The coronavirus was slow to come to Foster County, North Dakota, a community of just over 3,000 people in the eastern part of the state. When virus cases surged in the Northeast in the spring, the county recorded just one positive case. When national case counts peaked in mid-July, it had recorded just two more.

But by Tuesday, about 1 in every 20 residents had tested positive for the virus. More than half of those cases were reported in the past two weeks.

Most of the worst U.S. outbreaks right now are in rural places like Foster County. Where earlier peaks saw virus cases concentrated mainly in cities and suburbs, the current surge is the most geographically dispersed yet, and it is hitting remote counties that often lack a hospital or other critical health care resources.

Since late summer, per capita case and death rates in rural areas have outpaced those in metropolitan areas.

The total number of coronavirus cases and deaths in rural places remains smaller than those in cities because of the comparatively low population in rural areas. But the rural share of the virus burden has grown over time.

Now about 1 in 4 deaths from the virus is recorded in a rural county. That stands in contrast to March and April, when almost every death was in a metropolitan area as the virus tore through the Northeast after early clusters in the Seattle area and populous parts of California.


During the summer surge, rural outbreaks occurred more often than they had in the spring, but reported cases per million remained higher in cities and their suburbs than in rural counties.

It was not until August, when the outbreak was receding from Sun Belt cities like Houston, Miami and Phoenix. that per capita rates of cases and deaths in rural areas surpassed those in metropolitan areas.

Now, with the national case count and hospitalization rates approaching a third peak, none of the country’s biggest hot spots are in a large city. Almost all the counties with the largest outbreaks have populations under 50,000, and most have populations under 10,000. Nearly all are in the Midwest or the Mountain West.

Although the outbreak’s geographic spread is expanding, many of the same kinds of places remain at risk for clusters of infections. In Norton County, Kansas, the hardest-hit county in the country relative to its population, all 62 residents of one nursing home have been infected with the virus, and 10 have died. A state prison in the county also has an outbreak.

Hospitals across the upper Midwest and the Mountain West are also feeling the surge. Facilities are struggling with capacity, and in some cases residents are finding that the nearest hospital with available beds is hours away or in another state.

Earlier this month, hospitals in North Dakota had to turn patients away. Bismarck, the state’s capital, had one staffed intensive care unit bed available as of Monday.

Overwhelmed by the record case numbers, North Dakota suspended its contact-tracing program this past week. New Mexico’s governor, also seeing hospital beds fill up in her state, plans to put in effect new restrictions on restaurants, bars and retail stores.

And Alaska, which is experiencing record numbers, provides a cautionary tale: Even with extensive testing and robust contact tracing, the virus is poised to thrive as temperatures drop and people move activities indoors.