Rural areas of the country have vulnerabilities to the coronavirus and limited resources to respond to the pandemic.

The first wave of the coronavirus disease 2019 (COVID-19) pandemic inundated urban areas such as New York and Detroit, now rural areas are getting overwhelmed, two infectious disease experts say.

The United States has become a global hotspot in the COVID-19 pandemic, with the most confirmed cases and the most deaths in the world. As of April 23, the country had experienced more than 849,000 confirmed cases and more than 47,000 deaths, worldometer reported.

This week, the Infectious Diseases Society of Americaheld an online media briefing on the impact of COVID-19 on rural areas of the country. The situation in Nebraska is emblematic of how the pandemic is affecting rural communities, said Angela Hewlett, MD, MS, director of the Nebraska Biocontainment Unit, and an associate professor at University of Nebraska Medical Center.


“Nebraska, as a whole, looks pretty good. We do not have a lot of positive cases here. But when you break the numbers down by county, a completely different picture emerges. It’s alarming!” she said.

The pandemic is exposing the disparity of healthcare resources between urban and rural areas, said Andrew Pavia, MD, chief, division of pediatric infectious diseases, University of Utah School of Medicine. “We have to appreciate that the resources that we have to fight this epidemic are not evenly distributed. The bigger cities have major medical centers, a capacity of specialists, and ICU beds. But when you get 50 to 100 miles out from the big cities, the situation is very different.”


While rural areas of the country have some advantages in battling COVID-19 such as built-in social distancing from the geographic dispersion of populations, there are many significant disadvantages, Hewlett said.

  • Small towns are close-knit communities that often have large social gatherings such as family events drawing people from several towns.
  • Industries in rural areas including meat packing companies and power plants are considered essential and require most employees to work on-site, so the ability to telecommute from home is limited. “In these industries, there are often lots of people working in very close contact, which is a set-up for perpetuating a disease like this that is spread from person to person,” she said.
  • Smaller communities have smaller hospitals with limited capabilities such as few ICU beds and small stocks of ventilators.
  • Rural communities have small local health departments, which constrains essential pandemic responses such as contact tracing.

Poor rural communities are particularly vulnerable to the coronavirus, Pavia said.

“We have known for a long time that poverty is a strong indicator of poor general health. Poor people are more likely to have worse diets; greater risk of diabetes, obesity, and heart disease; and they get less care for chronic diseases. We know that all of those factors are risks of dying when you get infected with the coronavirus,” he said.

In addition, Pavia and Hewlett said air transport of severely ill COVID-19 patients from rural hospitals to larger medical centers poses serious challenges. The problems include the potentially large number of patients who will need this service and concern over virus exposure of flight crews transporting COVID-19 patients during long flights in small aircraft.


Most rural hospitals are overmatched in the struggle against COVID-19, Hewlett and Pavia said.

“In a rural area, you may have a critical access hospital, which is a hospital that may have 20 beds and possibly one ventilator, if that. They are just not equipped to deal with an influx of sick patients. They are used to caring for individuals within their community with conditions that a small hospital can handle,” Hewlett said.

“In the West, we have many hospitals that are critical access and frontier hospitals, and they may have fewer than 20 beds. They may have no ICU beds, or two or three ICU beds, and they are not staffed 24/7. Those beds are used to help patients in the postoperative period,” Pavia said.

Beyond the physical limitations of rural hospitals, staffing is a daunting challenge during the COVID-19 pandemic, they said.

“At some of these hospitals, they have done a good job at gearing up, but the staff is quickly overwhelmed. They have to be able to staff 24/7 for weeks at a time, and many of these communities barely have enough doctors and nurses to provide good primary care, let alone 24/7 ICU care,” Pavia said.

Shortages of key pandemic specialists are common in rural areas, Hewlett said, noting there are only two infectious disease physicians in western Nebraska.

“There are multiple hospitals that do not have infectious disease specialists or critical care specialists. These are hospitals that typically do not need a critical care specialist to operate 24/7, seven days a week, and that is the need we are seeing with this disease. We have patients who are very sick and require ICU care over an extended period. … These are patients who often require several weeks of ICU-level support; and in small communities, that is just not sustainable,” she said.

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