New York City is still battling America’s worst Covid-19 outbreak to date. And now, even as some states begin to consider reopening, many sparsely populated areas of rural America are seeing a worrying uptick in cases.
“The epicenter of this outbreak really has shifted into the smaller rural areas,” said Angela Hewlett, associate professor in infectious disease at the University of Nebraska Medical Center, in a recent Infectious Diseases Society of America briefing. And that’s a major problem, given that the health systems of many of these places are the least equipped to deal with a sudden surge in cases.
Testing in many less-populous areas has lagged even further behind the already-low national average, obscuring the extent of transmission in more sparsely populated areas. As protests in largely rural states show, some people assume rural areas might be spared the worst of Covid-19 outbreaks.
Yet many people in rural regions work in large-scale industries, such as food processing, where social distancing is challenging and they’re at higher risk. “Part of the reason that we’re seeing such dramatic increases in rural communities” is because the virus is running rampant through workplaces like factories and farms, says Hewlett.
“These are not places where typically people can work from home,” she notes. Instead, “there are often lots of people working in very close contact in these essential jobs — which really is a setup for perpetuating a disease like this.”
This deadly combination will lead to longer, more sustained outbreaks in rural regions, “making reopening much more challenging,” Andrew Pavia, chief of pediatric infectious diseases at the University of Utah School of Medicine, said at the IDSA briefing. “I think we’ve oversimplified this idea of peaks. We’re not seeing one epidemic nationwide, or even statewide — we’re seeing different outbreaks, thousands of them playing out in different parts of the country.”
What counts as “rural America”— and how much is the virus spreading there?
Rural can mean many things. The US census definition, for example, is any spot with a population of fewer than 50,000 people. But depending on what federal definition you use, some 17 percent to 49 percent of people in the US live in “rural” areas.
Additionally, otherwise-rural regions can have small and even fairly large metropolitan areas. According to a new Covid-19 map from the Dartmouth Atlas Project, the top 10 regions with the fastest growth rates in cases are primarily metropolitan areas with blue-collar industry, located in largely rural states.
Because they are small, many rural counties have few cases, giving the impression that broad regions of the country are still unaffected. A more accurate picture of what is happening with Covid-19 across the US emerges when the data are aggregated to larger geographic areas defined on where people get health care. “Both counties and states fail to reflect how and where people get care,” explains Elliott Fisher, a professor of health policy and medicine at the Dartmouth Institute.
Fisher and his colleagues’ maps show the current status of the Covid-19 epidemic through 306 US “hospital referral regions.” (They used data collected by the New York Times and the US census, and they will be updated every weekday.) In addition, unlike many of the maps which just show total case numbers, the Dartmouth Atlas Project shows population-based rates of the virus’s prevalence and the average growth rate.
Since hospital referral regions draw from multiple counties or even different states, Fisher hopes that the atlas may be able to provide “early signals about new outbreaks,” which may otherwise be missed.
For example, Houma, Louisiana, a town of around 32,000 people in the Atchafalaya Basin — live oak and Cajun country — has almost as many cases per capita within its hospital region as Chicago. Greeley, Colorado, where there is a large JBS meatpacking plant, has more cases per capita within its hospital region than Washington, DC.
That kind of case reporting is particularly critical given the ongoing shortage of testing. In areas of Utah, very few people are getting tested. “Does that mean there’s no disease? Absolutely not,” Pavia says. “It means we don’t have a good spotlight on what’s going on. And so we’re missing things.”
Testing scarcity is a reflection of the general unequal distribution of medical resources, which extends far beyond Covid-19. According to the Chartis Group, 63 percent of rural hospitals don’t have ICU beds. Many rural hospitals have only a month’s worth of cash on hand and have lost a substantial part of their income due to the reduction of outpatient services during the pandemic. This leaves them even less equipped to handle the crisis.
Most epidemiology models predict that initial peaks in less-densely populated states may still be weeks away, making understanding these kinds of nuances — and not relaxing social distancing prematurely — critical.
According to new federal guidelines, states should wait for a sustained decrease in cases over 14 days before easing restrictions. But these recommendations aren’t mandatory, and some states are behaving more cautiously than others — creating what Fisher terms a “natural experiment.”
