I read a wise essay in Mother Earth News in the 1970s, which pointed out that the number of people who can live in an area without seriously polluting it is dependent on technology. With that audience, the tendency was to think much more in terms of absolute numbers. The earth has too many people! We can’t support them all! Pollution is out of control! The author noted that a solitary person living in the wild, defecating on the ground without even a trench, pollutes a sizable area. Without any food preservation or storage techniques he might need a wide area as well. Yet with technology we can build Manhattan, treating our sewage and carting it off. Transportation allows food to travel, so some can specialize in making lots of it and sending it off.
Something similar came up in the C19 discussions that I think got missed. We should be glad that it got missed, because it would only be front-and-center in our thinking if things had gone wrong. Some rural places did have the possibility that their local health systems would be overwhelmed. As there weren’t that many of them, however, they could spread the medical response to nearby hospitals and clinics. In number of cases per thousand people, Dougherty County GA (pop 90K) got hit hard – 140 deaths, as did a couple of neighboring counties. The two counties next to it with about 8,000 people each have a death rate of over twice Dougherty’s 1500/mil. Per capita, Georgia’s rural counties are doing substantially worse than Atlanta. Over 2,000 deaths per million in that SW area. I think that’s worse than NYC.
Rural counties do fine until they don’t, which I think informed a lot of the thinking early on. Once they stop doing fine, it was impossible to get help there when test kits and everything else was so lacking. An outbreak of 20 people in a rural county can quickly become less manageable than an outbreak of 200 in Boston if there’s no hospital nearby. Considering how to handle these counties will definitely have to be part of a response plan going forward. 25 deaths in a county of 8,000 may not make the news, but when you consider 3-4 times as many may have been seriously ill, that’s a lot for one group to handle.
Franklin, NH has about 8,000 people but a disproportionate number of deaths because of one nursing home, with many positives among both staff and residents, who had and have contact with the rest of the community. (There may be more to the story if I were on the ground there. I only know what I read in the papers.) The city has a regional hospital which was nearly overwhelmed, but there are three other hospitals thirty minutes away, two of which were not treating many cases at the time. I didn’t even hear about it an hour away, but the news for that region was full of anxiety and apprehension for a few weeks. Nationally, a few local systems were briefly overwhelmed. How you view that largely depends on whether the word “few,” “briefly,” or “overwhelmed” jumped out at you. Such are the things which create confirmation bias, where we reinforce some ideas without much thinking about them.