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The language we’ve heard to describe Covid-19 in rural America is evolving. Early in the pandemic, healthcare professionals were concerned. Later, some were alarmed. Now, what I hear sounds a lot like shock.

In a story we published earlier today, Alan Morgan with the National Rural Health Association called the rural pandemic a horror story.

Carrie Henning-Smith with the University of Minnesota Rural Health Research Center has another word: ominous.

That’s not the kind of comforting word we like to hear from our caregivers. But a cheerful bedside manner doesn’t seem to be doing the job with rural America.

“I think that there was a chance early on to try to contain this, when we had this as a mostly urban phenomenon back in March and April,” said Henning-Smith, who is also an associate professor in the School of Public Health at the University of Minnesota.

“We blew way past that. And now this has spread into virtually every county in the country, in metro and non-metro alike.”

Welcome to the rural wave – the phase of the pandemic that is swamping rural America with record numbers of Covid-19 infections.

Late this spring, we still had swaths of rural America – mostly in the Midwest and Great Plains – that went weeks without a single case. On June 1, nearly 9% of rural counties hadn’t reported any infections.

Today, only one county in the Lower 48 hasn’t reported a case of Covid-19.

For the rest of rural America, most of the news is bad. The rate of new infections in rural counties is 65% higher than in urban counties. The number of new cases in rural America has set a record each of the last five weeks. Seventy percent of rural counties are at risk of uncontrolled spread, what the White House Coronavirus Task Force calls the red zone.

Something different is happening in rural America in this surge. The coastal and urban regions that bore the brunt of the summer surge look relatively contained now. The trouble spots, as shown in the map above, are in the interior.

Why is Covid-19 surging now in these areas that got off relatively easy this summer? Henning-Smith, who holds three master’s level degrees and a PhD, cited several possibilities. The first may be “Covid fatigue.”

“It took longer to get to rural areas and it’s hard to keep the public relentlessly engaged and being mindful and cautious as the pandemic wears on,” she said.

Another factor is politics, she said. “There are definitely some strong relationships where we’re seeing very, very mixed messaging at the highest levels of the federal government about even the most basic precautions for Covid.”

And some of it is just the nature of the coronavirus. All things equal, the virus spreads from one host to the next. Think of spreading peanut butter on toast. You won’t get it to a uniform thickness, but each swipe of the knife gets you closer.

“[The graphs] give every indication that rural areas will catch up to urban, and we’ll see proportional rates of Covid cases and Covid deaths in rural, relative to urban,” Henning-Smith said.

Rural areas could even get worse than urban ones eventually, she said. A host of factors make that a possibility. Rural employment may not be as suited for remote work. Services like online grocery ordering and delivery are less available in rural areas. Lack of broadband may mean rural people have to do more activities in person. Contact tracing may not be as robust. Testing can be more challenging in less densely populated areas.

Henning-Smith, whose research focuses on health equity, also said race is a factor in how Covid-19 is spreading and what happens when it reaches a community.

“I don’t think we’re talking enough about the intersection of [race and rurality], of the impact of structural racism among rural residents,” she said.

Most people have a choice about whether to wear a mask. Fewer of us have a choice about other factors that contribute to the spread of Covid-19.

“Who has the luxury of containing themselves to their household so they don’t get it?” she said. “Who lives in a house that’s not crowded, so they’re not spreading it to their family members? Who has access to healthcare, decent health insurance? Who still has a hospital or a clinic in town to get the care that they need, if they need it?”

Tim Murphy contributed data analysis to this article.