Many rural parts of the country have avoided the toll of cases and deaths that have haunted cities like New York — but it may not stay that way.
These areas tend to have an older population that typically has higher rates of chronic illnesses and is concentrated in close living institutions, according to federal data.
Don Taylor, a public policy professor at Duke University, said that combination makes rural populations vulnerable to the virus and practically invites the pandemic into nursing homes.
“The rural places are probably likely to see these hot spots in these institutions,” Taylor said. “Most people end up living in a nursing home because they are chronically ill, and these people are at much much higher risk than average. These are all reasons why it is worrisome.”
Centers for Disease Control and Prevention data shows that the 15 percent of the U.S. population that live in rural areas have higher rates of preventable death from heart disease, stroke and other ailments, as well as higher rates of underlying conditions like smoking and obesity.
Nancy Krieger, an epidemiologist at the Harvard T.H. Chan School of Public Health, said preexisting chronic conditions pose additional risks for people who catch the coronavirus.
“It is not like people suddenly stop having diabetes just because they have COVID. This is COVID on top of other systems that are already not equipped to handle the conditions they have,” Krieger said.
So far, the virus has mostly struck urban population centers — only a few states with less than 5 million people, like Mississippi, have surpassed 5 coronavirus deaths per 100,000 people.
But signs of the pandemic spreading in rural areas have emerged in pockets around the country. In some North Carolina counties, cases from state prisons, nursing homes and other institutions dwarf other areas.
Wayne County’s Neuse Correctional Institution has reported more than 400 cases — more than two-thirds of all cases in the county. To the west in the state’s Henderson County, the coronavirus has shown up mostly in long-term care facilities where more than half the patients are over 60 years old, according to county data.
“Even as things get more controlled in the cities, these institution-driven rural outbreaks are likely to come out,” Taylor said.
Agricultural work, like that at meat processing plants that Trump ordered to reopen Tuesday, also presents an opportunity for the virus to spread. For plants in rural areas, many of their employees return home to crowded living conditions.
“You can have a lot of open space, but if people are living crowded because there are not great housing options and low wages, it takes only one person to set off a household,” Krieger said.
Hospitals in trouble
People who get sick in rural areas may have fewer health care resources to turn to during the pandemic. A Kaiser Family Foundation survey released last week found a notable discrepancy between hospital resources in urban and rural areas nationwide, according to Matthew Rae, the foundation’s assistant director for health care marketplaces.
“There is not a huge discrepancy of hospital beds, but there is a huge discrepancy in ICU beds,” Rae said. “The capacity is going to be hit a lot harder there in rural areas.”
According to the Sheps Center for Health Services Research at the University of North Carolina, rural hospitals have long faced declines that have spurred closures and consolidations. According to the center, 170 rural hospitals have closed since 2005, including 10 so far in 2020.
Krieger said rural hospitals may soon face staffing issues if administrative issues and cases surpass their staff's capacity.
"It is not just whether there are adequate ventilators, it is who is going to be running those ventilators," she said.
The roughly $2 trillion coronavirus relief package cleared by Congress included $100 billion in aid for hospitals nationwide, which includes $10 billion carved out for rural hospitals, health care centers and other clinics. Advocates and some members of Congress argue it won't be enough.
West Virginia Democratic Sen. Joe Manchin III pushed for the Department of Health and Human Services to increase the proportion to 20 percent of the funds in a statement Monday.
“West Virginians have buckled down and our COVID-19 rates are lower than expected but make no mistake, our hospitals are hurting and this does not do enough. The next round of funding must include my formula to ensure rural hospitals are not left behind,” Manchin said.
West Virginia's population has shrunk and gotten older over the years, declining by an estimated 70,000 residents over the decade, with a median age that's now the fourth highest in the country, at more than 42 years old.
National groups like the American Hospital Association worry that rural hospitals may still founder even with the cash injection, said Erika Rogan, the group’s senior associate director for payment policy.
"Resources are still very much needed for rural hospitals. They are seeing many of the similar challenges from COVID that we have seen across the country but those can be exacerbated by a low level of resources," Rogan said.
Rural hospitals have comparatively fewer beds and rely heavily on outpatient elective procedures for their cash flow. Rogan said the nationwide slowdown of those treatments have hurt rural hospitals that rely on them for revenue.
"They are really experiencing cash flow issues to such an extent there is a concern about how some will keep their doors open," she said. "Given the limited resources they have and small size, we know it is tough for them to weather the current situation."
Smaller health care providers like rural health clinics have felt a pinch, too, according to the National Association of Rural Health Clinics director of government relations, Nathan Baugh.
“Like pretty much all outpatient office care and primary care, you are seeing a massive voluntary decline from patients not wanting to go to the doctor,” he said.
The rural health clinics are more akin to primary care doctor's offices, Baugh said, which are more involved in testing patients than treating critical cases. They’re facing the same drought as other facilities and don’t know how long they can keep their doors open.
“Is it enough money? Who is to say. It certainly will help, and it depends on how long patients are afraid of going to the doctor for their normal sort of services,” Baugh said.
Places like Cabell County in West Virginia have limited confirmed coronavirus cases, just 40 in a county of 91,000, which Dr. Michael Kilkenny said means “we did such a good job flattening the curve it looks like a bumpy baseline.”
But Kilkenny, medical director for the Cabell-Huntington Health Department, said that means a need for caution when reopening areas like his for business.
“The fact that we have had a small number of cases means there has been very little change in our baseline vulnerability from three months ago,” he said.
Kilkenny said his West Virginia community is lucky, as it has access to a 300-bed hospital in Huntington. Still, the focus remains on protecting vulnerable people in the first place.
“After 50-some days at home, any hint at reopening is good news and you want to burst out, but we have to crawl before we walk and walk before we run as we reopen,” he said.