An elderly woman plagued by bed sores, unable to get treatment. A man with gangrene left festering so long his leg had to be amputated. Patients splitting their medications in half, unsure of when they’ll be able to afford their next dose. The coronavirus pandemic looks different in rural America than in major U.S. cities, but health-care providers say it’s no less dire.

The surge that bludgeoned coastal metropolises has yet to hit the foothills of Appalachia—a rustic, mountainous region that stretches from West Virginia up to New York, where social distancing is more of a lifestyle than an emergency intervention. But providers here told The Daily Beast the extreme measures required by the pandemic are keeping their isolated, low-income patients from getting crucial health care.

And if the virus does make it to the area, one provider predicted, it would be “devastating.”

“[It would] wipe the whole community out,” she said.

The population of Appalachia is older, poorer, and generally less healthy than the rest of the country. The region’s historically dominant industries—tobacco farming and coal mining—wreaked havoc on the lungs of its older workers, and the poverty caused by the collapse of those industries drove out most of its young. According to the Appalachian Regional Commission, rates of chronic lung disease are 27 percent higher in Appalachia than in the nation as a whole; rates of heart disease, cancer, and diabetes are also above average.

“We’re the belt for everything—the cardiovascular disease belt, the kidney stone belt,” said Teresa Tyson, the president and CEO of Health Wagon, a mobile health service in Virginia. “The reason we pray here in the Bible Belt is because we’re praying for all of these health-care disparities.”

“ The reason we pray here in the Bible Belt is because we’re praying for all of these healthcare disparities. ” — Teresa Tyson, Health Wagon

Jerome Cline, a nurse practitioner at Williamson Health and Wellness in West Virginia, said his patients’ biggest problem is lack of access: They don’t have cars to bring them to the clinic, and they don’t have internet or smartphones to connect them with providers. So the clinic brings care to them, dispatching two community health workers to check in on 30 to 40 patients with diabetes, heart disease, and other chronic illnesses.

Only now, they can’t. When Aetna, the program's insurance largest partner, sent out a memo at the end of March advising all case managers to suspend home visits, Williamson Health and Wellness followed suit.

“We tried to make the patients aware and just let them at least know they can call us,” Cline said. “[But] we’re seeing a lot of anxiety and what seems like depression setting in, because I think the isolation is hitting some harder than others.”

One of the clinic’s oldest patients is a man we’ll call Jack—a blind, partial amputee who relies on the community health workers to check his blood sugar, monitor his breathing, and lay out his pills once a week. With home visits suspended, Jack has to call the clinic everyday about his medications, because can’t read the labels on his own. “This one feels round,” he says, or, “This one feels like a football. Is this the pill I should be taking?”

“He has no family, so we are his all-in-all, really,” said Melissa Justice, a nurse who oversees the community health worker program. “He had friends before COVID, but now he has no friends he can reach out to, either.”

“Today he said, ‘I don’t even want to go out, because I know that if I was to go out and to catch it, I will die,’” she said.

Before the pandemic, Justice and the community health workers had a network of providers they could call on to treat their patients: rehabilitation specialists for chronic lung disease, nurses to care for infected wounds. Now, with no one willing to make house calls, Justice said, “all of this stuff has been placed on the back burner, and these patients are continuing to decline.”

Justice described one patient suffering from huge, painful bedsores, whose family isn’t able to afford a home health aide. Recently, the family found a physical therapist who took insurance and who was able to get the woman walking again. But with the pandemic looming, the therapist isn’t coming anymore. Justice is convinced the patient will end up bedridden again.

“Now she's going to regress back,” Justice said. “That’s the fear—possibly dying of an infection related to a wound and not being able to stand on your own two feet.”

For her more critically ill patients, the options are even more limited. Williamson Health and Wellness is just an outpatient clinic, with no formal emergency room or intensive care unit. The hospital it used to work with, Williamson Memorial, shut down this week—part of a growing trend of rural hospital closures across the country. The hospital closest to Justice’s clinic is 30 miles away, and even that location doesn't have some of the necessary specialists.

If they’re lucky, the sickest patients make it to doctors like Scott Stevens, a vascular surgeon at the University of Tennessee Medical Center in Knoxville, who treats patients from Lexington, Kentucky, all the way to the North Carolina border. But because of the delays and shutdown caused by the pandemic, Stevens said, many of his patients aren't making it to him until it’s too late.