Here’s a closer look at how communities in Central California, Alaska, South Dakota, Missouri, Nebraska, and Georgia are handling the uncertainty, and threat, of Covid-19.
Central California: “The fear and the unknown, and a lot of different information — all these create a monster”
Salinas, California, in Monterey County, is sometimes called the “Salad Bowl of the World.” Around 70 percent of the country’s lettuce — and a substantial amount of other produce — is grown here. As of April 28, the county had 185 confirmed cases, many of which were connected to the local farms. An employee at one of the largest local lettuce companies, Tanimura and Antle, for example, tested positive on April 22.
Health experts say more farmworkers around the country could be hit hard by the epidemic. “My fear is that once Covid-19 enters the farmworker population, it will be very difficult to prevent the spread, regardless of what is happening in the workplace,” Heather E. Riden, manager of the Western Center for Agricultural Health and Safety at the University of California Davis, told Inside Climate News.
Many of the nearly 888,000 people in the US who harvest produce work in Central California. The US Department of Agriculture estimates that around half are undocumented immigrants, who have been excluded from the federal Covid-19 stimulus relief. The front line for the nation’s food supply, these jobs have been declared “essential,” but workers have had trouble accessing protective equipment like masks, and companies have been slow to institute measures that would enable social distancing. Masks in this environment are needed not just to prevent Covid-19; farmworkers are also regularly exposed to pesticides and chemicals.
As spring ramps up the growing season, farmers would normally be hiring additional workers, many of whom travel based on the season, adding another level of logistical difficulty and potential for disease spread.
California’s approximately 400,000 farmworkers are considered essential, but many, as immigrants, are exempt from the CARES package, nor do they have access to benefits like paid sick leave — or in some cases, even running water to regularly wash their hands. Some of those are at higher-risk work picking crops like strawberries, tomatoes, peaches, grapes, and apples.
“Strawberries and other harvesting like that, the workers are in rows, so that kind of forces people to be close by one another,” says Lauro Barajas, vice president of the labor union United Farm Workers, who previously worked on farms in California.
To add an additional hardship, H2A visas for foreign workers, like those strawberry season workers rely on, are also expected to be delayed due to the pandemic. Nor do many farms have much financial cushion if the season goes poorly; due to President Trump’s trade war, farm bankruptcies increased by 20 percent in 2019. In the 100 counties with the most farmworkers, $590 million in recent trade bailout payments were recently distributed without requiring improving conditions for farmworkers.
Barajas says, “The fear and the unknown, and a lot of different information — all these create a monster.” He notes that people working in agriculture are trying to protect themselves, but given their critical role in feeding the country, the government should do more. “Vegetables don’t grow in stores,” he says. “Farmworkers are always essential.”
Alaska: “Getting enough tests is a challenge”
When the sockeye salmon run arrives in Alaska’s Bristol Bay in May, the population of the small town of Dillingham usually triples. “Thousands of fishermen travel from 48 states to work in the fishery,” says Andy Wink, executive director of the Bristol Bay Regional Seafood Development Association.
But due to the high risk of imported coronavirus cases, the town of Dillingham, which has only 16 hospital beds, recently asked Gov. Mike Dunleavy to consider closing the season. “We cannot foresee ANY plan that would avoid a significant impact to our community,” wrote Mayor Alice Ruby in an open letter.
But the state of Alaska considers commercial fishing essential. Dillingham is now just one of many Alaskan towns bracing for an influx of travelers for commercial fishing — or a loss of the jobs that fuel the region’s economy. Gov. Dunleavy relaxed shelter-in-place restrictions on April 24, allowing restaurants, nail salons, and retail stores across the state to reopen. He has released state guidelines for commercial fishing vessels, requiring workers to self-quarantine for 14 days after arriving in Alaska, as well as screening before getting on a boat.
Even with statewide social distancing measures, the state’s daily case rate has still been almost doubling. While Alaska currently has some of the fewest confirmed Covid-19 cases in the country, it’s unclear how well the health care system — in a state where many towns can only be accessed by air or boat — will be able to cope with any kind of surge. The state’s chief medical officer has received a fraction of the supplies she’s requested, including inadequate numbers of personal protective equipment and test kits.
