COVID-19 cases, deaths spike in rural America: 'It was only a matter of time'

It’s hard to imagine there’s a county in America untouched by COVID-19. The U.S. reached a grim milestone this week, surpassing at least 250,000 deaths as at least 46 states see rising positive cases. But after a debate, a small county in Texas, dubbed “the last COVID-free county,” is still, in fact, officially free of confirmed cases of COVID-19. Loving County, which has a population of 169, originally reported two cases of COVID-19 this week, but the Texas Department of State Health Services (DSHS) later corrected that to say that the county still has no active cases. There were reports of the county having one case of COVID-19 over the summer, but it has not been reported in official DSHS data. Still, experts don’t expect this to last.

When COVID-19 first infiltrated the U.S., it took hold in major cities like New York and Seattle. But now, new data shows, it has seeped into rural America — and it’s killing Americans in those areas at a rate that’s nearly 3.5 times higher than those living in metropolitan areas.

The data, which comes courtesy of the Centers for Disease Control and Prevention, shows a steady increase in deaths in rural communities from COVID-19, starting in the middle of summer. Since October, those deaths have sharply increased, while rates in metropolitan areas have remained comparatively low.

A general view of the emergency room at Avera St. Luke's Hospital, a 119-bed rural hospital, as the coronavirus disease (COVID-19) outbreak continues in Aberdeen, South Dakota, U.S., October 26, 2020. Picture taken October 26, 2020. REUTERS/Bing Guan
A general view of the emergency room at Avera St. Luke's Hospital, a 119-bed rural facility, as the COVID-19 outbreak continues in Aberdeen, S.D. (Reuters/Bing Guan)

The same is true for cases of COVID-19: While they’re increasing no matter where you live, case counts in rural areas are much higher than those in cities. For example, the seven-day new average number of cases per 100,000 people in rural areas on Nov. 14 was 60.9. At the same time, the seven-day new average number of cases per 100,000 in metropolitan areas was 41.8.


What’s going on here?

CDC data clearly shows that rural areas were not affected as much as cities, both during the initial wave of COVID-19 cases in the U.S. and again in the early summer. It wasn’t until August that case counts equalized, with rural cases then surpassing metropolitan cases in the months to follow.

“It takes time for a virus to work its way across the country,” Dr. Amesh A. Adalja, senior scholar at the Johns Hopkins Center for Health Security, tells Yahoo Life. “Every area is on a different timeline. It was only a matter of time before the virus reached all areas of the country.” This phenomenon isn’t unique to COVID-19, Adalja says: It’s common for infectious diseases to hit more densely populated areas before moving to rural regions.

Perry N. Halkitis, dean of the Rutgers School of Public Health, tells Yahoo Life that this was predictable. “COVID-19 began by hitting the coasts — the East Coast and the West Coast. From there, the disease spread to other localities,” he says. “What is unfortunate is that those other locations, including rural areas, had an opportunity to prevent this disease from affecting their populations but instead chose to ignore the signs that this virus would eventually make its way to their geographic regions.”

It took time for the virus to reach rural areas, simply because they’re less densely populated, Cory Fisher, a family medicine physician at the Cleveland Clinic, tells Yahoo Life. “The benefit that rural America enjoyed for so long was simply geographical space,” he says. “There just aren’t a lot of people living in those communities, so the likelihood of exposure was much lower there than in our cities.”

But that slow migration of the virus affected mindsets about the pandemic. Many people in many cities were scared during the initial wave. “That got people’s attention,” Dr. James McDeavitt, senior vice president and dean of clinical affairs at Baylor College of Medicine, tells Yahoo Life. But, he says, many people in many rural areas felt like bystanders. “Smaller communities saw little to no COVID cases, and it seemed less real,” he says. “Now, when you drive through some rural areas, people aren’t wearing masks as much as they are in cities and aren’t taking the virus as seriously.”

The lack of overall mask usage is a problem, Dr. Richard Watkins, an infectious disease physician in Akron, Ohio, and a professor of medicine at the Northeast Ohio Medical University, tells Yahoo Life. “I suspect [the surge in rural cases] is due to less mask-wearing, and that too many people are in denial about the seriousness of the pandemic,” he says.

Adalja agrees. “People in rural areas may be less likely to take COVID precautions, as we’ve seen with mask-wearing, and that’s going to translate to an increased burden of infection,” he tells Yahoo Life. As for the higher risk of death, Adalja says it may be due to a greater prevalence of high-risk factors for COVID-19 like diabetes, hypertension and obesity in rural regions.

Limited access to health care is a potential issue too, Adalja says. “There are usually limited resources in the number of infectious disease doctors and clinical control doctors,” he says.

How people in rural communities can stay safe

Adalja says it’s important for people in rural areas to understand that geography won’t protect them from the virus. “The virus doesn’t draw distinctions between rural and urban areas,” he says. “As long as people are socially interacting, all rural areas are still at risk.”

Fisher urges people to take this seriously, no matter where they live. “We are dangerously close to overrunning our health care system — in fact, we’ve already done so in some communities — and if numbers continue to rise, there won’t be enough health care workers, facilities and equipment to care for those that are most sick,” he says.

Adalja stresses the importance of following strategies to prevent the spread of COVID-19, including wearing masks when you’re around people who don’t live in your household, social distancing whenever possible and practicing good hand hygiene. And, if you don’t feel well, isolate yourself immediately and call your doctor.

Overall, though, experts say it’s important for everyone to understand that the virus is everywhere. “For the first time in small communities in Iowa, the virus is real,” McDeavitt says. “Had they had that experience this summer, they would probably be ahead of the game now.”

For the latest coronavirus news and updates, follow along at According to experts, people over 60 and those who are immunocompromised continue to be the most at risk. If you have questions, please reference the CDC’s and WHO’s resource guides.

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