By The Washington Post · Reis Thebault, Abigail Hauslohner · NATIONAL, HEALTH
It tore though a pork processing plant and spread outward in a desolate stretch of the Oklahoma Panhandle. And in Colorado's sparsely populated eastern plains, the virus erupted in a nursing home and a pair of factories, burning through the crowded quarters of immigrant workers and a vulnerable elderly population.
As the death toll nears 100,000, the disease caused by the virus has made a fundamental shift in who it touches and where it reaches in America, according to a Washington Post analysis of case data and interviews with public health professionals in several states. The pandemic that first struck in major metropolises is now increasingly finding its front line in the country's rural areas; counties with acres of farmland, cramped meatpacking plants, out-of-the-way prisons and few hospital beds.
In these areas, where 60 million Americans live, populations are poorer, older and more prone to health problems such as diabetes and obesity than those of urban areas. They include immigrants and the undocumented - the "essential" workers who have kept the country's sprawling food industry running, but who rarely have the luxury of taking time off for illness.
Many of these communities are isolated and hard to reach. They were largely spared from the disease shutting down their states - until, suddenly, they weren't. Rural counties now have some of the highest rates of covid-19 cases and deaths in the country, topping even the hardest-hit New York City boroughs and signaling a new phase of the pandemic - one of halting, scattered outbreaks that could devastate still more of America's most vulnerable towns as states lift stay-at-home orders.
"It is coming, and it's going to be more of a checkerboard," said Tara Smith, a professor of epidemiology at Kent State University in Ohio. "It's not going to be a wave that spreads out uniformly over all of rural America; it's going to be hot spots that come and go. And I don't know how well they're going to be managed."
America's largest and most densely populated cities and suburbs still suffer more infections and deaths per capita, but those overall rates are increasing faster in smaller, rural counties where the virus has spread rapidly in the past month, the Post analysis found.
In many of those places, where the health-care system is already stretched thin, even a minor surge in patients is enough to overwhelm.
There are still more than 180 counties across 25 states that have yet to report a positive case, according to The Post's analysis. Nearly all of them are among the least populous places in the country. Experts say it's possible such locales have avoided the virus, but a lack of testing can also allow an outbreak to fester silently.
A University of Texas study found last month that in counties with no reported cases, there's about a 10 percent chance the virus is spreading undetected. Elsewhere, it may only be a matter of time.
Where and when hot spots arise in America's most isolated counties is, in part, a matter of chance. But crowded spaces, and populations with poor access to health care, quickly facilitate the spread.
Of the 25 rural counties with the highest per capita case rates, 20 have a meatpacking plant or prison where the virus took hold and spread with abandon, then leaped into the community when workers took it home.
Infection has raced through immigrant worker communities, where poverty or immigration status prevent some of the sick from seeking care and language barriers hinder access to information. It has taken hold in counties where residents flout social distancing guidelines or believe the pandemic to be exaggerated, the virus's lethality a myth spread by President Donald Trump's political foes and a liberal media.
"We've got a little bit of everything: folks who feel their rights have been taken away because they've been asked to stay home and they lost jobs and they're really hurting, and we have folks who are very concerned and frightened and won't leave their house," said Rebecca Burns, a health officer for the agency that covers Hillsdale County, Michigan, which last month topped the state for the highest death toll among rural counties, after a nursing home outbreak.
"We can't let our guard down. We have to continue to watch," Burns added, during a week when members of a conservative militia stood outside a Hillsdale County barbershop, brandishing guns to "protect" its reopening, in defiance of the governor's orders. "Anyone who thinks this is one and done is probably wrong," she said.
Close confines, chilled temperatures and sometimes spotty sanitation standards make meatpacking plants "the perfect storm as far as transmission events go," Smith said. A Centers for Disease Control and Prevention report this month found nearly 5,000 covid-19 cases in workers at 115 meat and poultry processing plants across 19 states.
That tally is likely an undercount, as testing varies widely among facilities and some companies and state officials have refused to release detailed data. The United Food and Commercial Workers Union, which represents those who handle about 75 percent of the beef and pork processed in the United States, says that at least 10,000 workers have so far contracted the virus - and at least 35 have died.
