Until now, cities such as New York, Seattle, Los Angeles and New Orleans have been hot spots for COVID-19 outbreaks in the United States.
But the coronavirus threat is growing in America's rural areas -- and in many ways, the risk there is even more dire than it has been in big cities, experts say.
That's because people tend to be older and sicker in rural areas, and have far less access to the health care services needed to help them get well and prevent community-wide spread of COVID-19, said Alan Morgan, chief executive officer of the National Rural Health Association.
"Rural America is a geographic area that continues to face significant health care workforce shortages at a time when the population is elderly, with a higher percentage of chronic health issues," Morgan said. "You've got that population most at risk for COVID-19 in a location together where you have a lack of health care access. It's unfortunately a perfect storm."
The risk posed by coronavirus to rural areas is not as remote as one might think.
Four of the 10 counties with the highest COVID-19 death rates are in the rural South, according to statistics gathered by the Washington Post. They include three in rural Georgia and St. John the Baptist Parish in Louisiana.
"As of last week, 86 percent of rural counties had at least one COVID-19 case, and one-third of rural counties had at least one COVID-19 death," said Carrie Henning-Smith, an assistant professor of health policy and management at the University of Minnesota.
COVID-19 hits smaller towns
And things are getting worse. Data that the White House coronavirus task force is using shows infection rates are hitting new highs in smaller communities across the country, NBC News reported Tuesday.
The 10 top areas recorded surges of 72.4 percent or greater over a seven-day period, a set of tables produced for the task force shows. They included Des Moines, Iowa Amarillo, Texas and Central City, Ky., which saw a whopping 650 percent increase in cases, NBC News reported.
The spiking infection rates suggest the coronavirus is spreading quickly outside major coastal cities that were early hot spots.
Morgan noted that COVID-19 has invaded rural America in a succession of waves.
The first wave came in rural communities that depend on tourism, such as ski resorts in Colorado, Utah and Idaho, experts said.
"You had people who didn't live permanently in the town, but were coming to visit for recreational purposes and spreading COVID-19 and suddenly overwhelming the health care systems and grocery stores and other resources in those places," Henning-Smith said.
The next wave involved rural areas located next to large metropolitan areas, Morgan said, pointing to St. James Parish in Louisiana as one example.
"People in St. James commute to either Baton Rouge or New Orleans, and they brought it back into the community," Morgan explained.
After that, COVID-19 started cropping up in rural communities with interstate highways running through them, where large truck stops serve as a revolving door for truckers from all parts of the country, Morgan said. Batesville, Ind., is one small town that saw a huge leap in coronavirus infections thanks to highway travel.
Hotbeds for infections
Now, COVID-19 outbreaks are starting to occur in rural workplaces such as meatpacking facilities, as well as in prisons out in the country, Morgan said.
Country folks don't live on top of each other as their city cousins do, but they do congregate in places where they could readily pass coronavirus from person to person, Morgan said.
"When you say rural America, everyone thinks about farmers and ranchers in Wyoming and Montana, right? These are the people who pioneered the concept of social distancing. They got that down," Morgan said. "What we're really talking about are these hundreds of small towns across the U.S., with two to four stoplights."
People in these communities "are all going to be at the same Walmart. They're all going to be at the same grocery store. They're all going to be at the same post office. It really is a bad situation," Morgan said.
At the same time, rural folks live far enough apart that it can be tough for public health officials to do the sort of investigative work needed to head off outbreaks, like contact tracing and viral testing, Henning-Smith said.
"It's really challenging to do track-and-trace when you have to drive 45 minutes to an hour to get to the next town," Henning Smith said. "It takes more time and a lot more effort to reach people in places where people are not living close to one another."
Folks living in rural areas also tend to be older and sick with chronic health conditions, which puts them at greater risk of dying from COVID-19, Henning-Smith said.
Local hospitals struggle
They also have to travel farther for health care, usually, and whatever local hospitals and clinics they have are struggling to stay open, experts added.
There are about 2,000 rural hospitals in the United States, and two-thirds of them have 25 or fewer inpatient beds available, Morgan said.
More than half these rural hospitals operate in the red on an annual basis, Henning-Smith added.
"Since 2010, 128 rural hospitals have closed, eight in 2020 alone," Henning-Smith said. "At least three have closed since the pandemic began."
The lockdowns required to keep COVID-19 from overwhelming the U.S. health care system also unfortunately robbed these rural hospitals of a key source of income.
Hospitals had to cancel elective procedures and stop treating outpatients, which represented up to 80 percent of the revenue of rural hospitals, Morgan explained.
"Rural hospitals were in trouble already, even before all this happened," said Leighton Ku, director of the George Washington University Center for Health Policy Research in Washington, D.C. "It could be that the losses right now are that extra little thing that would push them off the edge. I wouldn't be surprised to hear that some more rural hospitals or very small hospitals, this was the thing that pushed them into bankruptcy."
To make matters worse, rural hospitals are not in a good position to deal with a sudden COVID-19 outbreak. Small-town hospitals and clinics have to work harder to locate and buy the equipment they need, Henning-Smith said.
"You have a lot of very small clinics and hospitals, many of which are independent. They just don't have the buying power to jump to the front of the queue or to negotiate a reasonable price for additional equipment," Henning-Smith said.
These facilities also tend to be very lean operations, and the loss of some staffers to COVID-19 infection during an outbreak would put them squarely behind the eight ball, Morgan said.
"We've done a great job of building efficient small-town hospitals. By efficient, I mean absolutely no surge capacity," Morgan said. "For the facilities that have faced the pandemic, a common thread is one or two of the clinicians become COVID-19-positive. You have no room for error, and you start losing clinical staff. It compounds the problem, from a small town's perspective."
The federal government is distributing $10 billion in emergency relief to rural hospitals and clinics, and both Morgan and Henning-Smith are hopeful that money will help keep rural health care open until social distancing requirements are eased.
"What we're hearing from our membership, many are restarting their elective procedures and are taking outpatients again," Morgan said. "In a perfect world, this works out. As they utilize these federal funds, they're beginning to have revenue come back in their doors. Hopefully this is a glide path to keep rural hospitals open during this crisis."
"Rural hospitals have taken matters into their own hands as well, in some places forming buyers' consortiums so that they gain some extra leverage getting tests, ventilators, gloves, masks, gowns and other needed supplies," Henning-Smith added.
"Clinics banding together to make up one big order can be a big help here," she said. "Otherwise, many rural providers just won't come up to the top of the queue."
This article has been adapted from its original source.