to make us whole again from the job losses and the [economy] and just not being able to buy a home,” she said. “Because that’s kind of my biggest concern right now, is people being able to provide for their families.”

While three participants approved of some aspects of Trump’s performance — such as immigration enforcement — Thau said there’s a broad misalignment between the president’s priorities and what these voters say matters most to them. “They are frustrated … the president isn’t paying attention to what matters most to them,” he said.

Economy is the top concern. Twelve of the 13 said they’re more anxious about the economy now than before Trump returned to office, pointing mostly to rising prices.

“Everything is higher now,” said Dawn H., a 46-year-old Republican. “It’s not going down like he said. Cost of living of everything — food, oil, housing, health care, you name it.”

Joe J., a 56-year-old independent, said Trump’s economic record is the opposite of what was promised. “He said, day one, he was going to bring the prices down on eggs and other things. He’s cut subsidies to health insurance, so that’s gone up,” Joe said. “I see my pocketbook being hit and he’s building a new ballroom for some reason that we don’t need. How about you put some money toward us?”

Bryan M. worries the economy will worsen as the war continues. “No one can predict where this economy’s going to go with the oil prices rising and the food prices rising,” he said.

Other takeaways from the focus groups:
— While the country of Israel drew support from participants, only one voter said they view Israel’s government positively; four viewed it negatively and the rest were neutral.
— Nine of 13 said they’re “very likely” to vote in the November midterms, and most were undecided on which party they’d support. Only two planned to vote for Democrats specifically to send a message to Trump; none said they planned to vote Republican in support of the president.
— A majority expressed concern about data centers being built in their communities, mainly over the water and energy resources required to run them.

1) Blockades drain resources and are hard to enforce
Historically, blockades have required large, sustained naval forces to patrol choke points and control shipping lanes. Britain’s blockades during the Napoleonic wars tied up much of the Royal Navy and still could be evaded by blockade runners. Modern technology — satellites, drones, aircraft, shipboard systems, and helicopters — makes detection and tracking far easier than in the past, and boarding parties can be launched from fast boats or helicopters to inspect vessels. Even so, volume matters: before recent hostilities, roughly 138 ships transited the Strait of Hormuz daily. Analysts say the U.S. would likely need several destroyers in rotation to enforce restrictions; with that traffic volume, fully policing every vessel would be extremely difficult. Recent examples, like Russia’s partial and unsustained attempt to block Ukrainian maritime exports, show that lacking full capacity makes enforcement fragile. Practically, enforcement means stopping and diverting ships, forcing them to anchor in a marshaling area (possibly in neighboring Oman) or turning them back — a resource-intensive, ongoing task the Navy may not be able to sustain at scale.

2) Blockades aren’t always effective
The historical record shows mixed outcomes. In World War II, Germany’s U-boat campaign failed to cut Britain’s critical North Atlantic supply line, while the U.S. submarine campaign against Japan successfully choked oil and resource flows from the Dutch East Indies, seriously weakening Japan’s economy and war capacity. Whether a blockade succeeds depends on targeting (which supplies are truly nonsubstitutable), the defender’s resilience, and the blockader’s ability to maintain pressure over time.

3) Blockades often have unintended targets and consequences
Economic interdiction can break parts of an economy the blockader didn’t primarily intend to hit. In World War I, the Allied blockade aimed at Germany’s military supplies but ended up devastating German agriculture because restricted imports included fertilizer components, causing civilian food shortages. Similarly, Britain’s blockades around 1800 collapsed French trade and harmed the broader economy. In Iran’s case, oil revenue is central; sustained disruption could expose shortages in food or other civilian needs, but the extent depends on how long and how effectively maritime restrictions are maintained.

Bottom line: modern tools make detection and inspection easier than in past centuries, but the logistical burden of policing high volumes of commercial traffic is heavy. History shows blockades can work — but they’re costly to enforce, may fail to hit their intended military or economic targets, and can produce severe civilian consequences.

Magistrate Twanet Olivier on Thursday sentenced South African opposition leader Julius Malema to five years in prison for firing a rifle into the air at a party rally. Malema, 45, leader of the far-left Economic Freedom Fighters (EFF), was convicted last year on charges including unlawful possession of a firearm and discharging a weapon in a public place over the 2018 incident at a stadium in the Eastern Cape.

Malema pleaded not guilty, saying the gun was a toy. His lawyers applied for leave to appeal within minutes of the sentence being read in a court in KuGompo City (formerly East London).

