Small towns and rural hospitals brace for their coronavirus peak, which could be weeks away

It took less than three weeks for Hall County to become Nebraska’s biggest hot spot of Covid-19 cases. 

The county, which has roughly 61,000 residents, reported its first case of coronavirus in late March, just as the outbreak was surging along the nation’s coasts.   

The area now has more than 1,000 cases of Covid-19 as of Friday, the most of any county in Nebraska. The state’s most-populated county where Omaha is located has nine times the number of people of Hall County but nearly half the amount of cases, according to the Nebraska Department of Health and Human Services.

“The epicenter of this outbreak really has shifted into the smaller rural areas, small counties in western Nebraska,” Dr. Angela Hewlett, a member of the Infectious Diseases Society of America and professor at the University of Nebraska Medical Center, said.

While hospitalizations related to Covid-19 have started to decelerate in some cities, suggesting the worst may be over, it could take the virus weeks to peak in more rural communities across the U.S., health officials warn. Some hospitals haven’t had enough medical personnel for decades, are already operating at full capacity or are filling up quickly and don’t have enough ventilators to handle a surge of critically ill patients, they say.

Many people in rural communities, however, have also been deemed essential workers and continue to travel to work even as more cases are confirmed, ensuring the nation’s food supply remains stable. However, that supply could soon be running short as the coronavirus runs its course through the nation’s meatpacking facilities. 

“We have not reached our peak in any way here,” Hewlett said. “Although the vast majority of our state is very, very rural, we have not dodged this in any way, and I think more rural hot spots will surface over the coming days and weeks here and all over the United States.” 

The coronavirus can still spread rapidly through rural America, even though they’re not as densely populated as cities where the virus has proliferated, health officials and physicians say. Small towns are often tight knit with strong social ties. Some community events could attract an entire town, providing ample opportunities for the virus to spread.

As of Tuesday, nearly 84% of non-metropolitan counties reported a positive case of Covid-19, according to data from the University of Iowa. 

“Faith-based or community organizations, school activities, everybody goes to the same high school football game. Everybody kind of knows each other and stays in close contact, so it can potentially spread very, very rapidly,” said Maggie Elehwany, vice president of government affairs for the National Rural Health Association.

The virus also has the potential to be more deadly in many rural communities where a larger portion of the population are older and have underlying health conditions like obesity and diabetes that could put them at risk of serious illness or death.

Dr. Andrew Pavia, pediatric infectious diseases chief at the University of Utah Health, said these health disparities between rural and urban communities could cause a longer, more sustained outbreak in less-densely populated areas rather than a sudden peak, or the increase in the daily rate of new infections as seen in big cities.  

“That means that we’re going to be fighting this for weeks and months to come,” Pavia said. “It’s also going to make reopening much more challenging in these areas.”

Many rural communities have small critical access hospitals, which maintain 25 or fewer beds, but many of these facilities may have little or no intensive-care beds or ventilators. The National Rural Health Association estimates that nearly 63% of the nation’s rural hospitals don’t have any ICU beds. 

In many cases, they also lack critical care physicians who can care for patients on ventilators for extended periods of times, health advocates say. Coronavirus patients in critical care often need to be intubated for a week or longer and require extensive ICU care, which can be unsustainable for rural hospitals that lack around-the-clock personnel.

“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. ”They’ve done a heroic job of gearing up and caring for patients on ventilators in many of these small hospitals, but the staff were just pretty quickly overwhelmed.”

Before the pandemic took hold in the U.S., rural America was in the midst of its own health-care crisis, Elehwany said.

Since 2010, nearly 130 rural hospitals have ceased operations and an additional 453 hospitals are vulnerable to closing, according to projections by the Chartis Center for Rural Health. 

“When a hospital closes in rural America, it almost always closes for good,” Elehwany said. “When the hospitals close the doctors leave, the nurses leave, the pharmacists leave. We see these health care deserts erupt, which obviously is a terrible situation in rural areas going into this pandemic.”

Outpatient services, medical procedures or tests that can be conducted without an overnight stay, generate a large portion of revenue for rural hospitals. However, state officials canceled these procedures to contain the virus, which has resulted in these facilities losing 50% to 80% of their incomes over the last month, Elehwany said. 

An additional $10 billion of funding from the CARES Act will be allocated for rural health clinics and hospitals, most of which operate on especially thin margins and are far less likely to be profitable than their urban counterparts, the Department of Health and Human Services said last week. 

The CARES Act, signed by President Donald Trump in late March, allotted $100 billion for hospitals but none of that was specifically earmarked for smaller practices. Trump signed another relief bill on April 24 that allots an additional $75 billion for hospitals.   

Many rural communities have industrial-based economies where a majority of the residents work at a local factory or manufacturing where working from home isn’t an option, health officials say.

That’s made social distancing a challenge, especially in essential industries like food processing or mining. Meatpacking facilities have become hot spots for coronavirus outbreaks across the U.S. where people work in very close contact on processing lines, causing further spread.

At least 22 meatpacking plants have closed as hundreds of workers test positive for Covid-19, the United Food and Commercial Workers International Union said Friday. At least 22 meatpacking and food-processing workers have died after contracting Covid-19, according to union estimates. 

A Smithfield Foods pork processing plant in Sioux Falls, South Dakota, which processes approximately 5% of the nation’s pork, closed indefinitely on April 12 with more than 200 confirmed cases of Covid-19 connected to the facility. Approximately 245 employees at a JBS plant in Greeley, Colorado, which temporarily closed in mid-Apirl, have tested positive for Covid-19 as of Friday, according to the Colorado Department of Public Health and Environment. In Hall County, Nebraska, more than 230 employees at a JBS plant in Grand Island tested positive in late April, Central District Health Department Director Teresa Anderson said.

“If there’s one thing that might keep me up at night, it’s the meat processing plants and manufacturing plants,” Dr. Gary Anthone, Nebraska’s chief medical officer, said in a Facebook live event. 

State governors have scrambled to keep their meatpacking facilities open, warning that any plant closures could threaten the nation’s food supply.

After consumers began stockpiling food at the beginning of the U.S. outbreak, leaving many shelves picked over, beef producers shipped meat originally destined for restaurants to grocery stores instead, National Cattlemen’s Beef Association CEO Colin Woodall said.

But the meat supply will eventually thin out if the outbreak continues, Woodall said.

“There’s a big supply of cattle out there, it’s just a matter of being able to find enough capacity and time to process it into that beef and get it to the grocery store,” Woodall said.  

On Tuesday, President Donald Trump invoked the Defense Production Act to keep meatpacking facilities operating, classifying the facilities as critical infrastructure. The order is also expected to provide liability protections for employers if workers get sick, NBC News reported, citing a senior administration official.

On Monday, Tyson warned that grocery stores will get a limited supply of its products will until its processing plants reopen. It predicted that millions of pounds of meat could disappear from the food supply as the company temporarily shutters beef, pork and chicken plants. 

“The food supply chain is breaking,” Tyson Chairman John Tyson wrote.