I welcome and appreciate the focus of the media on C19 in rural America, but I would encourage journos to look at the causes behind the increased burden as multifactorial. What are some of these factors? Glad you asked!

1) Rural faces challenges in many of the risk-avoidance strategies we have in urban. Grocery pickup? Delivery of household staples? Work from home? Food delivery? Reliable broadband? These risk-minimization techniques are more prevalent blessings in urbanized areas.

(I also continue to wonder about the overlap of social networks in rural areas through the one grocery or big box: the whole community goes to one place. Would love to see work in this area. @PaulDelamater is looking at this.) https://twitter.com/JanProbst/status/1334183207764418560?s=20

2)Testing. We know that testing in rural areas has been more limited, which makes stopping outbreaks more difficult. https://www.castlighthealth.com/wp-content/uploads/2020/05/Retail-Clinics-COVID19-Report.pdf?utm_source=newsletter&utm_medium=email&utm_campaign=newsletter_axiosvitals&stream=top (May) and https://www.beckershospitalreview.com/public-health/most-rural-us-counties-in-covid-19-testing-deserts-analysis-finds.html (June)

3)We know rural America is older and has more risk factors – 50% of rural America is at increased risk for hospitalization vs. 40% of metropolitan residents. So given the same infection rates, we expect more hospitalizations in rural areas. https://onlinelibrary.wiley.com/doi/full/10.1111/jrh.12481

4) The capacity of the rural HC system to manage outbreaks – fewer doctors and nurses, hospital beds, ICUs, vents – makes Tx'ing cases more difficult. And if your local hospital has one resp therapist, you better hope they or their family don’t get sick. http://www.shepscenter.unc.edu/download/19926/ 

5) Yes, there are plenty of examples where rural policymakers and leaders have been more resistant to implementing evidence-based public health strategies. Of course, we can find numerous examples in urban areas and among statewide leaders as well.

6) With all these drivers, I get frustrated with the “here in rural America, they don’t wear masks” trope. At my local (urban) grocery, I always see >1 customer not wearing. That's rarely a theme in most urban-based stories.

Of course, I am NOT saying that people in rural areas don't wear masks less (they do) or that mask-wearing isn't correlated with cases (it is). I am saying it's one of many drivers. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0240785

So maybe rethink the story framed around the rural resident who refuses to wear the mask – it paints 60 million Americans with one broad brush and implicitly blames ALL of them for their higher C19 burden. It's far more complex than any one issue. -30-