Hundreds of EFF supporters, dressed in the party’s red, gathered outside the court for the politically charged sentencing. The maximum penalty for the offences is 15 years’ imprisonment. A custodial sentence of more than 12 months, if upheld after appeals, would bar Malema from serving as a lawmaker — a major setback for the EFF, which is the fourth-largest party in parliament and draws substantial support from young South Africans frustrated by enduring racial and economic inequalities since the end of white minority rule in 1994.

That muted reaction contrasts with the White House’s declaration that this would be the “largest tax refund season in U.S. history,” a claim tied to the Republicans’ signature 2025 tax and spending law. The administration projected the average refund would “rise by $1,000 or more this year.” So far, however, the bump has been far smaller.

By early April the IRS reported the average tax refund at $3,462, about $350 higher than last year and 11.1% above the same point in 2025. That increase falls well short of the $1,000 boost touted by proponents of the tax changes.

Many Americans also say the changes haven’t helped them. A Bipartisan Policy Center survey found 62% of respondents thought the changes either hurt them or made no difference; only 35% of Republicans said the changes favored them. “There’s a bit of a disappointment in how much those refunds are,” said Tom O’Saben, director of tax content and government relations at the National Association of Tax Professionals. “People are quietly, perhaps, happy but not to the extent where I would call it significant.”

Part of the reason the headline refund number looks modest is that some of the law’s benefits may be flowing more to taxpayers who would otherwise owe rather than to those receiving refunds. IRS refund data doesn’t capture reductions in tax liabilities for filers who end up owing less when they file. “The evidence is stronger that more tax relief is relatively flowing to those who otherwise would owe when they file,” said Don Schneider, deputy head of U.S. policy at Piper Sandler. But he noted, “Owing less money is harder to notice than getting cash in hand.”

Higher-income taxpayers so far appear to be getting larger gains. Andrew Lautz, director of tax policy at the Bipartisan Policy Center, said wealthier filers are “much more likely than lower income taxpayers to report significantly higher refunds this year.” A key reason is the increase in the SALT (state and local tax) deduction cap under the new law, raised to $40,000. That deduction mainly benefits homeowners with large mortgage and state tax bills. Because higher-income filers often file later, their receipts could lift the average refund later in the season — though Lautz said it’s unlikely to reach the additional $1,000 that had been predicted.

Another factor muting enthusiasm: higher consumer costs, especially at the pump. The war with Iran has pushed average U.S. gasoline prices above $4 per gallon, and consumers report continuing to spend more on gas. Economists warn the extra cash from refunds could be consumed entirely by higher fuel costs. “The tax refund season might be very good but it’s also being offset by this price in gasoline,” said Michael Pearce, chief U.S. economist at Oxford Economics.

Individual reactions mirror those trends. Retiree Bob Jones, also in Birmingham, welcomed his refund and benefited from an extra deduction of $6,000 available to many seniors 65 and up. But worried about rising gas prices linked to the conflict, he put the entire refund into savings. “You need the savings simply for gas,” Jones said.

For many taxpayers the changes have produced some relief, but it’s smaller and less visible than advertised. Some pockets of the population — especially higher-income taxpayers and those who would otherwise owe — are seeing larger benefits, but the broad, $1,000-per-taxpayer uplift hasn’t materialized for most filers so far.

The Vatican says themes of the visit, which begins Wednesday with Leo’s arrival in Yaounde, will include combating corruption in the mineral-rich nation and stressing proper uses of political authority. He was flying to Cameroon from Algeria, the first stop on his four-nation Africa tour.

The Vatican has signaled that Catholic social teaching rejects the authoritarian styles of leadership Leo will encounter on the trip. This is the pope’s first visit to the continent and he is history’s first American pope.

Biya, who has ruled since 1982, is the world’s oldest head of state. On arrival in Yaounde, Leo will meet Biya at the presidential palace, then address government officials, civil servants and diplomats, and visit an orphanage run by a Catholic order of nuns.

Cameroonian authorities made a last-minute change to the itinerary, the Vatican said: Biya — rather than the prime minister — will now speak before the pope, and the meeting with government authorities will take place in the presidential palace instead of at a conference center.

Opposition parties dispute the Oct. 12 election that gave Biya another term. His rival Issa Tchiroma Bakary says he won and urged Cameroonians to reject the official result.

This week Leo issued an unrelated message about the proper role of political leaders and the need for “authentic democracy” to legitimize authority and prevent abuses of power. In remarks to a Vatican academy for social science dated April 1, he wrote that democracy is healthy only when grounded in morality and a respect for human dignity; without that foundation, he warned, democracy can become “majoritarian tyranny” or a cover for economic and technological elites.

In Cameroon Leo will hold two major public events. The highlight is a “peace meeting” Thursday in Bamenda, in the country’s anglophone northwest, an area long beset by separatist violence.

