COVID-19 has been smoldering in rural America for months. Here’s why we missed it.

The houses in Chevak spring from an open sweep of tundra and lakes. The small community in western Alaska, near the mouth of the Yukon River, is accessible only by plane. Yet in the last several weeks, almost a quarter of its roughly 1,000 residents have tested positive for coronavirus.

For months, health officials had hoped Alaska’s rural villages would be protected by their isolation. But the state now ranks among the worst 15 in the country in per capita case rate. So many Alaskans are sick that officials are falling behind with logging data, so the state may only be accounting for half the true cases, according to Alaska Public Media.

Similar patterns are playing out across rural America. In the Midwest and the West, record numbers of COVID-19 infections are straining hospital capacity. Due to a dangerous combination of limited medical resources, stigma, and politicized opinions around public health strategies such as masking, the virus has been difficult to track in these areas, allowing its spread to go unnoticed all summer. Now, as temperatures drop and people congregate inside, the country is witnessing these widely seeded cases spark like Alaska’s wildfires—explosively hot and out of control.

“The virus was introduced first to cities,” says Stefan Baral, an associate professor of epidemiology at Johns Hopkins University. “But it was just a matter of time before we saw it in more rural settings.”

Many remote communities rely on traveling medical workers for health care. That makes responding to coronavirus cases much more difficult in places like Alaska. Dan Winkelman, the president and CEO of the Yukon-Kuskokwim Health Corporation, which provides care to Chevak and the 49 other villages in the region, says initial outbreaks this spring and summer were sparked by travel from urban areas with community spread, including people returning from medical visits in Anchorage. This fall’s much larger outbreak has stemmed primarily from gatherings among family, friends, and co-workers.

Because residents didn’t think the virus was present, not everyone practiced precautions like social distancing. “Some people don’t take it seriously until they know someone who is sick—and by that time, it’s usually too late,” Winkelman says. All of Alaska is now considered high-risk, prompting Governor Mike Dunleavy to send an emergency alert to all cell phones on November 12, though his message did not include a mask mandate or stay-at-home orders. Other rural states are struggling too.

“Big numbers often make headlines, but I’m worried about places with fewer resources to manage smaller numbers,” says Jennifer Nuzzo, the lead epidemiologist for Johns Hopkins University Testing Insights Initiative. Wyoming, for example, has a test positivity rate of 92 percent, meaning nine of 10 COVID-19 tests are coming back positive. South Dakota is at 56 percent, and Idaho at 43 percent—the World Health Organization recommends this rate stay below 5 percent. These statistics serve as a “measure of our response,” Nuzzo says, suggesting the alarming numbers are an indictment of how out of control the pandemic has become.

Overcoming testing gaps and the fear of being positive

As polar night descends, Winkelman is fighting for supplies for the Yukon-Kuskokwim region, only to be told that the most precise equipment for large-scale testing is on backorder or reagents are out of stock. Because local and state labs can’t keep up, it’s taking an average of five to eight days in the region to get test results back—far too long to effectively conduct contact tracing. “People are upset they can’t get results sooner, but there’s no national plan to improve testing,” Winkelman says.

Even when tests are more readily available, stigma can keep people from seeking them. One of the first American travelers with COVID-19 reported being ostracized, and this health-based discrimination has been seen against high-risk groups, first responders, and health-care workers. Health officials both in the U.S. and abroad warn of how stigma can hamper efforts to control the virus.

Kathryn Christensen, a family nurse practitioner at the Hendricks Community Hospital Association in Hendricks, Minnesota, says in her town of 700, “someone might see a car in the clinic parking lot, and then chatter downtown about seeing so-and-so, wonder if they have COVID.” At the same time, Christensen says the situation has lost its shock value, even though more and more cases are occurring. While currently one in 21 people in her county have the coronavirus, she says, “people are not taking it as seriously any more.”

That’s why Baral argues COVID-19 testing needs to be just the first step in a broader series of public health interventions. Pointing to successful practices with sexually transmitted infections like HIV/AIDS, he says: “You’d never just test someone and then say, Best of luck—we provide treatment, risk reduction services, and counseling.” A better policy would consider all of a sick person’s needs, like whether they have the space to safely isolate or the financial resources to stay home.

In Chevak, for example, many people live in multi-generational households or don’t have running water, making it harder to take steps like social distancing around high-risk groups, and to encourage frequent hand-washing. “Reducing risk is related to meeting basic needs,” Baral says.

But these communities can also be more resilient because of their tight-knit connections, strengths that have long helped people survive. When taken into context, this trait can aid prevention measures. Mark Peterson, the medical director of the Norton Sound Health Corporation, recognized this early in the pandemic while providing care to 15 villages near the Bering Sea.

“Our region, like a lot of Alaska, was decimated by the 1918 Spanish flu,” he says. “We still have elders who heard stories from their parents, and it added to the general fear when COVID started.”

With that history in mind, Peterson initiated early and aggressive testing and travel mandates, and so far his agency has run 37,000 tests for 10,000 people.

