One reason for low numbers of confirmed cases in rural areas is some natural social distancing that occurs in regions where houses are few and far between. But officials say much of it is due to delayed test results.

For weeks now, confirmed cases of the coronavirus have popped up in more of Ohio’s 88 counties every day. The virus has effectively spread across the majority of the Buckeye State – from its first cases in northeastern Ohio to clusters in almost every major city.

Some of Ohio's Appalachian counties, however, still had no cases to report as of Friday. Hocking, Vinton and Harrison counties had zero reported cases of COVID-19, according to the Ohio Department of Health.

Putnam County in northwestern Ohio also had reported zero cases.

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By March 25, almost two-thirds of Ohio’s 88 counties had at least one confirmed coronavirus case. Yet only 13 of Ohio’s 32 Appalachian counties had a confirmed case by that date, mostly coming from the northeast corner of the state.

The total number of cases in southern and southeastern Ohio pales in comparison to those in urban counties, and many of the state’s other rural counties are reporting cases in the single digits.

But health experts say that because these counties are reporting zero confirmed cases doesn’t mean the virus isn’t there or present in larger numbers.

Brody Davis, Meigs County’s emergency response coordinator, said he was just waiting for the news of the county’s first confirmed case, which finally came Tuesday.

Davis said the mood of residents was split as to how serious to take Gov. Mike DeWine’s and Ohio Health Director Dr. Amy Acton’s orders.

Part of their reasoning — and likely one of the reasons why there haven’t been as many confirmed cases — is because of some natural social distancing that occurs in more rural regions, Davis said.

"We’re not packed together like they are in Columbus and Cleveland, but they don’t understand that going to the grocery store is the same here as it is in Columbus," he said.

Molly Davis, an epidemiologist and emergency response coordinator for Lawrence and Scioto counties and Portsmouth City Health Departments (and no relation to Brody Davis), said that social distancing doesn’t account for all of Appalachia’s lack of confirmed cases.

Much of it comes from a lack of testing, she said.

Southern Ohio Medical Center in Portsmouth started offering drive-through testing in late March, but there were some delays in getting results back because the tests went through private labs.

"We don’t know how long this virus has been here, but it’s been here a lot longer than we’ve thought," she said.

Timothy McBride, a health economist and professor at the Brown School at Washington University in St. Louis, has long studied public health and policy in rural America. He said that coronavirus presents unique challenges in an environment that might not be well prepared for it.

"People are often surprised that parts of rural America looks like central cities: low income, high poverty rates, high-school education only, low-skill jobs," McBride said. "Access to resources is a problem and bouncing back won’t be easy."

The effects when the pandemic peaks will be no less great in rural counties than they are in urban centers. Rural areas traditionally have much higher rates of chronic illness — diabetes and lung disease chief among them — that put the population at greater risk.

And statistics bear that out. Researchers with the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute compile annual health rankings for every county in the nation. And historically in Ohio, the Appalachian region has fared the worst.

Something else about this pandemic that could be especially threatening to the region is that rural hospitals already have been financially ravaged for a couple of decades, with many closing across the country.

Some counties with little to no hospital infrastructure are seeing this issue play out in another way during the pandemic. Without a place to get tested, some residents are traveling to other counties or states to find out whether they have COVID-19.

That can become a problem when local health departments, especially those along the Ohio River, want to keep track of their positive cases.

Brody Davis said that plenty of Meigs County residents have traveled to West Virginia to get tested and vice-versa.

There’s also the question of how those counties that do have hospitals will manage when the surge hits, said Jody Walker, executive director at South Central Ohio Job and Family Services.

"Those hospitals have to be prepared because they’re almost regional hospitals," Walker said.

Rhett Holland, Adena’s vice president of quality, is leading Ohio’s Region 7 in Southern Ohio for surge plans.

He said that Adena Regional Medical Center in Chillicothe is preparing to double its capacity to about 400 patients at the surge. Other hospitals in the area — which includes, among others, Adena facilities in Greenfield and Waverly as well as hospitals in Portsmouth and in Fayette County — are planning for the same doubling of capacity, although most are small to begin with.

In addition, the hospitals are preparing space for COVID-19 respiratory clinics, where patients who need management of symptoms but do not require hospitalization can go for treatment.

Rural hospital systems in America have long been strained and under great financial pressure, Holland said, but he’s confident that southern Ohio is as well positioned as it can be.

Just as pressing there, however, is the personal toll on the health-care workers.

"This virus is deadly. And in rural America we face a little different scenario. All of these hospitals are treating friends and family. The people coming in are people they know from baseball games and basketball games and church," Holland said.

"The fear of not being able to fulfill your commitment to your friends is real."

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