Wink says that even as the state reopens, “Getting enough tests is a challenge.” Seafood companies in Dillingham have been working with a regional small laboratory, Northwest Pathology, to increase testing availability for the fishing season. The lab can now analyze 10,000 tests a day, but its efforts have been hamstrung by a continued lack of critical supplies, like reagents, as well as the CDC seizing supply orders.
Given Alaska’s limited health resources, as industries like commercial fishing — and normally, tourism — potentially bring new infection sources into Alaska, there’s a critical need to be able to identify and control new outbreaks before reopening.
South Dakota and Missouri: “They dock you a point if you stay home sick”
Minnehaha County, South Dakota, became a Covid-19 hot spot when almost 1,000 people became sick at a Smithfield Foods plant, a major pork processing center. Even as Covid cases in the state rise, Republican Gov. Kristi Noem has so far resisted issuing a statewide stay-at-home order.
A Smithfield Foods spokesperson tried to blame the outbreak on “living circumstances in certain cultures” in an interview with Fox News. But a BuzzFeed investigation showed that the company “did little to inform or protect employees during the critical two weeks after the first case at the plant surfaced.” Less than a week later, families were organizing a drive-by tribute for people to pay their respects to a former Smithfield Foods employee who had died of Covid-19.
It’s not just South Dakota. Investigate Midwest reports that as of April 22, there have been at least 2,700 reported Covid cases tied to 60 meatpacking facilities in 23 states.
An anonymous employee at a Smithfield Foods plant in Missouri has filed a lawsuit on April 24, saying that on the line, workers can’t even cover their mouths to cough. David Muraskin, an attorney with Public Justice representing the case, says, “If you miss a piece of meat, you get fined,” so workers, sometimes literally inches from each other, can’t take appropriate precautions.
The CDC has guidelines for critical workers, which would include slowing production lines and spreading people out. “That is a possibility, but companies are not doing that,” Muraskin says.
Instead, as other plants have closed — and more than a dozen have this month — more meat is added to the lines to compensate. This makes conditions even worse. The employee filing the lawsuit knows of at least 11 people who have Covid-19 symptoms, but the company is not doing contact tracing.
People with symptoms are often not encouraged to stay home. At Smithfield, employees are not given sick leave. “They dock you a point if you stay home sick,” Muraskin says. “If you have nine points in a year, they can fire you.”
To make things worse, the Occupational Safety and Health Administration has temporarily weakened enforcement mechanisms that might otherwise catch dangerous working conditions, leaving reporting violations up to employers.
As outbreaks balloon uncontrolled, some facilities have been forced to shut down. USA Today reports at least 17 facilities, including the JBS pork plant in Worthington, Minnesota, which produced 10 percent of the country’s pork, closed this week. “When you have a large outbreak associated with an industry like the meatpacking industry,” Hewlett says, “then you can have a sustained community transmission.” Politico reports that USDA meat inspectors have been told to buy their own masks because the department doesn’t have enough. So far, one inspector has died of Covid-19.
The outbreaks tied to meatpacking facilities and food processors have significant impacts beyond the community outbreaks they have sparked. As Covid-19 reduces processing capacity, hog farmers and chicken farms in other rural areas are considering euthanizing thousands of animals, with rippling effects in everything from long-haul trucking to grocery stores.
“Breakdowns in the food supply chain could have significant economic impacts for both consumers and agricultural producers,” 32 senators wrote in an open letter to Vice President Mike Pence. “It is also imperative that precautions are taken to ensure the stability and safety of our food supply.”
Nebraska: “We’re in the middle of a red state, so a lot of them believe this is like the flu”
On the Dartmouth Atlas Project tracker, some of the highest growth rates in cases are in western Nebraska. In addition to the meatpacking industries that employ many in this region, there are many other industries in Nebraska where people work in close contact, like nursing homes and correctional facilities.
Sue Krohn-Taylor is an administrator at a 72-apartment low-income senior living facility in the large town of Grand Island. She says her building is now on a self-imposed lockdown with restricted visiting rules and hours.
