When describing COVID-19, White House Coronavirus Response Coordinator Dr. Deborah Birx warned: “No state, no metro area will be spared.” Evidence suggests she is right. Rural Americans should take note.

To date, densely populated, urban areas have borne the brunt of the virus’s opportunistic nature. Approximately one-fifth of the country’s confirmed COVID-19 cases are in New York City, America’s most densely populated metropolitan. Other major cities, such as Los Angeles, Boston and Chicago, are also currently within the virus’s purview.

Rural residents are fortunate their geographic distance from heavily hit cities has mostly insulated them from the pandemic. Of the five states (i.e., North Dakota, South Dakota, Iowa, Nebraska, and Arkansas) yet to issue “shelter in place” or “safer at home” directives, each is significantly rural in composition. However, with South Dakota now containing one of the largest single coronavirus clusters, that list may be shrinking. Moreover, if COVID-19 spreads beyond America’s urban enclaves, rural patients will be at risk.

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Indeed, geographic and social distancing may prevent COVID-19 from spreading fully into rural America. However, experts believe it will eventually reach rural areas to some degree.

While rural towns may not get many outside visitors, residents increasingly drive to larger cities for medical treatment, work, and entertainment. When social distancing enforcements ease and more regular transit resumes, particularly with the prospect of reopening parts of the economy by early May, the virus will gradually infiltrate into rural areas.

Experts at the Centers for Disease Control (CDC) believe COVID-19 puts two populations at high risk: older adults (i.e., 65 years and older) and individuals with serious chronic medical conditions (i.e., cardiovascular disease, cancer, and diabetes). These guidelines should put much of rural America on alert.

Statistically, rural Americans are both older and sicker than their urban counterparts. On average, 18.6 percent of rural residents are over the age of 65, compared to 14.7 percent of urban adults.

Moreover, data trends from China’s Center for Disease Control showed substantial increases in mortality for patients 60 and older. Patients aged 60-69, 70-79, and 80+ comprised 30.2, 30.5, and 20.3 percent of the total deaths observed in mainland China, respectively. What’s more, experts have warned that asymptomatic Gen Z (aged 8-23) and millennial (aged 24-39) populations risk spreading COVID-19 to older, at-risk individuals. In fact, U.S. Census Bureau data suggests that the share of urban and rural residents under 25 is roughly equal, at 32.5 and 31.3 percent.

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Moreover, older populations tend to have a higher prevalence of chronic illness. In the World Health Organization’s report on China’s outbreak, the fatality rate of people with no chronic disease was 1.4 percent, but 13.2 percent for those with cardiovascular disease, 7.6 percent for those with cancer, and 9.2 percent for those with diabetes. Alarmingly, rural Americans suffer more deaths per 100,000 people from cardiovascular disease (86.9 vs. 56.6) and cancer (103.4 vs. 74.3) and have higher percentages of diabetic populations (12.6 vs. 9.9) than their urban counterparts. Perhaps more concerning, data from Italy shows that 99 percent of those who died from COVID-19 had underlying health issues.

Additionally, rural patients already face dilemmas in access to health care services. Not only are physician shortages prevalent, but unprecedented rates of rural hospital closures have created geographic barriers to care. Since 2005, 168 rural hospitals have closed, including 40, since 2018. Furthermore, twenty-five percent of rural hospitals are at high risk of closing (in an analysis performed prior to the COVID-19 pandemic).

These hospital closures also reduced access to intensive care unit (ICU) beds. Nationally, 26 million citizens live in counties with hospitals but no ICU, and nearly 11 million — including 2.7 million seniors — reside in counties with no hospital, many of which are in rural areas. If COVID-19 spreads into rural America, just like in urban areas, questions will emerge about hospital bed shortages and medical triage.

If you look closely, you can find the word “panic” inside the “pandemic.” But panic is not inevitable. Policymakers and health care leaders must heed Dr. Birx’s warning and prepare proactively to protect the country’s 60 million rural residents. Moreover, rural patients need to recognize that if COVID-19 spreads beyond America’s urban enclaves, they will not be immune.

Mark E. Dornauer is a visiting fellow at The Foundation for Research on Equal Opportunity and previously worked at the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response.