Last week, Stevens amputated the leg of a homeless man who came to his office with gangrene—a disease that can usually be treated with a simple outpatient procedure. The community clinic the man usually frequented was running on a skeleton crew and hadn’t been able to see him. A slightly luckier patient—a blue-collar worker from rural Tennessee—was passed from one overbooked provider to another before he made it to Steven’s office. He spent a week in the ICU and endured multiple surgeries for his gangrene, but got to keep his leg.

Stevens is struggling to find a balance between responsible social distancing measures and restrictions that keep patients from seeking care. His own hospital has emptied out hospital beds to make space for COVID-19 patients, canceled all elective surgeries, and cancelled all nonessential visits to prevent contagion.

“It’s really a tough situation,” he said. “You don’t want to be unprepared and spend resources we might need for COVID patients, but on the other hand you hate to see these patients suffer.”

Compounding the problem, some people simply don’t want to go to the hospital right now. Many of Stevens’ patients are afraid to leave the house, much less come to the “big city” and sit in a waiting room full of sick people. He’s tried offering video chat, but many of his patients don’t have computers or smartphones. Plus, when dealing with seriously ill patients, there are some things that just need to be done in person.

“You get so much more information when you actually see patients,” Stevens said. “I can feel their pulse, I can look at the wound. If I can just see the anxiety on their face or the pain when they move. You can’t really pick up all those nuances over the phone.”

Back in Williamson, the crisis is hurting even some of the clinic’s most manageable cases. A number of patients rely on the clinic for free samples of their daily medications, for everything from high cholesterol to depression. But with pharmaceutical representatives not making visits anymore, the clinic is slowly running out of free supplies. Some patients have started splitting their doses in half, while others are reducing the number of drugs they take or switching to those available over the counter. “It may not be the best choice for them, but it’s better than nothing at all,” said Samantha Runyon, another community health worker.

For some patients, even paying for groceries is a struggle. Since the pandemic hit, the clinic has started keeping an emergency stash of food at the office. They're also dropping off deliveries from Meals on Wheels, which stopped making house calls when the crisis struck. At the Health Wagon, Tyson said her clinics have also gone “back to basics.” When an entire apartment complex was quarantined due to possible COVID-19 exposure, clinic staff dropped off meals for the residents who could no longer work.

The providers are feeling the strain of the crisis, too. With fewer patients coming in and elective procedures cancelled, hospitals and clinics around the country hemorrhaging money. Stevens said some of his colleagues at the University of Tennessee Medical Center have been furloughed, and members of his own staff have seen their hours cut.

At Williamson Health and Wellness, 15 members of the 97-person staff have been laid off. The clinic, which usually has at least eight staff members at a time, now runs on four. A number of staffers with underlying health conditions took the layoffs voluntarily, because they were worried about contracting coronavirus on the job. Now, Justice said, they don’t know if they will ever get their positions back.

Asked if her patients would survive another few months of social distancing, Justice said she didn’t know if the clinic even would.

“We may be laid off, we don’t know what the future holds,” Justice said. “We’re all in fear for our jobs and our lives.”

“ All of this stuff has been placed on the back burner, and these patients are continuing to decline. ” — Melissa Justice, community health worker

The Health Wagon, which has served patients in southwest Virginia for more than four decades, has also experienced cutbacks. Its providers are relying mainly on telehealth, and keeping the staff in its three locations separate. An annual event at the local fairgrounds which provides medical, dental, and vision care to more than 2,500 people was canceled this year due to crowd size.

But Tyson, who has worked with the clinic for 27 years, remains positive. Her clinic has treated three COVID-19 patients so far, all of whom appear to be recovering. The daughter of a third-generation coal miner, Tyson described the population of Appalachia as “resilient,” adding, “You have to be resourceful here just to survive.”

“They’re the most wonderful people in the world,” she said of her community. “We know that it’s a very vulnerable population, but we are very optimistic that we will come through this and we will be better for it.”

Cline, the nurse practitioner from Williamson Health and Wellness, was kind enough to extend that sentiment to everyone.

“I think Americans in general are pretty big on resilience,” he said. “We just each have a different way of looking at it or talking about it.”