Everett Butler has been in the health care business for more than 50 years — and he's never experienced anything quite like this.

Butler came out of retirement about a year ago to become CEO of Kittson Healthcare, in the far northwestern Minnesota town of Hallock. The hospital has 15 beds, an attached long-term care facility with 60 beds, and an ambulance service.

He knows if any serious cases of COVID-19 turn up in Hallock, patients would need to be transferred to larger hospitals an hour away in Grand Forks, or two hours away in Fargo, N.D.

"We just don't have the capacity,” Butler said. “Not only in equipment, [but] we don't have the capacity and manpower to maintain and and provide those people with the quality of care that they're going to need.”

Confirmed cases of COVID-19 are showing up in rural counties across the state as the virus continues its spread in Minnesota. And because many rural areas have limited health care options — and often a small number of workers to keep critical services going — health workers and local officials are paying close attention to the coronavirus’ trajectory, and bracing themselves as they plan.

Butler’s hospital has one ventilator, a critical piece of equipment needed to help people with acute respiratory illness, like COVID-19, breathe. But he said they don't have the staff needed to use the equipment in treating patients.

Butler has been closely watching the spread of the coronavirus in Minnesota and neighboring North Dakota — Hallock is about 15 minutes from the state line. His hospital is implementing its pandemic plan. But the biggest challenge right now is the uncertainty.

"One of the things we deal with every day, and internally even with our own staff, is keeping that anxiety level down,” he said.

Just south of the Canadian border, Jeff Pelowski is also keeping a close watch.

"We're pretty much taking it day by day, like everybody else, and monitoring the situation, and if we feel like we have to change something we'll do it," said Pelowski, who is mayor of Roseau and also works as the Roseau County administrator.

So far in Roseau, Pelowski said he’s seen some panic-buying at the local grocery store. Businesses, city buildings and even the hockey arena are closed. The police chief went door to door to explain to bars and restaurants why they had to shut down. He said most of those businesses quickly switched to offering food delivery or pickup options.

And in the meantime, he said, it’s important for local leaders to work to reduce anxiety.

"You know, when you're in northern Minnesota and you're shutting down arenas, how could you not panic?” he said, hastening to add: “That was a joke. But we are telling people not to panic — and so far they're pretty good."

While there are still people who don’t take the pandemic seriously, Pelowski said, it's critical for a small town to prepare for the worst.

"We have 21 employees in a city of 2,700 people. We provide water, sewer, garbage, electric — all those services, and so we need to keep our workforce safe," he said.

In Clay County — which includes Moorhead — Sheriff Mark Empting has refused to enforce eviction notices and he’s canceling the mortgage foreclosure sales that are usually held at the sheriff’s department.

He’s concerned about his staff, too, as the reality of pandemic settles in. His deputies are responding to calls without masks or other gear to protect them from the virus, though the sheriff’s department has purchased hand sanitizer made by a distillery across the river in Fargo.

And Empting said most residents are staying home and social distancing. But because of that isolation, his top concern is people’s mental health.

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"With people that may potentially be losing their jobs, their houses and their vehicles, things like that, I am afraid that we may start to see more assaults on people, maybe more property crimes, maybe more people wanting to harm themselves,” he said. “That also takes a toll on our staff, as well."

Across rural counties and small towns, public health workers are encouraging people to be aware of their physical and mental health. They're also advising local leaders, coordinating messaging and preparing to respond to cases of COVID-19.

Cars parked near businesses on Fourth Street near Main Avenue in Moorhead, Minn. On a normal business day, parking is hard to come by. Matt Mikus | MPR News

"This is really kind of a marathon for all of us, and we are not sure how long the marathon is,” said Jody Lien, public health director for Otter Tail County, which includes Fergus Falls. “Some days can feel like a sprint, but this really is a marathon."

Lien and her staff are using public service announcements, social media and help from local officials to get the message out that people need to take precautions. Most people are cooperating, she said, although some are less concerned than others.

And while it can be tough to get the word out, one benefit of working in rural Minnesota, she said, is that local officials often have relationships developed over years of working together — and they know each communities' strengths and weaknesses as they implement pandemic plans.

She’s relying on those relationships more than ever right now.

"We might have to do things a little bit more creatively because we don't have access to certain things that a metro or more urban place has,” Lien said.

“But I think that's what rural [Minnesota] has always done well is coming up with creative ways to meet our needs and we’ll continue to do that through this pandemic as well."

Health officials for weeks have been increasingly raising the alarm over the spread of the novel coronavirus in the United States. The disease is transmitted through respiratory droplets, coughs and sneezes, similar to the way the flu can spread.

Government and medical leaders are urging people to wash their hands frequently and well, refrain from touching their faces, cover their coughs, disinfect surfaces and avoid large crowds, all in an effort to curb the virus’ rapid spread.

The state of Minnesota has temporarily closed schools, while administrators work to determine next steps, and is requiring a temporary closure of all in-person dining at restaurants, bars and coffee shops, as well as theaters, gyms, yoga studios and other spaces in which people congregate in close proximity.

Map: Confirmed cases across the state