He’s also been creative about getting people the support they need to stay healthy. When families test positive, they are provided with free groceries for the duration of their isolation or quarantine, delivered to their door. The Norton Sound Health Corporation has leased housing units in villages, where patients can be isolated if they don’t have space at home. They have also hired village security staff who receive federal health privacy and infection-control training so that they can help with grocery delivery and contact tracing.

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Federal funding for tribal health during the pandemic has supported the groceries and housing units, but Peterson added their organization’s financial situation was fortunately solid before COVID-19 hit: “if a place was just getting by, even the federal funding wouldn't help them catch up.” In addition, many rural health organizations have received CARES Act funding, but it is due to expire by the end of the year unless Congress extends it. “It’s a lot of work,” Peterson says, “but it’s gotten us through the larger outbreaks.”

Running out of beds and staff

Creative measures like these are even more important as surging cases threaten health-care capacity. Last week, the 18 beds in Anchorage’s Alaska Native Medical Center were full. Even if the medical center boosts capacity by building an emergency field hospital, there won’t be enough medical professionals to staff it. The state now has only 34 open ICU beds, and more than 500 medical workers are unavailable because of COVID-19 infections or exposures.

COVID-19 hospitalizations start weeks after cases begin to rise, which means by the time a medical center notices that its resources are stretching thin, it might already be too late. And hospital capacity doesn’t just mean bed space—it also refers to the resources and trained staff needed to appropriately care for patients. While the worst of Alaska’s hospitalizations will likely arrive around late November, other states with earlier surges are offering a preview of this rural devastation.

“Local and regional governments are taking steps, but we need to do it together as a state, or we’ll be overwhelmed,” says Robert Onders, a medical director at Alaska Native Tribal Health Consortium, which co-manages the medical center. “We can’t test our way out of it. We can’t build capacity if we don’t get community spread under control.”

Before the pandemic, many rural hospitals relied on traveling medical staff when they couldn’t find enough people to hire locally. Wissam Rhayem, an emergency physician with Innova Emergency Medical Associates, splits his time between six hospitals, primarily in Arizona, New Mexico, Colorado, Michigan, and Indiana.

“My biggest fear is: How am I going to take care of really sick patients with nowhere to send them?” he says, recounting that this already has happened twice in the last 24 hours. It can take hours to transfer a patient from the small hospitals where he works to larger facilities with more resources for the severely ill. Now, even those are filling up.

Rhayem describes a recent episode with a 21-year-old who was on a cross-country family road trip when he got sick with COVID-19. “This kid ...” he trails off. “His heart stopped. We had gotten it pumping again, but he was paralyzed and intubated. I don’t think his Dad thought it was a real thing. I had to tell him that your son is probably not going to make it.”

Caring for this patient until he could be transferred occupied all of the hospital’s minimal resources, the way a highway backs up after an accident. Now that the patient has moved, Rhayem is left wondering about the outcome.

For another non-COVID patient, Rhayem and his colleagues recently called more than 30 hospitals before finding a willing recipient—600 miles and two states away. “At one point I was on the phone with UCLA, while my colleague was talking to someone in San Antonio, when a hospital in Las Vegas gave us a bed,” he says.

No backup

As demands increase, the limited pool of rural medical workers is dwindling. Some doctors and nurses Rhayem works with have quit during the pandemic. “I don’t blame them. They don't have the appropriate resources—it’s too scary to put themselves and their kids and spouses at risk,” he says. “We’re all exhausted.”

Rural facilities have little flexibility to manage personnel. In Hendricks, Minnesota, four people regularly staff the joint hospital, emergency department, nursing home, clinic, and home health care facility, which serves a 40-mile radius. If one of the medical staff is out, there’s no backup—they can’t even find traveling nurses to hire. Just this week, a nurse called in sick with COVID-like symptoms, and her shift had to be parceled among the remaining staff to keep the hospital covered.

“Rural physicians know every facet about their patients’ lives,” adds Londyn Robinson, a medical student at University of Minnesota who grew near Hendricks. “So when you see these same individuals not wearing masks, and then watch them get COVID and die ... it’s basically a moral injury.”

In North Dakota, Governor Doug Burgum just announced that the state is so short of staff, it will allow health-care workers to keep working even if they have COVID-19. And in Alaska, some of the villages in the Yukon-Kuskokwim region have decided to lock down, now that most have cases of the virus. As winter storms complicate air travel and hospitalizations from current cases surge, Winkelman is worried because Congress has not extended the CARES Act, making it harder to plan responses.

“If you want equitable outcomes, you have to disproportionately invest in at-risk areas,” says Onders from the Alaska Native Tribal Health Consortium. He points to data for the 2009 H1N1 strain of influenza, which found that Alaska Natives were four times more likely to die of the disease than other U.S. residents, and were more likely to have comorbidities. That’s not because of their ethnicity, Onders says, but because of lack of access to health care.

Until a more uniform approach emerges, people like Winkelman describe a hopeless sense of waiting. “It’s horrible,” he says, describing it like watching a tidal wave. “You’re watching it coming. And you just feel like there’s nothing you can do.”