Why The Worst Coronavirus Outbreaks Are Now in the Rural U.S.

The coronavirus was slow to come to Foster County, N.D., a community of just over 3,000 people in the eastern part of the state. When virus cases surged in the Northeast in the spring, the county recorded just one positive case. When national case counts peaked in mid-July, it had recorded just two more.

But by Tuesday, about one in every 20 residents had tested positive for the virus. More than half of those cases were reported in the past two weeks.

Most of the worst outbreaks in the United States right now are in rural places like Foster County. Where earlier peaks saw virus cases concentrated mainly in cities and suburbs, the current surge is the most geographically dispersed yet, and it is hitting hard remote counties that often lack a hospital or other critical health care resources.

Since late summer, per capita case and death rates in rural areas have outpaced those in metropolitan areas.

The total number of coronavirus cases and deaths in rural places remains smaller than those in cities because of the comparatively low population in rural areas. But the rural share of the virus burden has grown over time.

Now, about one in four deaths from the virus is recorded in a rural county. That stands in contrast to March and April, when almost every death was in a metropolitan area, as the virus tore through the Northeast, after early clusters in the Seattle area and populous parts of California.

These maps show the case rates in rural areas at different points of the national outbreak:

During the summer surge, rural outbreaks occurred more often than they had in the spring, but reported cases per million remained higher in cities and their suburbs than in rural counties.

It was not until August, when the outbreak was receding from Sun Belt cities like Houston, Miami and Phoenix that per capita rates of cases and deaths in rural areas surpassed those in metropolitan areas.

Now, with the national case count and hospitalization rates approaching a third peak, none of the country’s biggest hotspots are in a large city. Almost all the counties with the largest outbreaks have populations under 50,000, and most have populations under 10,000. Nearly all are in the Midwest or the Mountain West.

Though the outbreak’s geographic spread is expanding, many of the same kinds of places remain at risk for clusters of infections. In Norton County, Kan., the hardest-hit county in the country relative to its population, all 62 residents of one nursing home have been infected with the virus, and 10 have died. A state prison in the county also has an outbreak.

Hospitals across the Upper Midwest and the Mountain West are also feeling the surge. Facilities are struggling with capacity, and in some cases residents are finding that the nearest hospital with available beds is hours away, or in another state.

Earlier this month, hospitals in North Dakota had to turn patients away. Bismarck, the state’s capital, had one staffed I.C.U. bed available as of Monday.

Overwhelmed by the record case numbers, North Dakota suspended its contact tracing program this week. New Mexico’s governor, also seeing hospital beds fill up in her state, plans to put in effect new restrictions on restaurants, bars and retail stores.

And Alaska, which is experiencing record numbers, provides a cautionary tale: Even with extensive testing and robust contact tracing, the virus is poised to thrive as temperatures drop and people move activities indoors.

Most of the counties with the worst per capita outbreaks now have fewer than 10,000 people

COUNTY		POPULATION	AVG. DAILY CASES, LAST 7 DAYS	AVG. DAILY CASES PER 10,000
1	Norton, Kan.	5,486	39	72
2	Miner, S.D.	2,229	7	31
3	Bon Homme, S.D.	6,969	21	31
4	Harding, S.D.	1,311	4	31
5	Faulk, S.D.	2,322	6	26
6	Sheridan, Kan.	2,506	6	26
7	Carter, Mont.	1,318	3	23
8	Menominee, Wis.	4,579	10	22
9	Foster, N.D.	3,290	7	21
10	Webster, Neb.	3,571	7	21
11	Buffalo, S.D.	2,053	4	20
12	Izard, Ark.	13,559	27	20
13	Oglala Lakota, S.D.	14,335	28	20
14	Blaine, Mont.	6,727	13	19
15	Towner, N.D.	2,246	4	18
16	Sheridan, N.D.	1,405	3	18
17	Eddy, N.D.	2,313	4	18
18	Decatur, Kan.	2,881	5	18
19	Madison, Idaho	38,705	68	18
20	Carroll, Miss.	10,129	17	17
21	Hill, Mont.	16,439	27	16
22	McIntosh, N.D.	2,654	4	16
23	Valley, Mont.	7,532	12	16
24	Sully, S.D.	1,331	2	16
25	Roosevelt, Mont.	11,228	18	16
26	Golden Valley, N.D.	1,882	3	16
27	Campbell, S.D.	1,435	2	16
28	McLean, N.D.	9,608	15	16
29	Mercer, N.D.	8,570	13	16
30	Langlade, Wis.	19,164	29	15
31	Hettinger, N.D.	2,576	4	15
32	Logan, N.D.	1,927	3	15
33	Florence, Wis.	4,337	6	15
34	Walworth, S.D.	5,510	8	15
35	Turner, S.D.	8,264	12	15
36	Glacier, Mont.	13,699	20	14
37	Big Horn, Mont.	13,376	19	14
38	Gove, Kan.	2,619	4	14
39	Perry, Tenn.	7,912	11	14
40	McCone, Mont.	1,630	2	14
41	Oliver, N.D.	1,837	3	14
42	LaMoure, N.D.	4,100	6	14
43	Golden Valley, Mont.	724	1	14
44	Dickey, N.D.	4,970	7	14
45	Deer Lodge, Mont.	9,100	12	14
46	Hayes, Neb.	943	1	14
47	Burleigh, N.D.	93,737	126	13
48	Morton, N.D.	30,544	41	13
49	Shawano, Wis.	41,009	54	13
50	Todd, S.D.	10,146	13	13