Forty minutes to the east of uptown Charlotte, in rural Stanly County, you might think that COVID-19 poses relatively little threat.
You'd be wrong.
In fact, the death rate from the coronavirus is almost three times higher in Stanly than in the much more densely populated county of Mecklenburg.
What's happening in Stanly County illustrates a broader problem: In North Carolina's rural counties, people are dying from COVID-19 in greater overall numbers — and at higher rates — than in the state's urban and suburban counties.
A recent study by the UNC Highway Safety Research Center came to that conclusion. So did a Charlotte Observer analysis, which looked at more up-to-date COVID-19 data.
In the state's 80 rural counties — as those are defined by the N.C. Rural Center — about 33 of every 100,000 residents had died from COVID-19 as of Sept. 9, the Observer found. In suburban and urban counties, the rates per 100,000 are 26 and 24, respectively.
"I hope people don't assume this is just an urban problem," state epidemiologist Zack Moore told the Observer. " ... This is something affecting all parts of the state. And rural areas are in no way immune to this problem."
Why is the death toll higher in rural counties?
Many in those areas work in food processing plants, where crowded working conditions have contributed to the virus's spread. Others live or work in cramped prisons that suffered outbreaks. Still others reside in nursing homes where the virus jumped from bed to bed.
But researchers and infectious disease experts also point to more systemic problems: Those who live in rural counties tend to be older, poorer and sicker than those in the suburbs and cities. They tend to have less access to health care. And they are less likely to have the sorts of office jobs — and internet connectivity — that allow them to work from home.
Chris Vaughn, who runs the only medical clinic serving the uninsured of Stanly County, says all of that helps explain the high COVID-19 death rate there: 83 deaths per 100,000, compared with 29 in Mecklenburg.
"I see an awful lot of diabetes, a lot of high blood pressure, a lot of people who are smokers," said Vaughn, executive director of the John P. Murray Community Care Clinic in Albemarle.
But getting medical care isn't easy for all residents there. Some people in the county lack cars and are more than 15 miles from the nearest hospital, Vaughn said.
A family reels
In Burke County, a county northwest of Charlotte with about 90,000 people, Bobby Strickland and his brother Jason have encountered the problems firsthand. More than 30 people have died from COVID-19 in Burke, and their father was among them.
Bobby began feeling so dizzy and disoriented in late March, "it was like I was drunk. I was in a fog ... I was bouncing off everything like bumper cars. Without the bumpers."
One night, at the home in Morganton that he shared with his parents, he fell asleep in a recliner. His father — 79-year-old Robert Strickland — woke up early that morning to find him in a coma. Robert tried to resuscitate his son, but was unsuccessful. An ambulance rushed Bobby to the hospital, where doctors said he had COVID-19 and warned that he probably wouldn't make it.
Bobby awoke from his coma about three days later, and his condition improved. The day he returned from the hospital should have been a happy one. But his father entered the hospital that same day because he was having trouble breathing.
Robert Strickland loved to cook hot chicken wings, to root for the Atlanta Braves, and to go saltwater fishing with his family.
"He was always happy," Jason Strickland said. "He loved to laugh. He loved to make other people laugh."
After growing up in Burlington, Robert moved to New Jersey when he was a teenager. He worked as a chemical operator for a pharmaceutical company, and later as a much-loved bartender in North Jersey, before he and his family moved back to North Carolina last year.
He had a lot to look forward to, his sons said. He'd just gotten cataract surgery, which allowed him to see clearly for the first time in years. He'd also just bought a new car — a Dodge Journey.
But he never got to drive it. As a diabetic, a smoker and a senior citizen, he was particularly vulnerable to COVID-19. And when the virus struck, it struck quickly. He died a couple of days after he entered the hospital.
His sons say they still struggle with what the disease has taken from them. But not everyone in Burke County realizes just how dangerous the disease can be, they say.
About a month after Robert Strickland died, Bobby was in Walmart when he encountered a customer without a mask who made fun of him for wearing one.
"I told him this virus killed my father. And it almost killed me," Bobby said. "And I walked away from him."
No longer just a big-city problem
In North Carolina, as in many other states, COVID-19 got its first foothold in cities, where the population density helped the virus spread.
Few wore masks in rural areas in the pandemic's early days, said Patrick Woodie, president of the N.C. Rural Center.
"I think they felt safer," Woodie said. "I think they felt this was going to be a big-city problem."
While COVID-19 was slow to strike rural counties, it later "showed up with a vengeance," Woodie said.
The virus gradually began to take hold In places like Columbus County, on the state's southeastern border, where many residents live in poverty and suffer from chronic health problems.
Nonetheless, county health director Kim Smith said large groups — particularly extended families — continued to gather without wearing masks.
In May, 29 people in the county gathered for a birthday party, she said. Later, she said, 25 of them caught COVID-19. Two of them died.
They are among the more than 50 people in Columbus County who have died from the coronavirus so far. Today, the death rate from COVID-19 is more than four times higher in Columbus County than in Wake County, the large urban county to the north where about 20 of every 100,000 residents have died from the virus.
Daniel Buck, a spokesman for the Columbus County health department, hopes families are beginning to get the message: "If you want to celebrate that person's birthday next year, it might be best not to celebrate it this year."
But some in rural areas still don't wear masks.
Hertford County, a sparsely populated area near the state's northeastern corner, has suffered one of the state's highest COVID-19 death rates: about 95 deaths for every 100,000 people.
Kim Schwartz runs a health center there, and sees practices that allow the virus to thrive. She spoke of attending a recent funeral, in which about 125 people crowded into a small church.
"They were packed into the pews," Schwartz said. "There was no social distancing."
The pastor walked around shaking people's hands. Very few people wore masks, she said.
"There's not attention being paid to these preventative measures," she said.
'A human equity question'
The need to make a living has also helped accelerate the spread in rural counties.
The UNC Highway Safety Research Center found that people in rural areas cut back on their driving during the pandemic — but not as dramatically as those in the cities and suburbs. In rural areas, center director Randa Radwan said, more people have "essential" jobs that can't be done from home. That has contributed to the virus's spread.
"People there still have to go to their jobs," she said. "More people have to travel."
And for some who contract the virus in rural areas, getting medical care can be difficult, Woodie and others say. That's partly because a higher percentage of people lack health insurance in rural counties.
And some don't have easy access to hospitals that have much experience treating COVID-19 patients, said Dr. Cameron Wolfe, an infectious disease expert at Duke University Hospital.
Experts interviewed for this story said they hoped a greater recognition of the disparities could lead to policy decisions that help rural residents — decisions that could provide better access to testing, health care and high-speed internet, among other things.
"Hopefully this drives policy decisions that save lives," Wolfe said.
"It's a human equity question, first and foremost," Wolfe said. "Your health should not be different based on where you choose to live."
Database reporter Gavin Off contributed to this story.
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