Josh Salman and Mark Nichols

USA TODAY

Kenneth Anglin felt sick when he returned from a trip through seven states in early March to pick up his daughter and son-in-law from Colorado and bring them back to rural central Florida.

The 58-year-old complained of a sore throat, dry cough and tightness in his lower chest, compounded by body aches, chills and a low-grade fever. Within days, his wife, Michelle, was feeling it, too.

Disabled and dependent on their fixed income, the couple feared COVID-19 especially because of Kenneth’s chronic pulmonary disease.

“We were just so sick, so sick – like nothing we’d ever experienced,” Michelle Anglin said. “I am 99% sure it was COVID. I’m still coughing, and it’s been three weeks now.”

According to the Anglins, their primary physician said no to a COVID-19 test, insisting the problem was bronchitis. He prescribed antibiotics and steroids.

They went to the emergency room and were rebuffed again, told they didn’t qualify because they had not been out of the country or come in contact with a known person who tested positive.

Michelle Anglin said both doctors told her that if they performed a COVID-19 test, they would have to report the results to the authorities.

“They make it impossible to get tested here,” she said. “They wouldn’t take it seriously. Everyone was more concerned about calling the CDC.”

While the number of COVID-19 tests across the nation has exploded in recent weeks, a USA TODAY review of state and local data shows that access remains haphazard for many patients. Communities operate under widely varying guidelines for who can get tested. Some have a greater abundance of test supplies than others.

READ:From Texas to New York, vastly different COVID test rates

Perhaps nowhere is the ability to test patients and identify those carrying the virus more critical than Florida, where state officials delayed aggressive social distancing efforts and one in five residents is 65 or older, putting them at higher risk from the virus.

USA TODAY examined testing rates in each of Florida’s 67 counties. The review shows that some communities far lag others in aggressively testing, even when patients arrive showing symptoms of COVID-19.

Income and remoteness may be part of what’s driving the outcome.

Florida Department of Health figures through April 1 show seven of the 10 counties with the lowest coronavirus test rates per capita are poor – with median incomes less than $40,000 – or rural, or both. None would be considered high-income.

Nearly all counties with the highest testing rates have median incomes above $40,000, and two earn north of $60,000.

One county with a particularly high rate of testing is St. Johns, home to the quaint coastal enclave of St. Augustine, which has the highest household income in the state: $73,600. The county has completed 422 tests per 100,000 residents.

That stacks up well against Highlands County, where the Anglins live in a retirement community tucked between the cow pastures that flank inland Florida. The median income in Highlands is about half that of St. Johns, and the testing rate is just one-fourth what it is in the wealthier community.

Highlands ranks near the top for percentages of tests awaiting results and the share of tested patients whose results were positive for COVID-19.

It’s unclear how much of the disparities are driven by the unequal distribution of test kits versus decisions at the local level. Individual doctors and health systems apply their own judgments about whom to test, and the state chooses how to allocate requests for supplies county by county.

Counties differ in how much their residents travel outside the state, a factor that can increase the likelihood the virus is carried home.

Emergency managers said they see one systemic reason for shortages in some communities: When ordering test supplies from the state for health care providers, counties with the highest case counts are the ones most likely to get additional test kits.

That creates a kind of Catch-22, emergency managers said. Rural communities need more positive cases to get more tests, but they need more tests to show that sick residents have COVID-19.

Health care workers fear low testing rates produce statistics that give rural residents a false sense of security. They said the virus is battering Florida’s struggling small towns, where supplies that have run out, and a health care infrastructure that’s woefully unequipped.

“We are in a part of Florida where it’s denial,” said Kelly Adelberg, chief operating officer for Treasure Coast Medical Associates, which operates urgent care clinics in Highlands and neighboring Okeechobee County. “There are no tests in these areas. It gives people false hope, and they go out shopping.

“There are people in these areas with COVID, but there are no tests to test them.”

A vulnerable county

Before infections took deep hold in the USA, John Nelson, a mapper at Esri, which supplies geographic information system software, predicted Highlands County would be among four places most vulnerable to the virus in America.

The research cited Highlands' high proportion of residents age 60 or older and its score on the Centers for Disease Control and Prevention’s Social Vulnerability Index, which identifies communities most likely to need support during an emergency, using an algorithm that analyzes poverty, mobility and housing conditions.

The culmination “puts them in what could be considered a dangerous position for COVID-19,” Nelson said of the analysis.

Despite the risk, the pace of testing has lagged.