English-speaking separatists began an uprising in 2017 aiming to secede from the majority French-speaking state and form an independent anglophone country. The International Crisis Group estimates the conflict has killed more than 6,000 people and displaced over 600,000.

On the eve of Leo’s arrival, anglophone separatists announced a three-day cessation of hostilities to allow “safe travel” for the pope. The Unity Alliance, an umbrella of several separatist factions, said late Monday the pause reflected the “profound spiritual importance” of the visit and was meant to enable civilians, pilgrims and dignitaries to travel safely.

Leo’s other major event in Cameroon is a Mass Friday in Douala, where authorities expect around 600,000 people to attend. On Saturday the pope will travel to Angola for the third leg of his trip, which concludes next week in Equatorial Guinea.

Pieper was stunned. “I guess I’ll just bloat up and die in a month,” he recalled thinking when he heard the news. He was one of 17 patients who depended on the Chadron unit, where each treatment lasts about four hours. For people in this sparsely populated region, the local dialysis unit was not just a medical service but a lifeline.

The closure is an example of the shrinking health services in rural America, where chronic illness rates are higher but access to care is poorer. The Trump administration’s Rural Health Transformation Program pledged $50 billion to help rural health, and Nebraska celebrated receiving $219 million in first-year funding, but that money is intended for experimenting with new models of care rather than sustaining existing services. States can use only up to 15% of the funds to pay providers for patient care, limiting immediate relief for struggling units.

Chadron Hospital’s CEO, Jon Reiners, said the dialysis program lost about $1 million a year because reimbursement didn’t cover operating costs. The hospital is a critical access facility, which boosts Medicare payments for some services, but that designation doesn’t increase outpatient dialysis payments. Reiners said the hospital spent more than a year seeking solutions, including asking private dialysis companies to take over the unit; each declined after seeing the likely losses.

Nephrologist Mark Unruh described the closure as part of a broader trend of staffing and funding challenges that displace rural patients. Rural Americans are more likely to develop end-stage kidney disease and face higher mortality rates after diagnosis, studies and national data show. Unruh said prevention is key, and pointed to tele-education programs such as Project ECHO that help rural primary care doctors manage and prevent kidney failure. He also urged expanding home dialysis training and increasing transplantation for rural patients, including testing “fast-track” evaluation approaches to reduce travel burdens.

Some patients are moving closer to care. Jim and Carol Wright now rent a small house near Rapid City, South Dakota, and live there on weekdays so Jim can get dialysis. They said they’ll eventually have to sell their home near Chadron and relocate to a larger city to stay near treatment. Others transferred to nursing homes nearer to centers, a choice that can separate patients from family.

Many are making long drives. Pieper found treatment in Scottsbluff, the largest town in the Panhandle, but the one-way trip takes about 90 minutes, making his weekly driving time more than nine hours. Linda Simonson drives her husband, Alan, over four hours round-trip for his dialysis in Scottsbluff. She said closer centers either lacked capacity or have routes that are unsafe or impractical in poor weather. The region’s rural transit system exists but its schedule doesn’t suit many dialysis patients who need reliable, timely transport and support during trips.

Home dialysis is more common among rural patients than urban ones—nearly 18% of rural patients used home dialysis in 2023 versus about 14% in urban areas, according to NIH data. But home dialysis requires substantial training: one form needs surgery to place an abdominal catheter and up to about two weeks of training; another type requires up to eight weeks of training. The nearest center offering training for peritoneal dialysis is in Scottsbluff; the center for training in the other modality is three hours away in Cheyenne, Wyoming. Pieper said doctors told him he’s not a candidate for home dialysis or transplant, leaving him little choice but to travel.

Patients and families have tried to persuade policymakers and hospital leaders to find a fix. The Wrights wrote letters proposing that federal rural health funds help keep the unit open. Simonson said she spoke with legislative aides but felt ignored. “It feels like they don’t know that we exist at this end of the state,” she said.

The closure underscores structural problems: low reimbursement for outpatient dialysis, thin patient volumes that make units financially fragile, difficulty recruiting staff who can provide and train for home dialysis, and long distances that make routine treatment onerous. For the affected patients, the change is immediate and severe—more driving, greater expense, disruption of routines, and, in some cases, moving away from homes and support networks.

Efforts to address rural kidney care include prevention programs, tele-education for primary care, expanding home dialysis training and access, creative state uses of rural health transformation funds (some states have proposed mobile dialysis units or support for in-home therapy), and faster transplant evaluations to reduce travel. But those strategies take time and resources; for patients facing the sudden loss of a nearby clinic, the gap is already personal and pressing.

KFF Health News is a national newsroom producing in-depth journalism about health issues and is one of the core operating programs at KFF.