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Experts say rural areas have older populations that are less healthy and have fewer medical facilities than urban and suburban regions. Jeremy Hogan / Echoes Wire/Barcroft Media via Getty Images

The COVID-19 pandemic has already swept through cities and urban centers.

It attacked the Sun Belt with a vengeance this summer and then shifted its focus to the Midwest.

Now, the illness appears to be building like an infectious prairie fire in rural America.

That wasn’t the case during the initial surge of cases this spring.

“Many rural communities aren’t seeing anything. They’re simply having to prepare for what they know is coming,” Dr. Randall Longenecker, the assistant dean for rural and underserved programs at Heritage College of Osteopathic Medicine at Ohio University, told Healthline in late March. “[But] it will come, no matter what.”

Longenecker’s prediction appears to be coming true.

On Sunday, Dr. Deborah Birx, a member of the White House coronavirus task force, said COVID-19 is now “extraordinarily widespread” in rural areas in the United States.

“To everybody who lives in a rural area, you are not immune or protected from this virus,” Birx said in an interview on CNN.

A daily tracking graph done by the New York Times shows 13 states where new confirmed COVID-19 cases have increased the past two weeks. Among the states are Missouri, Minnesota, Oklahoma, South Dakota, Wyoming, and Nebraska.

It also shows 29 states where COVID-related deaths have increased the past 14 days. Among those states are Oklahoma, Iowa, Montana, South Dakota, Missouri, Wisconsin, Utah, Indiana, and Nebraska.

A weekly tracking graph updated on Monday by Reuters showed that in past 7 days new COVID-19 cases have increased by 15 percent in Oklahoma, 14 percent in South Dakota, 9 percent in Missouri, and 2 percent in Nebraska.

All of this has had experts worried for months about what’s in store for the middle of the country.

Rural areas may end up being among the hardest hit regions due to their demographics and lack of resources.

The 15 percent of people in the United States who live in rural areas are largely a higher-risk population that’s particularly vulnerable to serious outcomes with COVID-19.

In addition, many people in rural areas live 30 or more miles away from the nearest hospital.

“Systems that are under stress during routine times will be more stressed during disasters and times of crisis. Sometimes we forget those systems that are at the brink,” said Tricia Wachtendorf, PhD, director of the Disaster Research Center at the University of Delaware.

Rural health systems already stretched financially are therefore particularly vulnerable, but so are rural areas that don’t have as deep a bench of resources to tap when times get tough.

“When you start thinking about recovery trajectories and impacts, the extent to which there is community functioning before a disaster has strong implications in that recovery trajectory post-disaster,” Wachtendorf told Healthline in late March. “That goes right down the spectrum: transportation systems, employment support, hospitals and public health, food security — all the key systems. If those are low pre-disaster, those are going to have substantial effects on what communities experience during the disaster, as well as their post-disaster recovery.”

Rural populations tend to be older and face a higher risk of death from heart disease, cancer, lower respiratory disease, stroke, and unintentional injuries.

Nearly 20 percent of the population in completely rural counties is 65 and older, according to U.S. census data, compared with around 15 percent in mostly urban centers.

Americans living in rural areas also tend to have higher rates of cigarette smoking, high blood pressure, and obesity, compared with their urban counterparts.

Both older age and cigarette smoking are two factors tied to a higher risk of severe illness or death from COVID-19.

Despite these statistics, there’s a sense among some experts that some people in rural communities, as well as political leaders in these states, haven’t taken the threat of COVID-19 seriously enough.

Initially, “Less dense areas might be at an advantage compared to geographic areas that are more densely populated, and they may also be less connected to some areas where there’s a concentrated case,” Wachtendorf said.

But once these communities do start to see cases, they might struggle to fill basic public safety and administrative roles, especially if people such as police officers and firefighters get sick and have to self-quarantine.

Experts say any lack of physical distancing could have ripple effects that overwhelm rural hospitals and disrupt essential services down the line.

“If someone gets sick in those areas or an agency or department gets sick, there may be fewer people within those agencies to continue operations, leaving that particular community more vulnerable,” Wachtendorf said.