In Texas County, Oklahoma, patients pouring into the hospital with covid-19 symptoms are predominantly Hispanic and work in the local Seaboard Foods pork processing plant, which like many others has stayed open even after becoming the locus of an outbreak.
Some of the workers tell Jeffrey Lim, one of the county's few internal medicine physicians, that they have seen colleagues who appear ill continue to show up at the plant. State health officials tested everybody at the plant two weeks ago and found that of some 1,600 asymptomatic employees, 350 were positive, nearly four times as were known, Seaboard said in a statement. "As of May 20, 440 employees have active cases of covid-19," the company said.
But Lim also fears the outbreak is facilitated by people in the conservative farming community not following preventive measures.
"If you go to the local Walmart, I would say 10 percent of people are wearing masks, and the restaurants ... that are open are packed," Lim said.
"I'm a registered Republican, by the way," he added. "But (people) don't seem to know the science behind it. Even though they see the news, they just think it's all overblown."
In prisons, linked to six of the top 25 rural county outbreaks, the coronavirus pinballs through close living quarters, sickening inmates with alarming efficiency and infecting some guards, who act as a bridge to the world outside.
At the Cummins Unit, an Arkansas state prison farm, hundreds of cases among inmates and scores in staffers have made Lincoln County's infection rate the second highest among rural counties and third highest in the country. In Ohio, an explosive outbreak at the Marion Correctional Institute infected 80 percent of the prison population and more than 160 guards and staffers.
And across the country, more than 29,000 inmates have tested positive and 415 have died, according to data gathered by the Marshall Project, a nonprofit news outlet. Lawmakers have urged the release of low-level offenders, and Sen. Cory Booker, D-N.J., has said contracting covid-19 behind bars "is tantamount to a death sentence."
To epidemiologists and physicians, this checkerboard spread was all very predictable. It was never a question of whether the virus would hit rural America, but when.
Early on, two warning signals blared from opposite sides of the country.
In Blaine County, Idaho, population 2,200, an outbreak spurred by the annual influx of wealthy tourists seeking ski slopes turned the resort region into one of the first rural hot spots. The infection rate soared and was, at one point in late March, the highest in the nation.
That same month, more than 2,000 miles away, the virus began its siege on southwest Georgia. Most believe it was introduced at a well-attended Dougherty County funeral, an event that soon led to many more funerals. From Albany, the county seat and a regional hub, infections radiated to neighboring locales with ferocious intensity. Covid-19 has since preyed on the state's southwest, hitting hardest in counties that are majority black with high rates of poverty and a severe shortage of health care.
The area also ranks high on the CDC's social vulnerability index, which uses 15 social factors, including poverty, lack of vehicle access and crowded housing, to help local and federal authorities identify where people were "less likely to recover, and more likely to die" in the event of a disaster like a hurricane, a chemical spill or an epidemic.
There is little indication that the Trump administration or others have used the tool this way, even as its predictions about places like Dougherty County have come true.
When a group of cardiologists at Emory University compared rates of covid-19 with social vulnerability index rankings, the overlap was obvious.
"Essentially the results showed that as the social vulnerability index increased, the incidence of covid increased in those counties - in general, significantly so - and so did the case fatality rate," said Arshed Ali Quyyumi, the director of Emory's Clinical Cardiology Research Institute.
"We're swamped with patients now," said Lim in Oklahoma, where Texas County ranks high on the index. He said the local hospital's pleas for better testing have gone largely unheeded.
"A month ago we practically could not test anyone," he said. "Finally, a week ago, we started getting testing kits." The National Guard now comes each day to pick up the samples and drive them five hours to a lab at Oklahoma State University in Stillwater. It takes three to four days to get the results.
When Lim's colleague sought to purchase rapid tests from the lab company that developed them, a company representative responded that the tests were being reserved for designated "hot spots," which did not include Texas County.
"We are under strict allocation and the ID NOW product line is not available at this time," the representative of Abbott Testing Diagnostics wrote in an email reviewed by The Post. "We are working to prioritize delivery of COVID-19 tests to hotspots in the U.S. where the tests are needed most."
