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As the coronavirus crisis careens toward smaller towns and rural areas, a new data project highlights a stark, looming reality: This pandemic could take a crushing toll on rural areas that are less prepared than many of their urban counterparts.

The examination of every U.S. county’s preparedness level, produced in a STAT collaboration with the Center on Rural Innovation and Applied XL, also reveals that some rural areas are better prepared than others.

Portions of states like Vermont and New Hampshire and regions like the Midwest, for example, appear equipped to better handle the brunt of the outbreak than other rural communities.

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The dashboard also points to the places at higher risk. Some are areas where concerns have already been raised — including segments of the Deep South, where some governors were slow to implement physical distancing measures, and sparsely populated expanses in Western states outside larger cities. Others, like the Upper Peninsula of Michigan, which has suffered hospital closures, have received less attention.

“There are variations in terms of capacity and demographics in rural areas around the country, and those variations can have life-and-death implications in this pandemic,” said Matt Dunne, the executive director for the Center on Rural Innovation, which was established in 2017 to identify ways to close the urban-rural opportunity gap. 

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The dashboard aims to look deeper than statewide preparedness and scored counties based on measurements like the number of nearby critical care staff and hospital beds and the underlying demographics of the community, including age and socioeconomic conditions. It also incorporated data from a Covid-19 model that forecasts the intensity of the pandemic by state. (For more on the methodology, click here.)

Robert Redfield, the director of the Centers for Disease Control and Prevention, wrote in a tweet Monday that “reopening the US will be a careful, data-driven, county-by-county approach.”

Experts say the pandemic could accentuate the urban-rural divide in health measures, just as it has shined a light on other existing health disparities, killing disproportionate numbers of Black Americans, for example.

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Some urban counties also scored low on the preparedness scale, often driven by the age of their population and low socioeconomic status. But as the pandemic spreads, rural areas overall are more vulnerable than their urban counterparts because they have older populations and higher rates of the health conditions that increase the risk of more severe Covid-19 infections. They also lack the specialized units and capacity that city health systems have mobilized to take care of an influx of patients with critical cases of the respiratory disease.

“There are different kinds of rural areas in the United States, but many of them suffer from a number of epidemics,” said Jorge Salinas, a University of Iowa epidemiologist and infectious disease specialist. “Epidemics of obesity, epidemics of diabetes, some parts of the Deep South have epidemics of HIV, epidemics of poverty generally.”

If these communities are dealing with populations in poorer health to begin with, then their access to care is also generally worse. Rural hospitals have been shuttered in droves in the past decade. Those that have survived are also not staffed with the specialists or resources like a fleet of ventilators that could be needed to absorb waves of severely ill patients.

It’s not just clinicians that are lacking. Caitlin Rivers of the Johns Hopkins Center for Health Security said at a media briefing last week that in some parts of the country, several counties share one epidemiologist, whose job it is to spot the spread of cases and coordinate strategies for stopping chains of transmission.

“The public health system tends to be less robust, less funded,” Rivers said.

The dashboard is intended to spotlight areas that might struggle with the impact of the pandemic should they get hit with a surge of cases, and those that authorities at the state and federal might need to assist, its developers said.

“We’re hopefully providing some signal of where to look first,” Dunne said. 

“You look at a place like the Upper Peninsula of Michigan, which is very rural and has had hospital closures, and you see a lot of risk in that part of the state,” he said. 

Rural areas tend to feel protected from diseases that depend on people being in close contact with each other to spread. Indeed, experts say that with a pathogen like SARS-CoV-2 (the full name of the coronavirus), which was spreading in other countries before the United States, it made sense that the first places to feel the brunt here were major cities that imported lots of cases from travelers. Some of those went on to ignite community transmission. 

Indeed, the five states where governors have not ordered people to stay at home are relatively rural: Iowa, the Dakotas, Nebraska, and Arkansas.

But as cases grew in major urban areas, they spilled over to smaller cities, and from there to rural areas. Rural areas also might not realize the scope of the problem that is brewing in their communities; for all the well-publicized diagnostic testing snafus in cities, access to tests is even more limited in rural areas, experts say.

There are notable exceptions to the expectation that the pandemic will affect rural areas after cities. Idaho’s Blaine County has one of the highest infection rates in the country — city or rural. But it is home to a resort town, and it saw an early arrival of imported cases compared to other rural areas. Other smaller communities had “superspreader” events that caused a wave of early cases.

Population density can drive transmission, experts say, which is one reason cases in New York City are thought to have exploded the way they did. But with more people staying at home, transmission is often concentrated among people who share households — and that can happen no matter how dense the broader community is. One person can pick up the virus at work or at a gathering or through an errand and then bring it home to their families. Salinas, of University of Iowa, noted that workers in agriculture or meat processing often work and live in close quarters.

“It might have a harder time traveling to rural areas, but once it gets there, it will affect rural areas in a similar fashion to more densely populated areas,” he said.

Experts say the virus has likely arrived in most rural communities, with case counts picking up notably in some areas. But it can take some time to feel the full brunt of the crisis after it’s begun, because those who will need hospital care eventually take two or so weeks to get sick enough to get to that point. 

The staggered impact of the pandemic means that rural areas might enter the peaks of their local curves after the worst has passed through larger cities. In a way, this creates an opportunity. Resources like personal protective equipment and ventilators could be shuttled to communities in acute need if there are surpluses elsewhere. Medical societies have been trying to learn from the experiences of treating patients in cities to offer guidance to hospitals that so far have not been inundated.

Paul Biddinger, an emergency preparedness expert at Massachusetts General Hospital, said that hospitals in cities often direct patients to other medical centers to find the empty bed or the unused ventilator, even if the facilities are not part of the same network. He said rural hospitals and public health agencies needed to start preparing to similarly aggregate resources and manage capacity. 

“As more rural areas get hit,” Biddinger said, “clearly they will need to do the same.”

  • Looking at the data for Colorado, some of it looks quite suspect. For example, Dolores gets a 61, San Miguel gets a 46, but neither has a hospital and must rely on the hospital in Montezuma county which gets an 8. Doesn’t seem even remotely right.

    • I agree. I’m looking at North Central Washington, Chelan vs. Douglas counties (next to each other). Chelan County is scored very low, while Douglas is scored high. The biggest cities in these counties are across the Columbia River from each other. Douglas County has NO hospital. The hospital for the area: that would be located in Chelan County, right across the river.

      STAT, maybe you need to have a little more skepticism when a tech company tries to sell you on their “big data” and “AI” capabilities. Gary and I have identified two cases that make no sense whatsoever.

    • I found the flaw in this analysis (https://www.statnews.com/feature/coronavirus/county-preparedness-scores/):

      “The model is based on five variables:

      The number of licensed hospital beds within a 40-minute drive. This was used to estimate the physical capacity of a community, as a way to assess how ready hospitals are to handle a surge of cases. The pandemic comes after years of dozens of rural hospital closings.
      The number of critical care staff within a 40-minute drive — a measure of the human resources. In addition to lacking the health infrastructure of cities, rural areas have fewer specialists, nurses, respiratory therapists, and other health care workers who would be needed to handle local outbreaks.”

      In my example, Douglas County gets credited for Chelan County’s medical facilities, but its own (more favorable) demographics.

      Twain is right again: lies, damned lies, and statistics.

      STAT, I’d retract this analysis until your collaborators can fix this.

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