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The town of Rockton, Illinois, issued a shelter-in-place order in the spring, but many parts of the Midwest and South didn’t implement such procedures. Getty Images

Medical facilities known as critical access hospitals, which have 25 beds or fewer and are 35 miles away from the closest facility, are among the ones that have closed at the highest rates in the past two decades, even as their closure rate slowed somewhat thanks to provisions in the Affordable Care Act.

“Rural hospitals, on the whole, they’re going to see their curve, whether it’s flat or not, start a whole lot later, maybe 3 weeks, 6 weeks,” Longenecker told Healthline.

In the meantime, however, “Rural hospitals right now are seeing a steep decline in activity, empty beds, and empty practices, so for right now there’s a steep loss of revenue.”

For those rural hospitals — ones that remain after more than 80 have closed since 2010 and nearly 700 more found themselves on the brink of closure — that loss of revenue illuminates a dangerous teetering in our health system, as administrators try to balance the costs of staying afloat against the predicted flood of eventual COVID-19 cases.

In the meantime, many of these critical access hospitals are operating with bare-bones staff.

“What’s happening is the wave hasn’t come yet here,” said Jane, a travel nurse working at a critical access hospital in Wisconsin. “We’re down to two teams working here per day, which is OK most days because procedures keep getting canceled and falling off, but yesterday, we were working our (tails) off and I’m wondering why are we down to a skeleton crew? It’s because they’re trying to save money for when the s— really hits the fan.”

By then, supply shortages and other issues may have already rocked the system, Longenecker said.

“Hopefully some things will be worked out, like the supply of testing and supply of personal protective equipment, or not. They may have already sent them to the city,” he said.

Jane agreed.

“What scares me is that — because there’s not confirmed cases up here yet and there’s only two in the county. I’m just worried that we’re going to get overlooked when it happens, and we’re going to be up a creek,” she told Healthline. “I think a hospital is not a place you want to be right now unless you absolutely have to be.”

Part of the reason rural areas are so vulnerable to the COVID-19 health crisis is that they were vulnerable to begin with.

Rural zip codes lost almost 20 percent of their hospital beds between 2006 and 2017, according to a study from the Economic Innovation Group (EIG), a bipartisan public policy organization.

But that doesn’t tell the whole story. Within this study, EIG found that economically distressed rural areas were especially affected.

Put another way, “There are fewer than half as many hospital beds per capita reasonably accessible from the average rural distressed zip code as are from the average rural prosperous one,” the report says.

Wachtendorf noted the example of hospital closures funneling people from a wide geographic radius into central, overburdened regional health centers, as well as local clinics that aren’t full hospitals, as potential points of strain in the system in a crisis.

Rural areas that rely on farming as a main source of income might also find themselves in a particular bind.

“It’s not like you could just take 2 weeks off and think the crops will still be there,” Wachtendorf said. “Some of that seasonal work is very much dependent on timing. And it’s not just a matter of pushing off that production for 2 weeks or a month. It’s either done now or it’s not done at all.”

One way in which hospitals and doctors are dealing with this ongoing crisis in rural and urban centers is through telemedicine.

Not every patient is a patient with COVID-19, so those who can receive care from their homes and thus stay out of overburdened hospitals are a benefit to the system at large.

“Prior to COVID-19, we were seeing much more of a demand for telehealth in rural areas,” said Pamela Ograbisz, DNP, FNP-BC, director of telehealth at, a healthcare staffing agency. “In a way, COVID-19 leveled the playing field in healthcare by erasing the boundaries between rural areas and large cities. It doesn’t matter where patients are located; they need care.

“Because of this and because clinicians are overwhelmed, demand for telehealth has gone up across the board,” Ograbisz told Healthline.

But telemedicine can only go so far, and won’t fix the fragmentary nature of the American healthcare system, Longenecker said.

“It’s hard, as individualistic as we are as Americans, for us to think about the good of the community or think epidemiologically, which is a very different way of thinking than just thinking about me and my family,” he said. “But anything we could do to be less fragmented and to be more systemic (as a healthcare system) would be really, really good.”