Roxine Poznich says she won't close her used book shop in Fort Scott, Kansas, until someone makes her.
The 73-year-old proprietor worked in the lab at the town's hospital for decades. But that job vanished when Mercy Hospital closed its doors two years ago. She now relies on the bookstore income for grocery money, she said.
Like many who live away from the country's large population centers, Poznich says she isn't too worried about the coronavirus. But she said the lack of a hospital in the southeast Kansas town of 7,800 will exacerbate any local outbreak.
"I think it will make a big difference," she said. "It just depends on how hard it hits our county."
As U.S. cities virtually shut down and brace for an influx of coronavirus infections, the story in rural America is a different one. From small-town Florida to Georgia's central peach region, from southern Mississippi to the Kansas and Texas plains, some residents say the threat is overblown. Others worry about how they will face the pending crisis with a widespread lack of resources, supplies and preparedness.
Across the country, more than 125 rural hospitals have closed since 2010, according to the Cecil G. Sheps Center for Health Services Research at the University of North Carolina.
"Rural populations are older, sicker, poorer, and have less access to private health insurance," said Kristie Thompson, a research associate at the Sheps Center. "These are issues that make providing health care challenging in rural communities in the absence of a pandemic."
And in a pandemic, even small communities that have held onto their hospitals may lack ICU beds and ventilators needed to care for the critically ill during a widespread outbreak.
The crisis underscores what many rural residents already know: Rural and urban health care are not two distinct systems. Rather, they are intricately connected, with rural patients frequently traveling long distances to receive specialized care. That means a lack of rural capacity may further heighten competition for hospital beds and ventilators in major metropolitan areas.
Yet even as the virus rapidly spread across the nation this week, some who live outside large metropolitan areas wondered if too much was being made of the threat to them.
"I tried to downplay it, too, until everything around me started closing," said Sharon Hupp, 77, as she waited in line for lunch Wednesday with a small group of friends in Arcadia, Fla., a town of fewer than 10,000 residents. "Look at Disney, spring training and Broadway. That's when I thought 'OK, this must be real.'
"People need to wake up."
For now, rural communities in Florida and across the country may seem a safe haven. Compared to cities, relatively few cases have been reported there.
On Tuesday, President Donald Trump said he thought the virus would remain concentrated in certain "hotspots."
"It's going to be different for New York than it's going to be for, you know, Iowa or from Idaho or from West Virginia, frankly," Trump said.
But that same day the disease officially reached West Virginia, though experts said it likely was a lack of testing that made it the last state to report a case.
Polling released on Wednesday showed only 25% of Americans living in rural areas considered the pandemic a risk to them, compared with 33% of city dwellers.
In Motley County, Texas, volunteer fire chief Rodney Williams said there have not been any emergency declarations at the county or city level, and there most likely will not be any.
"Other than city folk coming down trying to buy all our toilet paper, we haven't been affected," Williams said.
But as COVID-19 begins to spread, rural counties could see their limited public-health infrastructure stretched too thin. And it could happen more quickly than anyone is prepared for, experts warn.
Some rural communities have large senior populations and only one small hospital serving several towns. And no ventilators, the critical lifeline for patients who can't breathe on their own.
Randy Hubbard, emergency management coordinator for Washington County in north-central Kansas, said the county has about a dozen towns and unincorporated areas, three nursing homes and two hospitals.
"If we had a big outbreak we would probably be scrambling, because they are smaller hospitals," Hubbard said.
Another frightening prospect? Not a single ventilator in the county of 5,700 residents.
"We have access to get some," Hubbard said, "but we don't have them."
That access, however, may be severely limited. The Kansas Department of Health and Environment on Wednesday said hospitals reported that there were 168 ventilators available across the state, with hundreds more currently in use. Well over half of those are located in Kansas City and south-central Kansas, which includes Wichita.
For the north-central region of the state, only seven of those machines were available.
In some counties, the emergency managers were unsure if they had any ventilators.
"I don't believe ours does," said Kris Casper, the emergency manager and undersheriff for Wichita County in western Kansas, which has three towns and one hospital. He said his office would be talking to the hospital about that issue this week during a meeting with county health and safety officials.
Casper said there have been no coronavirus cases in the county so far. The only case confirmed in the western half of the state is a woman in her 60s who had traveled to Ford County.
Some local officials across the country expressed frustration with guidance from Trump, as well as members of the White House coronavirus task force, after they were encouraged to find critical medical equipment such as respirators and ventilators � in short supply worldwide � on their own.
Trump argued that state and local purchases would streamline the direct supply of materials, cutting out a federal bureaucracy increasingly overwhelmed by requests for aid.
But rural communities have neither the money nor the contracting power of the federal government to secure supplies from a limited number of vendors currently swamped with international orders.
Holton Community Hospital in Jackson County, Kansas, has no ICU and only one ventilator. But it's not designed for long-term care and is mostly used to stabilize patients who are transported to bigger hospitals, CEO Carrie Saia said.
She acknowledged that access to ventilators will be a major challenge in rural Kansas in the case of a widespread outbreak.
"I think that is a big worry for all of us," she said. "If it gets to that point, how will we handle that?"
Generally, about half the beds at Holton's 12-bed hospital are full. But lately, about eight or nine beds have been occupied.
The private, not-for-profit facility has transfer agreements with bigger hospitals in Topeka, about 30 miles away. But Saia said it's also bracing for the possibility of caring for less critical Topeka patients who are sent there if beds in the state capitol fill up from more severe cases.
