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Since late last year, COVID-19 has been overwhelming health care facilities in urban areas around the world, causing more than 12,200 in New York City alone.

As has become increasingly clear, however, rural areas are not immune.

During the past month, hundreds of pork plant workers in Sioux Falls, South Dakota, have tested positive for COVID-19 – one of many outbreaks in meat processing facilities throughout the country. And the Navajo Nation reservation, which includes parts of Arizona, Utah and New Mexico, has more than 1,600 cases.

While distance and low density offer some protection against the spread of infectious diseases, rural areas also have their own unique vulnerabilities.

"We see higher rates of hypertension, heart disease, obesity and less physical activity in rural areas," said Dr. Regina Benjamin, the 18th U.S. surgeon general under President Barack Obama. She founded a health clinic in rural Alabama and continues to work there today.

"All of those things contribute to overall health in rural communities," she said, and serious underlying health conditions may increase the risk of severe illness from COVID-19.

According to the Centers for Disease Control and Prevention, rates for heart disease, cancer, unintentional injury, chronic lower respiratory disease and stroke – the five leading causes of death in the United States – are higher in rural areas than in urban ones.

Benjamin said low education levels, financial health and access to clean water and healthy food account for much of the rural-urban disparity.

"We've learned that your ZIP code is a better predictor of your health outcomes and longevity than your genetic code," said Benjamin, who also is the founder and CEO of the Gulf States Health Policy Center, an Alabama-based research institute.

In addition, sparsely populated regions often don't have the same resources that many urban ones do. Generally, availability of hospital care is less in rural areas. In fact, 128 rural hospitals have closed since 2010, nine of them in 2020.

This is compounded by a shortage of doctors. There are only about 55 primary care physicians per 100,000 residents in rural areas compared to more than 79 per 100,000 in urban areas. And urban areas have nearly nine times as many specialists as rural areas.

Dr. Michael D. Eisenhauer, a cardiologist in Great Falls, Montana, is affiliated with a hospital system that serves 11 rural communities with only critical access hospitals, which by law have 25 or fewer beds, and many of them only have one ventilator. Some are staffed with nurse practitioners rather than doctors.

"If they get one COVID patient with compromised respiration, that can cripple their facility," Eisenhauer said, noting that some are physically attached to nursing homes.

Many hospitals have temporarily halted elective procedures, Eisenhauer said, resulting in a significant loss of revenue and further strains on resources. Paradoxically, this has led to layoffs in some regions at a time when medical staffs may already be strained.

Even those who may require acute medical care are staying away, Eisenhauer said, citing a 40% to 50% reduction in the number of heart attack patients in his hospital.

"By definition, a hospital is a coronavirus hot spot," he said. "The problem is that if you ignore chest pain, three days later you might have a big heart attack."

Moreover, "what happens in a small town with two nurse practitioners if both of them get sick?" Eisenhauer asked.

An published earlier this year in its journal Circulation called for more sustainable funding models to help rural hospitals and clinics. Benjamin was a co-author of that advisory. It recommended employing telehealth and digital technology to address provider shortages.

While less density makes social distancing easier in some rural areas, it also can cause problems. For example, some of Eisenhauer's patients live more than 100 miles away.

"Patients are being driven 130 miles down the highway to the next larger referral hospital," he said. "In a metropolitan area, you might be a four-minute ambulance ride away from four different hospitals."

Rural areas are struggling with shortages of personal protective equipment and testing supplies, said Donna Arnett, dean of the University of Kentucky College of Public Health and a past AHA president.

"We ran into shortfalls very early in this pandemic," Arnett said. She said many hospitals do not have enough of the long swabs used for coronavirus testing.

Increased testing, she said, will allow public health officials to identify cases, isolate them and trace their contacts to ensure they are not infected.

"If we could do that real boots-on-the-ground public health work, we could arrest cases quickly and flatten the curve in these small rural areas," she said.

In the meantime, Arnett recommends people in rural areas continue to practice social distancing, use proper hand-washing techniques and develop a plan if they become infected, answering questions such as: Who is going to provide food? Where is the nearest hospital? Who can I call for help?

"One of the great things about rural communities is that people tend to know their neighbors, and they do rely on each other," she said. "That may be an advantage."

Editor's note: Because of the rapidly evolving events surrounding the coronavirus, the facts and advice presented in this story may have changed since publication. Visit Heart.org for the latest coverage, and check with the Centers for Disease Control and Prevention and local health officials for the most recent guidance.

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