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Experts say rural areas have older populations that are less healthy and have fewer medical facilities than urban and suburban regions. Jeremy Hogan / Echoes Wire/Barcroft Media via Getty Images

The COVID-19 pandemic has already swept through cities and urban centers.

体育投注网址Now, the illness appears to be building like an infectious prairie fire in rural America, as well as in larger towns in the Midwest.

体育投注网址That wasn’t the case just a month ago.

“Many rural communities aren’t seeing anything. They’re simply having to prepare for what they know is coming,” , the assistant dean for rural and underserved programs at Heritage College of Osteopathic Medicine at Ohio University, told Healthline in late March. “[But] it will come, no matter what.”

Longenecker’s prediction appears to be coming true.

A May 7 White House document obtained by NBC News in COVID-19 in communities across the middle of the country.

Among the areas with increasing COVID-19 cases were Nashville, Tennessee, Des Moines, Iowa, and Central City, Kentucky.

In addition, the in Minnesota, Wisconsin, Iowa, North Dakota, and South Dakota have been increasing since the beginning of April.

体育投注网址Iowa has surged past Minnesota and Wisconsin and now has the highest number of confirmed cases of those five Upper Midwest states with more than 12,000 cases.

Black Hawk County is the state’s hot spot right now with . Many of those cases are connected to the Tyson Foods plant near Waterloo as well as long-term care facilities in the region.

体育投注网址In South Dakota, more than have now tested positive for COVID-19. Almost are linked to the Smithfield Foods meat processing plant in Sioux Falls that was closed in mid-April. That plant, however, is this week.

Despite the increase in COVID cases, there are , 10 of them in the middle of the country, that have partially lifted shelter-in-place orders.

In Iowa, Gov. Kim Reynolds has to allow malls, restaurants, retail stores, fitness centers, churches, and libraries to reopen in most areas.

体育投注网址The Nebraska Crossing mall held a for employees and shop owners in late April. The mall owners 11 of their 80 stores on May 1. That complex sits along Interstate 80 between the population centers of Lincoln and Omaha.

In addition, President Donald Trump in late April mandating that meat processing plants remain open to avoid a disruption in the nation’s food supply.

All of this has experts worried about what’s in store for the middle of the country.

体育投注网址 that’s particularly vulnerable to serious outcomes with COVID-19.

In addition, many people in rural areas live 30 or more miles away from the nearest hospital.

“Systems that are under stress during routine times will be more stressed during disasters and times of crisis. Sometimes we forget those systems that are at the brink,” said , PhD, director of the Disaster Research Center at the University of Delaware.

体育投注网址Rural health systems already stretched financially are therefore particularly vulnerable, but so are rural areas that don’t have as deep a bench of resources to tap when times get tough.

体育投注网址“When you start thinking about recovery trajectories and impacts, the extent to which there is community functioning before a disaster has strong implications in that recovery trajectory post-disaster,” Wachtendorf told Healthline in late March. “That goes right down the spectrum: transportation systems, employment support, hospitals and public health, food security — all the key systems. If those are low pre-disaster, those are going to have substantial effects on what communities experience during the disaster, as well as their post-disaster recovery.”

Rural populations tend to be older and face a higher risk of death from heart disease, cancer, lower respiratory disease, stroke, and unintentional injuries.

体育投注网址Nearly 20 percent of the population in completely rural counties is 65 and older, according to , compared with around 15 percent in mostly urban centers.

Americans living in rural areas also tend to have of cigarette smoking, high blood pressure, and obesity, compared with their urban counterparts.

Both older age and cigarette smoking are two factors tied to a higher risk of severe illness or death from COVID-19.

Despite these statistics, there’s a sense among some experts that some people in rural communities, as well as political leaders in these states, haven’t taken the threat of COVID-19 seriously enough.

Initially, “Less dense areas might be at an advantage compared to geographic areas that are more densely populated, and they may also be less connected to some areas where there’s a concentrated case,” Wachtendorf said.