The facility is near a cluster of meatpacking cases and across the street from a hospital, so she says the quarantined senior residents count the Life Flight emergency helicopters coming and going. “We’re used to one to two a month, and geez, last weekend it was 13 or 15 in one day,” she says. Forty-six percent of the people tested in Krohn-Taylor’s county were positive for Covid-19.
Because there have been no state-sanctioned restrictions on facilities like hers, she’s been left in the uncomfortable position of setting the rules — and not all the residents appreciate it. “We’re in the middle of a red state, so a lot of them believe this is like the flu,” she says. “It’s a battle every day to get reality into focus.”
She also feels alone in the battle. “I’m 58 years old, and I have never felt so abandoned by my government,” Krohn-Taylor says. “Maybe I just lived in a bubble, but I always thought in times of crisis, as Americans we would never have to worry. Our government would take care of things.” Instead, she’s the one telling people to wear masks that some of the residents of the senior living facility stayed up all weekend making.
“Rural communities are all experiencing the same thing — a lack of resources,” says Jody Rutledge, who is deeply concerned for her mother, who is in a nursing home in Gordon, Nebraska. At least five nursing facilities in Nebraska now have confirmed cases of coronavirus, but testing and personal protective equipment like masks remain in short supply.
Krohn-Taylor says her daughter works for a correctional facility and is coughing and has lost her sense of taste. “They still want her to go to work,” she says. (Jails and prisons have also become epicenters for Covid-19.) But despite the risk of transmission, when her daughter went to the doctor, she wasn’t initially given a test, although she’s now scheduled for one, due in part to Krohn-Taylor’s urging.
“The lies are taking lives,” she says, “and that is not okay.”
Georgia: “No meal is worth dying for”
Due to two now-infamous funerals, the town of Albany, Georgia, has one of the highest growth rates of cases in the US. Rural Georgia was unprepared for the introduction of Covid-19: Nine counties in the state not only don’t have hospitals, but have no practicing doctors at all. Many residents have underlying health conditions, and a third of the population lives under the poverty line.
Nevertheless, Georgia Gov. Brian Kemp announced April 21 that he too would reopen some businesses. Six other southern states with Republican governors have also announced they will be reopening, although not a time frame for when they will do so.
Around the country, the lack of federal mandates and unenforceable guidelines has left business owners to create their own standards for maintaining social distance. For example, the Georgia Board of Cosmetology and Barbers is suggesting barbers wear masks and disinfect shops, but there is no enforcement mechanism in place.
Hugh Acheson, a restaurateur in Athens, Georgia — a progressive university town near Atlanta — says even the state’s more metropolitan areas are bracing for the worst. As a chef, he wants step-by-step instructions on how to sanitize, and what social distancing really means before restaurants reopen. “No meal is worth dying for,” he says. A CBS poll found that 71 percent of Americans wouldn’t feel comfortable going to a bar or restaurant even if stay-at-home restrictions were lifted.
Those numbers reflect the disconnect between many government responses and how people are feeling. In a poll of 1,200 rural Americans, Rural Organizing found that while approval of the federal response tended to fall along partisan lines, a majority of nonmetropolitan respondents said they didn’t believe Trump adequately prepared for the coronavirus outbreak, and 44 percent said they didn’t think the federal government had gone far enough to slow the spread of the outbreak. In the meantime, Attorney General William Barr has suggested that he may sue states in order to force reopening measures.
Across the US, Fisher says he’s worried about confusing messaging. “There’s been a major absence of federal leadership,” he says. “There is absolutely an essential federal role in managing this pandemic, from setting clear national policy guidance that doesn’t confuse people to managing and distributing resources.”
Federal health officials estimated in early April that more than 300,000 Americans could die from Covid-19 if social distancing measures are lifted. This may be a conservative estimate; some models suggest as many as 400,000 Americans may die from Covid-19 by June 1. Nor is it a safe assumption that many of these deaths will occur in cities.
Pavia suggests that this next phase of the pandemic won’t have a smooth curve so much as jagged crests and valleys, like the Wasatch mountains of his home state.
“When the valleys occur, we’re going to have to be very careful about how we try and return things toward a new normal.”
Lois Parshley is a freelance investigative journalist and the 2019-2020 Snedden Chair of Journalism at the University of Alaska Fairbanks. Follow her Covid-19 reporting on Twitter @loisparshley.