In Highlands County, 112 patients were tested for coronavirus out of every 100,000 residents for whom results were available as of Wednesday. Only seven Florida counties had a lower testing rate.

By contrast, Collier County – home to the state’s wealthiest retirement enclaves – has tested more than 370 patients per 100,000 residents. Only seven Florida counties tested at a higher rate.

Providers in Collier set up a task force, staffed a call center and opened two drive-thru testing sites, one operated by the health department for residents who’ve completed a prescreen and another by the private hospital. Together, the sites can test up to 74 people a day.

Some residents expressed frustrations even in Collier, where cars with sick residents were turned away from the hospital as testing began.

Richard Abood, a physician with Collier Urgent Care, where most of the patients come for respiratory ailments, said he has had no shortage of tests lately for those who need them.

“We haven’t heard that at all,” Abood said.

Some of the difference in each county’s approach reflects unequal access to supplies, but health providers and residents said some of it is because not all counties view the threat of COVID-19 equally.

All health officials in Florida are part of one statewide agency, reporting to the state’s surgeon general. As a practical matter, though they coordinate with the state, the approach to managing the pandemic varies from one community to the next.

“The response is definitely local,” said Kristine Hollingsworth, spokeswoman for the Collier County branch of the Florida Department of Health.

Across Florida, pharmaceutical companies reach out to private physicians daily with sales calls for newly developed tests.

Rural providers are last on the delivery list when competing for these limited supplies of test kits, according to Adelberg, the clinic owner in Highlands County. Those that do become available are reserved for the critically ill. The same goes for other basic medical supplies.

“The medical supply chain being as fragmented as we are, we’re getting a little supplies every day, but not what we are ordering,” said Mitch Smeykal, emergency management director in neighboring Okeechobee, an agricultural county of about 40,000. “We don’t have as many testing sites as the metropolitan areas.”

Highlands County health officials declined to be interviewed by phone. Amanda Tyner, a spokeswoman for the department of health in DeSoto and Highlands counties, said in an email that residents who feel sick should first go to their primary care provider, and if they don’t have one, they can call for an appointment to be tested with the health department.

Tyner insisted the region could meet testing demands and said a recent order of 2,500 more statewide test kits would help. She had no explanation for why residents and physicians could not get testing.

Highlands' tests are sent to both state and private labs, which face major delays across the country. Only nine counties have a greater proportion of their tests awaiting results.

With 21 positives and 127 tests awaiting results in Highlands as of Thursday afternoon, the stakes are high. In Highlands County, as in most of its neighboring rural counties, at least one person has died.

Highlands' death rate per 100 tests is the second-worst in the state among counties with a fatality.

“There is a long history of discrimination in the deployment of scarce health resources to poorer populations,” said Jay Wolfson, senior associate dean of the Morsani College of Medicine at the University of South Florida in Tampa.

“Testing is less prevalent in poorer versus wealthy counties because of fewer public health resources to divert,” he said. “There has been a dearth of test kits statewide, and the allocation of scarce kits has gone to counties with generally larger populations.”

'Creative solutions'

With scarce resources and infrastructure never meant for such a pandemic, small and rural towns in Florida are forced to innovate.

Putnam County, a rural suburb of Jacksonville, was among Florida’s lowest-income counties in 2017, with a median household income of less than $34,000.

Despite facing shortages in tests, Putnam was the lone low-income area among Florida’s top 10 counties for testing. Health officials said they bucked the trend by devising novel approaches.

The local health department creates its own tests from synthetic swabs and a sterile saline when kits from the state run out. Emergency officials wash and reuse surgical masks, which are needed for workers to administer tests for the virus, on the laundry’s “gentle” cycle. They hand-deliver tests to the nearest public lab, so the results are typically back within 24 hours.

“We’re finding creative solutions that are consistent with CDC guidance in an effort to conserve resources,” said Mary Garcia, administrator and health officer for the Florida Department of Health in Putnam County.

In Putnam, officials have tested more than 300 residents and contacted 800 who had direct contact or close association with someone who tested positive. They say one reason for their relative success is that everyone in the county has taken COVID-19 seriously.

“When we’re dealing with scarce resources,” said Ryan Simpson, Putnam County emergency management coordinator, “we’re able to identify needs quickly and respond quickly.”

Contributing: Matt Wynn and Kevin Crowe, USA TODAY. Josh Salman is an investigative reporter for the USA TODAY NETWORK covering the Southeast. Contact him by email at jsalman@gatehousemedia.com or by phone, 941-361-4967.