A Hard Winter Looms for Rural America


In late October, Kelly Chandler sat 10 feet from me, masked, at a conference-room table in Grand Rapids, Minnesota. For the past nine months she’d had the unenviable task of preparing the surrounding county for Covid-19. Three hours from the Twin Cities, the area had largely avoided the early surge of the virus. But last month, the case numbers started ticking upward alarmingly. “I feel like we’re going to teeter until the end of this year,” she told me.

On Nov. 9, Itasca County, population 45,000, announced that it had recorded an additional 205 Covid diagnoses over the previous seven days — a 22% increase — bringing its total to 1,109. In response, county officials suspended contact tracing and redeployed their limited resources to protect the most vulnerable populations. Chandler, the manager of Itasca County’s public-health division, issued a stark warning to residents: “If you are in a group setting, just assume that someone has Covid.”

Similar scenes have been playing out in rural areas across the country. Three of every four rural counties in the U.S. are in what the White House Coronavirus Task Force defines as a “red zone,” where the virus is spreading out of control, while the 10 counties with the highest number of cases per resident are all nonmetropolitan areas with fewer than 50,000 people.

To some extent, resistance to wearing masks and social-distancing has played a role in these outbreaks. But the explosion of Covid in rural communities isn’t a simple morality tale. In most of these areas, the virus has intensified vulnerabilities decades in the making, and worsened chronic problems that can’t be solved with public-awareness campaigns.

As Chandler put it: “My observation thus far is that any vulnerability we had prior to Covid — it’s just exacerbated.”


In Minnesota, the 21 most unhealthy counties are all rural. In Itasca, rates of adult smoking, obesity, physical inactivity, excessive drinking and alcohol-impaired driving deaths exceed both state and national averages. Similar patterns have emerged from coast to coast. Mortality rates for the five leading causes of death — heart disease, cancer, stroke, unintentional injury and chronic lower respiratory disease — are all higher in rural areas. So, too, are common indicators of mental illness, including suicide rates and drug overdoses.

There’s no one cause behind these bleak statistics, but several factors are clearly contributing. For one, people in rural America tend to be older and poorer than average, making it less likely that they’ll have access to decent health care in the first place. Poverty layered across sparsely populated areas contributes to social isolation, drug abuse and mental illness.

These problems are only compounded by the glaring inequities of the U.S. health-care system. Rural hospitals have struggled for years to stay afloat as they treat aging populations whose only payment option is often government insurance with low reimbursement rates, making them unattractive to providers. Federal and state programs intended to prop up these facilities have had only limited success: Since 2005, 175 rural hospitals have closed, with 19 shutting down last year alone.

Those closures can be devastating for isolated communities. They’ve been shown to significantly increase mortality for people who have conditions that require immediate help, and they contribute to an acute shortage of intensive-care unit beds. And even when a bed is available, a doctor may not be: Rural areas on average have only about 40 physicians for every 100,000 people, compared to about 53 in cities.

In short, rural America is a very bad place for a pandemic to spread.


Initially, at least, Itasca County thought it was prepared for the coronavirus. The Grand Itasca Clinic and Hospital, in Grand Rapids, made a series of facilities upgrades before the county’s first case even came through its doors. It improved air circulation and divided its lobby to separate Covid patients from the uninfected. For coronavirus patients with more critical needs, the plan was to send them to facilities in nearby Duluth with more capacity and expertise.

The national surge of cases over the past two months has put that plan at risk. In neighboring North Dakota, hospitals are running at full capacity and staffing is stretched so thin that the governor is calling back Covid-19-positive nurses. So far, the situation isn’t as critical in Minnesota, but things aren’t trending in the right direction.

One complication is that while rural Minnesota’s lingering, chronic health problems didn’t go away during Covid, many people delayed seeking treatment for fear of getting infected. Now they’re turning up at exactly the wrong moment. Dr. Jon Pryor, who oversees health-care facilities for Essentia Health, a network of hospitals and clinics, told me that his company’s Duluth facilities had been filled up in recent weeks — but mostly by patients with problems like hypertension and diabetes, not Covid.

“It’s been about three or four weeks that the Duluth facilities have started to fill up,” Jean MacDonell, the president and chief executive officer of Grand Itasca, told me. “If we can’t transfer to Duluth, we need to keep the patients here. Or, if the patients are that critical, we need to send them down to the Minneapolis-St. Paul area.”

The problem is that if ICU beds in the Twin Cities aren’t an option — and they’re almost full — then Grand Itasca will have to implement surge plans that call for using any available space for patients, including corridors.


The middle of a pandemic isn’t the best moment to address the underlying problems plaguing rural health care. But even so, some lessons have been learned during the crisis that could mitigate what’s likely to be a bleak winter of infection ahead — and perhaps offer a blueprint for systemic changes down the road.

Pryor told me that the outbreak has forced the region’s health systems — many of which are competitors — to collaborate in ways that were unlikely back in January. Early in the crisis, they held daily information-sharing calls, which allowed disparate systems to work more closely on managing patients and the pandemic’s broader effects across a large region. Chandler said a similar spirit of collaboration had guided efforts in Itasca County.

Infrastructure, though, remains the crucial problem. Like much of rural America, Minnesota faces a shortage of ICU beds, for instance. The time to build them isn’t during a crisis, but rather before the next one. Essentia Health is lobbying Congress to create a $1 billion fund to upgrade under-construction hospital rooms into ICU-ready units. In normal times, those rooms would operate as regular medical beds, but during a crisis the hospital could simply “flip the switch,” Pryor said. 

Staffers, too, are in short supply. For decades, federal and state programs have been trying to attract health-care workers to rural regions. At best, they’ve staved off greater shortages and highlighted the need to rely on distant hospitals. One bright spot during the pandemic, though, has been increased use of telemedicine. Expanding access to such technology should be a priority for policy makers. As a start, they should invest more in rural broadband and build on efforts to help turn public libraries and other government facilities into telemedicine hubs.

Ultimately, though, rural health care can’t be improved without addressing the chronic poverty and social isolation that drive so many problems to begin with. Changing those facts will, among other things, require increased economic development and investment to attract employers and health-care providers.

In the meantime, rural Americans will need to mask up and socially distance. It’s an unsatisfying answer. But until vaccines are widely available, it may be the best these struggling areas can hope for. “Are we doing okay now? We are,” said Pryor. “But this is going to be a long, hard winter. Will be doing okay tomorrow? I don’t know.”

This column does not necessarily reflect the opinion of the editorial board or Bloomberg LP and its owners.

Adam Minter is a Bloomberg Opinion columnist. He is the author of “Junkyard Planet: Travels in the Billion-Dollar Trash Trade” and "Secondhand: Travels in the New Global Garage Sale."

©2020 Bloomberg L.P.

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