For now, Holton's hospital has started screening visitors and has converted a shed into a temporary testing site. It may begin limiting elective surgeries in an effort to conserve supplies.
"If we're out of supplies and then we have to start triaging who receives what type of care," Saia said, "that will be a challenge for us."
On Thursday, state officials confirmed the county's first case.
Reynolds County, Missouri, with a population of less than 7,000 in the Ozark Foothills region, doesn't have a hospital.
Renee Horn, the county's emergency manager, said no one has tested positive for COVID-19 yet. If someone had coronavirus, Horn said, the nearest hospitals are in Poplar Bluff, about 70 miles away, or Farmington, a 54-mile drive.
For testing, Horn said Reynolds County would probably have to send residents to St. Louis or Cape Girardeau, both of which are roughly two-hour drives.
"Some of (my concern) is when you look at the hoarding and that type of thing, especially in our area because everything is so far away to access supplies for our daily life," Horn said. "Part of my concern as well is transferring of people with underlying issues. We have a lot of elderly people in our county."
In rural Georgia, county sheriffs are more than just the head of local law enforcement. They're responsible for their own mini-cities _ county jails _ which are often the second-largest health care provider in the county.
COVID-19 threatens to both spread quickly among inmates and cut into the number of available deputies.
Terry Deese, the sheriff in Peach County, which straddles Interstate 75 and is home to 27,000 people in the heart of the state's peach-growing belt, has in recent days reminded deputies and jailers to wash their hands and be on the lookout for signs of illness.
He has a staff of about 50 and a jail that houses 90 or so inmates. On a recent afternoon, Deese gathered some of his charges and told them, "Y'all are priority No. 1. If y'all go down, we can't serve the people we are sworn to serve."
Deese has equipped them with extra protective gear _ gloves, masks and sanitizer _ and has committed to helping other law enforcement agencies in his county deliver groceries to the elderly.
"We're in uncharted waters here," the sheriff said.
Already, one DeSoto County, Florida, firefighter is in quarantine after coming into contact with a patient believed to have COVID-19, said Chad Jorgensen, public safety director for a county of fewer than 40,000 people.
"There's not a lot of reserve capacity in the department as far as personnel," said Jorgensen, whose roughly 75-person department provides fire-rescue and paramedic services for the entire county. "It's not like heart attacks and strokes stop. This is an added burden."
The county is seeing an uptick in 911 calls from people reporting flu-like symptoms, he said. First responders are using masks, goggles and in some cases Tyvex suits. If they believe they may have been exposed on a call, they must decontaminate their persons, equipment and trucks.
"The reality for places like DeSoto county is we work very well in our world, but the redundancy in our system does not lend itself well to having 10 people not being able to show up to work," Jorgensen added. "For bigger departments, that's an inconvenience. But for us that could be very very detrimental."
Research has shown that infectious diseases spread more rapidly in densely populated urban areas than in rural communities. But rural areas can be easily overmatched.
"In one sense (rural areas) are a little less at risk, but if they get one case and then another and so on, they may be ill-equipped to deal with it," said Mary Jo Trepka, a professor of epidemiology at Florida International University's Robert Stempel College of Public Health and Social Work.
Back in Fort Scott, Kansas, just steps away from the namesake 1842-era historic Fort Scott National Historic Site, customers at Poznich's Books & Grannies must navigate a narrow pathway that separates towers of westerns, fiction and children's titles.
With classes canceled through the end of the school year by Kansas Gov. Laura Kelly, Poznich said she might see more demand from families seeking books to help pass the time. She said the small shop isn't exactly a gathering spot for large groups.
So she won't close unless the government orders her to.
"If they shut me down, they shut me down," she said earlier this week.
In nearby Wilson County, emergency preparedness coordinator Terry Lyons said residents are concerned, but "not in panic mode." Some people, he said, think the response by government agencies has been overblown.
"With social media and stuff, you hear comments from both sides," he said. "But I think we're just being pretty calm about it. The mortality rate is lower than the flu. It's more contagious than the flu. So we're trying to take those precautions so that we don't transmit the virus from one person to another."
Dr. Anthony Fauci, the federal government's leading infectious disease expert, says the novel coronavirus is 10 times more lethal than the seasonal flu, which has a 0.1% mortality rate.
Stone County, Miss., population estimated at 18,717, waited until Wednesday to consider limiting access to the courthouse.
"All of our offices and everything are still functioning at this point," said Clark Byrd, vice president of the county Board of Supervisors. Byrd said Wednesday morning that he is still operating his tax business downtown.
"Everything is going on pretty much as normal," Byrd said.
Board president Lance Pearson said the county has not restricted access sooner because officials and employees feel a duty to serve the public and because Stone County has no reported cases of COVID-19.
Raven James, the emergency manager for Stone County, said people are still out and about, buying supplies and preparing.
"I don't think we need to panic at this point," James said. "Just be careful, try to be as smart about it as you can and don't take any unnecessary risk."
Owners at Arcadia's Yellow Deli Bakery in Florida said Gov. Ron DeSantis' restaurant capacity mandate hasn't been an issue, especially in a shop that doesn't typically fill up with customers.
"We actually want people to come in and eat with us. They don't have to be turtles in a shell," said co-owner Hushi Hartgraves.
Still, the risk of an outbreak in such a small city is cause for concern.
"From my perspective, the information we've been given so far on the number of cases and deaths compared to something like the swine flu is making people wonder why this coronavirus has become such an issue," Arcadia City Administrator Terry Stewart said. "However, the last thing you want to do is act like it's a hoax, because before you know it, you're right in the middle of it only to find out you're wrong."