体育投注网址But once these communities do start to see cases, they might struggle to fill basic public safety and administrative roles, especially if people such as police officers and firefighters get sick and have to self-quarantine.

Experts say any lack of physical distancing could have ripple effects that overwhelm rural hospitals and disrupt essential services down the line.

“If someone gets sick in those areas or an agency or department gets sick, there may be fewer people within those agencies to continue operations, leaving that particular community more vulnerable,” Wachtendorf said.

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The town of Rockton, Illinois, has a shelter-in-place order, but many parts of the Midwest and South haven’t implemented such procedures. Getty Images

Medical facilities known as critical access hospitals, which have 25 beds or fewer and are 35 miles away from the closest facility, are among the ones that have closed at the highest rates in the past two decades, even as their closure rate slowed somewhat thanks to provisions in the Affordable Care Act.

“Rural hospitals, on the whole, they’re going to see their curve, whether it’s flat or not, start a whole lot later, maybe 3 weeks, 6 weeks,” Longenecker told Healthline.

体育投注网址In the meantime, however, “Rural hospitals right now are seeing a steep decline in activity, empty beds, and empty practices, so for right now there’s a steep loss of revenue.”

For those rural hospitals — ones that remain after more than 80 have closed since 2010 and nearly 700 more found themselves on the brink of closure — that loss of revenue illuminates a dangerous teetering in our health system, as administrators try to balance the costs of staying afloat against the predicted flood of eventual COVID-19 cases.

In the meantime, many of these critical access hospitals are operating with bare-bones staff.

体育投注网址“What’s happening is the wave hasn’t come yet here,” said Jane, a travel nurse working at a critical access hospital in Wisconsin. “We’re down to two teams working here per day, which is OK most days because procedures keep getting canceled and falling off, but yesterday, we were working our (tails) off and I’m wondering why are we down to a skeleton crew? It’s because they’re trying to save money for when the s— really hits the fan.”

By then, supply shortages and other issues may have already rocked the system, Longenecker said.

体育投注网址“Hopefully some things will be worked out, like the supply of testing and supply of personal protective equipment, or not. They may have already sent them to the city,” he said.

体育投注网址Jane agreed.

体育投注网址“What scares me is that — because there’s not confirmed cases up here yet and there’s only two in the county. I’m just worried that we’re going to get overlooked when it happens, and we’re going to be up a creek,” she told Healthline. “I think a hospital is not a place you want to be right now unless you absolutely have to be.”

from the Economic Innovation Group (EIG), a bipartisan public policy organization.

But that doesn’t tell the whole story. Within this study, EIG found that economically distressed rural areas were especially affected.

Put another way, “There are fewer than half as many hospital beds per capita reasonably accessible from the average rural distressed zip code as are from the average rural prosperous one,” the report says.

Wachtendorf noted the example of hospital closures funneling people from a wide geographic radius into central, overburdened regional health centers, as well as local clinics that aren’t full hospitals, as potential points of strain in the system in a crisis.

Rural areas that rely on farming as a main source of income might also find themselves in a particular bind.

“It’s not like you could just take 2 weeks off and think the crops will still be there,” Wachtendorf said. “Some of that seasonal work is very much dependent on timing. And it’s not just a matter of pushing off that production for 2 weeks or a month. It’s either done now or it’s not done at all.”

, a healthcare staffing agency. “In a way, COVID-19 leveled the playing field in healthcare by erasing the boundaries between rural areas and large cities. It doesn’t matter where patients are located; they need care.

体育投注网址“Because of this and because clinicians are overwhelmed, demand for telehealth has gone up across the board,” Ograbisz told Healthline.

体育投注网址But telemedicine can only go so far, and won’t fix the fragmentary nature of the American healthcare system, Longenecker said.

“It’s hard, as individualistic as we are as Americans, for us to think about the good of the community or think epidemiologically, which is a very different way of thinking than just thinking about me and my family,” he said. “But anything we could do to be less fragmented and to be more systemic (as a healthcare system) would be really, really good.”