Covid-19’s fierce winter resurgence in California is notable not only for the explosion in overall cases and deaths in the state’s sprawling urban centers. This latest surge spilled across a far greater geographic footprint, scarring remote corners of the state that went largely unscathed for much of 2020.

In the past two months, covid-related infection and death rates have jumped exponentially in California’s least populated counties.

From March through November, the state’s 25 least populated counties collectively reported 235 covid-related deaths, a per-capita death rate about 60% lower than that of the rest of the state. (California has 58 counties.) From Dec. 1 through Jan. 29, those same rural counties reported 427 covid deaths. That is nearly twice as many deaths in 60 days as in the preceding 250.

These 25 rural counties encompass some of the state’s most dramatic and rugged terrain, spanning mountains, forests and vast grasslands in California’s far north and along its eastern border. About 1.2 million people live in those counties, in small towns and agricultural outposts largely buffered from the state’s big cities and suburbs by distance and topography.

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In the months after covid first emerged in California in January 2020, its reach was deadly but comparatively contained. It initially surged across densely populated areas of Southern California and the San Francisco Bay Area, then seeped into major agricultural and industrial hubs in the Central Valley and rural Imperial County, which shares a border and close community ties with Mexico.

For months, residents of the state’s remotest counties were able to move about more freely — and with less fear — than their urban peers. The covid death rate in the state’s 25 least populated counties was 90% lower from March through June than the rate in the rest of the state.

That began to shift in summer and changed dramatically during a third covid surge that exploded in late fall. In December, the 25 least populous counties collectively reported about 24,600 new covid infections — a 141% increase from November. In December, the death rate in those 25 counties roughly matched the rate in the state’s urban centers.

The rural death rate plateaued in January while the urban death rate continued to swell. Even so, the rural death rate in January was more than six times as high as in November.

Epidemiologists point to several reasons for the shift. While these counties are remote, they are not walled off. Many rural residents regularly drive to urban areas for goods and services. They get tourists. Several of California’s rural counties are home to large state prisons, teeming facilities that have experienced some of the worst covid outbreaks in the nation. Those outbreaks infect not only inmates housed in close quarters, but also guards and other staffers who live and shop in the surrounding communities and carry the virus out with them.

Once covid arrived, it multiplied. Rural communities tend to have a few central places where many people congregate. Those places became breeding grounds for the virus.

“In very small towns, you’ve got Dollar General, the coffee store, Walmart, church,” said Alan Morgan, chief executive officer of the National Rural Health Association. “You get the entire community going into three or four chokepoints, you’re going to infect the whole town.”

While covid has stressed public health agencies across the state, the challenges are brutal in rural areas, which tend to operate on tight budgets, with minimal staffing. As covid cases multiplied, rural health directors struggled to expand their response.

Dr. Gary Pace is the public health officer in Lake County, a wine-growing region and recreational mecca in north-central California that’s home to about 63,000 residents. Pace recounted how, early in the pandemic, his department was able to conduct intensive contact tracing as cases emerged, keeping outbreaks contained.

“There was a farmworker outbreak in June or July, and we basically drove out to that vineyard and set up a testing site and tested 150 people that day,” he said. “Same thing happened with the tribal outbreak recently. So in these high-risk communities where the spread can get out of control really fast, we were able to sort of jump on it and really try to stay on top of it.”

The county reported an average of four infections a day from March through November. In December and January, the figure jumped to about 31 a day. Contract tracing became untenable. “That worked until it didn’t,” Pace said.

In some rural counties, the viral spread was exacerbated by politicization of basic public health safeguards like wearing masks and physical distancing. California’s rural counties tend to run politically conservative, and many residents and elected leaders were indignant about state covid mandates that closed businesses and strictly limited social gatherings.

“You have two segments of people,” said Valerie Lakey, executive director of community relations and business development at Mayers Memorial Hospital District in Shasta County. “You have the people that are definitely on board with doing all the things they’re supposed to be doing, and then you have the rest of the people that don’t want to be told what to do.”

Lakey’s hospital is in Fall River Mills, a short drive from the border with Lassen County, a mountainous tourist destination that’s home to 29,000 people — and where covid deaths jumped to 14 in December and January from only two in the previous nine months.

Mayers Memorial normally sees three or four patients each day in its acute care hospital. In mid-January, it was seeing about 14 a day, Lakey said. Her small staff has struggled to keep up.

Lakey noted that the hospital’s covid patients “have all been on the older side, like probably 70-plus,” underscoring another vulnerability for rural counties. Residents of California’s least populous counties tend to be older than the statewide average: about 20% are 65 or older, compared with 14% of residents statewide. Age has emerged as the No. 1 risk factor for covid-related hospitalization and death.

In rural enclaves, as in the rest of the state, the number of new covid cases reported each day has begun to subside, though case rates are still much higher than in November. The state’s expansive vaccine rollout offers further hope, but in the short term it serves as another stress on resources as health officials try to vaccinate thousands of people while continuing to manage the pandemic.

“Everybody’s been working seven days a week for the whole 10 months now,” said Lake County’s Pace, “and it’s starting to show.”

Phillip Reese is a data reporting specialist and an assistant professor of journalism at California State University-Sacramento.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

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