Map of counties in NC by coronavirus spread. Rural counties are mostly in the higher categories, while urban counties are in the lower tiers.
Coronavirus spread across North Carolina has spiked in rural areas. Source: NCDHHS

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By Liora Engel-Smith

Avery County was North Carolina’s last coronavirus holdout. In early May, as cases mounted elsewhere, the mountainous county had not seen a single case. By mid-May, however, the tiny border county had lost that distinction, as county officials reported a case.

By mid-summer, as the state’s largest urban centers saw a spike in cases, Avery County saw only a moderate increase in cases per capita, data from the North Carolina Department of Health and Human Services shows. As of this week, however, the county, tucked into the mountains on the Tennessee border, is just shy of 1,000 cases per 100,000 residents (928/100,000), the highest rate in the state.

Meanwhile, Wake County’s case rate is about a third of that number, with 350 infections per 100,000 residents.

Metropolitan areas continue to have more total coronavirus infections, but sparser, more rural counties such as Avery, have been seeing community spread accelerate in recent weeks, the state’s county alert system shows. That spread pattern follows national trends, data from the CDC shows. Coronavirus could potentially devastate smaller communities, where hospitals are small or nonexistent and the residents are generally older and sicker.

The virus’ spread is particularly pernicious in rural areas because many residents there have pre-existing conditions that could result in more serious coronavirus infections. As those people become critically ill, even a small number of infections could potentially overwhelm rural hospitals. The death toll in these communities could likely be higher, said John Sanders, chief of infectious diseases at Wake Forest Baptist Health. The risk of serious complications from coronavirus also is magnified in rural areas because there are few health care providers there.

“Simply by the lack of easy access, it puts them in a riskier position compared with someone who lives next door to a major medical center,” he said.

Social ties

While many might imagine an isolated existence in rural burgs, the realities of rural living make total isolation difficult.

Unlike in urban areas, where options such as contactless food delivery and online shopping have thrived, the essence of rural living is having rich social ties. You might hitch a ride to the grocery store with a neighbor, or ask your adult child to pick up medicines for you at the pharmacy. The lack of services makes some outings a necessity, said Paul Bolin Jr., who heads East Carolina University’s Department of Internal Medicine at the Brody School of Medicine.

When people get sick in rural areas, he said, they are more likely to go to work anyway, either because they are hourly workers without sick days or because of what Bolin called “a work ethic culture.”

Yet Bolin said that neither pattern fully explains how quickly coronavirus has spread in rural areas. Other factors, such as the presence of migrant workers, who tend to live in large groups on farms, or outbreaks in meatpacking facilities are part — but not all — of the equation. Summer travel from cities could have spread COVID-19 in areas with tourist attractions, combined with lax mask compliance could have exacerbated the spread.

Bolin suspects there are other yet unknown reasons for the differences in how coronavirus spreads in rural and urban areas, but the bigger concern, he said, isn’t just how someone gets infected, but how they fare once they are.

Infographic credit: Liora Engel-Smith

Complications from lack of resources 

As a physician in eastern North Carolina, Bolin knows that many people opt out of doctor visits, either because of cost, complexity or because they don’t want to take time off of work. That means that a portion of the estimated 42 percent of North Carolinians who have pre-existing conditions that put them at risk for complications from coronavirus, don’t even realize that’s the case.

Bolin and his team have devised a program that screens people for conditions such as diabetes and high blood pressure and offers flu shots for free. Their secondary goal is to educate and inform patients about their coronavirus risk while helping them adopt healthy behaviors with the goal of preventing severe bouts of coronavirus.

“People are more likely to say ‘If I have high blood pressure, I want to know it ‘cause it can make me die of COVID,’” he said.  “We are trying to capture this moment.”

From urban to rural spread

Coronavirus spread in the United States first began in cities with major international airports. Indeed, Wake County saw the first documented case of coronavirus in the state. Perhaps because there were so few rural cases earlier on, a perception emerged among some rural residents that the virus was an urban problem only. The lack of adequate testing in rural areas may have masked coronavirus’s arrival to those locales, allowing it to spread unnoticed, Sanders, of Wake Forest Baptist said.

As a result, people in rural areas may have not been as quick to alter their behavior as people in areas where cases first emerged.

“This is natural human behavior,” Sanders said. “When we see that cases go up, we tend to pay more attention and get more serious about trying to prevent the spread of infection. When it looks like we are past it, then we relax and [infection rates] go back.”

Recently, though, the state released a map that paints coronavirus risk in stark colors: yellow, orange and red. Many rural counties popped out as red, for experiencing “critical community spread.”

“All of the news outlets in the Piedmont Triad were carrying the news about the red counties and the orange counties when this first became available to the public,” said Davidson County health director Lisa Koontz. At first, her county was designated as yellow, for significant community spread.

That changed last week, when the map was updated and Davidson County was downgraded to orange, for “substantial” community spread. Several neighboring counties turned red.

“When the update came… it really opened some eyes locally and people started to think,” she said. “That really made people stop, pause, and many people make changes to holiday plans after seeing that information.”

In those first stages of the pandemic, Bolin said that limited resources dictated the focus on cities, but it was a missed opportunity when it came to outreach, education and addressing gaps in care that could make rural areas more vulnerable.

In the meantime, the politicizing of mask-wearing flourished, with some of it occurring in rural areas, said Paul Kamitsuka, chief epidemiologist at New Hanover Regional Medical Center.

“The reality is that if less than 100 percent of us mask every time we leave the house, the pandemic will continue to spread,” Kamitsuka, who is also an infectious disease doctor at Wilmington Health, said.

Sanders, for his part, said that mounting case numbers and the increased attention to the rural burden of COVID could be the key to flattening the curve there.

“People are people whether they live in rural counties or cities,” he said.

Liora Engel-Smith

Liora Engel-Smith joined NC Health News in July 2019 and covers policies, programs and issues that affect rural areas. She has previously worked for the The Keene Sentinel in New Hampshire and the Muscatine...