Almost every year, I make a pilgrimage to a little town on Lake Huron in northeast Michigan, where my family has vacationed since my mother was a child. Not far from the quaint, two-block downtown, with its ice cream parlors and tourist clothing shops, sits an old lighthouse marked with a terribly sad plaque. The plaque tells the story of Blanche Deckett, the daughter of a lighthouse keeper, who died a century ago during the influenza pandemic. Deckett had come from out of town to visit her father with her three young children, two of whom suddenly fell ill. The youngest, only two years old, remained well and fetched water for his sick family members. But Deckett eventually succumbed to pneumonia, and her body was carried from the lighthouse across the frozen bay and into town for burial. 

Deckett didn’t die during the first or second wave of influenza in 1918, or even during the third wave in early 1919. She died in early 1920, when the pandemic finally arrived in the tiny town in northeast Michigan, sparking a rush of illnesses and school closings. The virus took its time percolating through the United States, as it did through many parts of world. And for years after influenza was mostly eliminated in major cities, smaller outbreaks continued to occur, mainly in rural areas that had been spared the initial deadly waves.

In May, I warned in Foreign Affairs that the coronavirus pandemic in rural America would lag behind the pandemic in urban areas and that it would be “slower, steadier, and likely to continue for a longer period of time.” That is what has happened so far. After initial outbreaks in the spring that were mostly clustered around specific industry-related hot spots—including meatpacking plants, nursing homes, and jails—many rural areas are now experiencing widespread community transmission. The virus took longer to reach these areas, but now it is making up for lost time. Although cases are rising across the country, the highest per capita infection rates tend to be in rural areas and small towns. In Ohio, for instance, nine of the 12 counties with the highest per capita incidence of COVID-19 have populations of less than 50,000.

The virus took longer to reach rural areas, but now it is making up for lost time.

Geography alone does not explain this discrepancy. Rural areas are less likely to have mandated that residents wear masks, and even in those areas that have mask mandates, residents are less likely to comply. Take the tragic case of South Dakota, where cases began to rise after an August motorcycle rally in Sturgis. Governor Kristi Noem steadfastly refused to require masks in businesses or other public places, even as COVID-19 transmission spiraled out of control. North Dakota also resisted restrictions to curb the spread of the virus, although Governor Doug Burgum finally mandated masks and restricted bar and restaurant capacity last week. The per capita death rate in the Dakotas is now among the highest in the world, and hospitals in both states are rapidly filling up. In North Dakota, nurses are in such short supply that the state has allowed those who have tested positive but are asymptomatic to continue working—a controversial, untested policy that could accelerate the spread of the virus.  

The situation in rural areas is likely to get worse before it gets better. Hospitals in these regions (if there are hospitals at all) are smaller and have fewer resources than metropolitan facilities. As a result, a flood of COVID-19 patients can easily overwhelm them. And with rising infection rates straining the health-care system across the country, rural hospitals may not be able to transfer critically ill patients to larger, more urban ones.

The United States is averaging an incredible 170,000 new cases per day, with no slowdown in sight. Assuming a lag between case diagnosis and hospitalization of about two weeks, roughly 1.5 million newly infected people have yet to reach the stage of illness where they might require medical attention at already overburdened hospitals. And the holidays are certain to bring more sickness and death. One recent survey showed that almost 40 percent of Americans plan to attend a family Thanksgiving event with ten or more guests. According to the Institute for Health Metrics and Evaluation, 110,000 more people could succumb to the disease between now and President-elect Joe Biden’s inauguration on January 20, 2021.

Biden has promised to implement more aggressive policies to curb transmission until a vaccine can be distributed. But how rural Americans will respond to these measures remains to be seen. Many Republican governors have already rejected the nationwide mask mandate that Dr. Anthony Fauci has suggested and that Biden appears to support. Vaccines produced by Moderna and Pfizer could receive emergency authorization as early as the end of this year. But the Pfizer vaccine must be kept at ultracold temperatures to stay viable, meaning that it will be hard to administer far from cities. “Early, when we don’t have lots of doses, I frankly do not anticipate that vaccine will be widely available in every rural community,” Dr. Amanda Cohn, chief medical officer for the Centers for Disease Control’s Vaccine Task Force, said on a November 3 phone call with rural officials and health-care providers. 

Vaccine distribution also presupposes that people are willing to be vaccinated. But potential COVID-19 vaccines have been highly politicized. Just as President Donald Trump’s promise to roll out a vaccine prior to the election sowed distrust among Democrats, the Biden administration’s likely effort to distribute one early next year could meet with skepticism among Republicans, especially in rural areas where Trump supporters will have heard over and over that Biden and the Democrats “stole” the election. Black Americans in both rural and urban environments may also be suspicious of any new vaccine after years of mistreatment by the medical establishment, even though they are at high risk for severe COVID-19 infections.

For all these reasons, COVID-19 may continue to circulate in rural areas into 2021 and beyond, even as cities get the virus under control through a combination of vaccination and nonpharmaceutical interventions such as mask use, targeted business closures, and test-and-trace efforts done in conjunction with isolation and quarantine. COVID-19 was slower to reach small towns and rural regions of the United States, and it is likely to linger longer in these communities, just as influenza did more than a century ago.

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