Morgan County, Colorado, also ranks high on the social vulnerability index. The county of 28,000 sits on the sprawling prairies in the state's northeastern corner. The coronavirus was slow to arrive, but once it did, the refrigerated trailer was not far behind.
The mobile morgues became a fixture in New York last month, signaling a dire situation: hospitals that were literally overflowing with dead bodies. As Morgan County's fatality rate shot up, higher than anywhere else in the state, a similar trailer pulled into town and parked behind the sheriff's office.
"I've been involved in the coroner's office and mortuary services for 50 years and I've never seen anything like this. Ever," said Don Heer, the county coroner and owner of a local funeral home.
A triumvirate of outbreaks has shaken the community, infecting more than 150 at two food processing plants and killing 20 at a nursing home. Before the virus, the county saw four or five deaths a week, but as the disease spread, "we were doing four, five deaths a day," Heer said.
The area's factories, including the meat and dairy plants that became hot spots, have attracted thousands of immigrant workers, lending the county seat, Fort Morgan, big city diversity. Some live together, sharing rooms in small houses, where the virus has spread easily, said Heer.
"It's been a challenge," he said, "because we don't have the equipment and resources like the cities do."
At the University of Nebraska Medical Center's covid-19 unit in early May, infectious disease specialist Angela Hewlett was seeing more patients every day, many of them transferred to her care from small, rural hospitals ill-equipped to handle such a crush of the newly sick.
In Nebraska, the worst outbreaks haven't been in Lincoln or Omaha, the state's capital and its largest city, but in the meatpacking counties. Outside those two cities, there are only two infectious diseases specialists in the state.
That's a common shortage. Health officials have estimated that urban areas have more than twice the number of physicians per capita as rural areas and more than 8.5 times the number of specialists.
And in many more regions, there are no hospitals for hundreds of miles, the result of closures amid crushing financial pressures. Since 2010, 130 rural hospitals have shut their doors, according to an ongoing study from the University of North Carolina.
"This makes it very simple for cases of coronavirus to really overpower the health-care system in those smaller communities," Hewlett said. "Smaller hospitals have significant barriers in normal times. This accentuates all of the things that were already going on."
It was a good year for boys' basketball in Decatur County, Indiana, where two local high schools rode winning seasons to the sectional tournament title game in early March. The blockbuster matchup in the county of 27,000 drew thousands, said Sean Durbin, Decatur's public health preparedness coordinator.
He and the other three full-time county health workers traced several infections back to that game. And from there, he said, there were 20, then 40, then 80. Now, Decatur is among the country's top 30 counties in deaths per capita.
It's exactly what Durbin feared, as he read news reports in January of the mysterious but highly contagious virus ravaging Asia and creeping stateside. He soon pulled out his dusty Ebola prep plan and rewrote it to fit this new emerging disease. The county was quick to act, implementing restrictions before the state's governor mandated them.
Yet the coronavirus was already there.
"We had our first positive case, and shortly after, things started spiking," Durbin said. "It just kept going up and up and up. It skyrocketed."
The virus spread into nursing homes, killing several residents there and elsewhere who had conditions such as diabetes and heart disease that run high in the region. Durbin knew most of his county's 31 victims; one was a close friend.
"Being a small community, what is that line in 'For Whom the Bell Tolls'? 'Every man's death diminishes me,'" Durbin said, quoting the John Donne poem. "If I didn't know every death, if I didn't know them personally - and I knew many of them personally - you always know someone who knows them in a community this size."
The health official said the county did a good job preparing for and battling the virus, especially with little federal help early on.
"We didn't have supplies, I had the most paltry shipments," Durbin said, referring to the Strategic National Stockpile.
The county received fewer than 50 gowns, about 100 N95 masks and one box of gloves, which was already open when it arrived. He had to use an expired box of N95s, stored in the health department's building since the 2008 H1N1 response.
Durbin is nervous about Indiana's reopening, but for now, new infections and deaths have slowed. The outbreak seems under control. Still, he wonders, asking questions that may come to haunt officials across the country in the coming weeks.
"I feel like we put together a really good plan, but still, when you see all that you just wonder, 'What else could I have done?'" Durbin said.
"I go to bed every single night and I think, 'What could I have done differently today to ease some suffering?'"