Ocracoke is one of the most remote places in North Carolina. A view of Ocracoke’s harbor with Portsmouth Island in the distance beyond. Photo: C. Leinbach

Reprinted by permission from the Raleigh News & Observer

By Adam Wagner

Columbia, N.C. — On U.S. 64, just past Full Circle Crab Company, a N.C. Department of Transportation sign flashes a message: “Dare Co. Access Limited” followed by a warning that there’s a checkpoint ahead.

“The more people that find out about that, the less people that are going to come through here,” said Jacob Rhodes, who oversees peeler crabs and catches fish as Full Circle’s dock boss. The crab company sits on the outskirts of Columbia, the seat of Tyrrell County, one of a handful in North Carolina that have recorded few if any cases of coronavirus.

Tyrrell County is the state’s least populous, with just over 4,000 residents, according to the U.S. Census Bureau. Elected and public health officials alike believe that lack of density was pivotal in Tyrrell’s not having a confirmed case for so much longer than most other corners of the state.

The county is also relatively isolated in the state’s northeastern corner, with most visitors coming through on U.S. 64 en route to the Outer Banks. People point to Dare County’s shutdown, which has made outside traffic effectively nonexistent, as another factor protecting Tyrrell from the coronavirus.

“No question that cut the traffic coming through to Tyrrell County and people stopping at stores and buying gas, which we enjoy and appreciate, but in this situation it has curtailed the potential exposure to the virus from the outside,” said James Cahoon, Columbia’s mayor.

There are seven counties that still do not have any confirmed cases of COVID-19. Of those, Camden and Hyde are near Tyrrell in the state’s northeastern corner. Another five — Avery, Graham, Madison, Swain and Yancey — run along the state’s western border.

It is not surprising that urban parts of North Carolina have seen confirmed cases rising faster than rural areas, said Mark Holmes, director of UNC Chapel Hill’s North Carolina Rural Health Research and Policy Analysis Center. Generally, Holmes added, rural areas’ tendencies toward less dense populations and having fewer places for people to congregate can provide some protection in the early days of a pandemic.

But at the same time, rural communities — including nearly all of the seven North Carolina counties without cases — tend to be older, poorer and have higher rates of uninsured people. Those seven counties also have a total of 16 long-term care facilities or nursing homes, as well as three state prisons, the congregant living facilities where outbreaks have had the most significant impact nationally and across North Carolina.

Rural areas also, Holmes said, tend to have more households with multiple generations of family members living together, a potential risk factor for COVID-19.

“Once it gets seeded in a rural area, it can spread quickly and grow really fast, partly because of the generally higher risk profile of rural communities, certainly in North Carolina, but even nationwide,” Holmes said.

COVID-19 in Tyrrell County
Columbia, which sits on the banks of the Scuppernong River, was virtually abandoned on Monday. A visitor’s center near the foot of the Scuppernong River Bridge was closed. Anyone walking on the town’s river walk seemingly inches above the water could clearly hear the tinny squawk of the drive-thru at the nearby BB&T switching on when someone drove up.

In downtown Columbia, visitors still passed in and out of the local hardware store. But the town’s pharmacy was only offering drive-up service, with customers waiting in their cars while masked employees brought their prescriptions out of the store. Next door to the pharmacy, The Red Wolf Coalition had a handwritten chalk sign in its window stating, “What you do today can improve all your tomorrows.”

Less than a mile away, the town’s Food Lion had one-way signs on all of its aisles and plastic shields up in front of all of its cash registers — requirements, per an executive order signed by Gov. Roy Cooper. In nearby Alligator, Colon Bailey sprays disinfectant and wipes down the counter while chatting with a visitor at Bailey’s Southside Store.

“People here have taken it seriously for the biggest part,” Cahoon said.

At Full Circle, Rhodes, the dock boss, noted that while business from tourists passing through to the Outer Banks has come to an abrupt stop, locals have filled in some of that missing business. This year, though, the fish house made about a fourth of its normal Easter weekend sales.

Rhodes said the fish house needs the seafood markets throughout the country to reopen so it can start making sales. But at the same time, he recognizes that more connections outside of the county mean more chances for the virus to get in.

“The biggest concern with me is not trying to spread it to my older people,” Rhodes said. “If I get it, whatever, I’m going to live through it more than likely, but if I get it and my grandma or somebody catches it, that would be terrible.”

Many rural corners of North Carolina are like Tyrrell, said Greg Griggs, executive vice president of the N.C. Academy of Family Physicians. Before speaking with a reporter about COVID-19 in rural areas, Griggs checked with physicians in Bladen, Sampson, Transylvania and Vance counties.

“All the doctors I talked to said that they thought people were taking the social distancing very seriously. … Their patients are legitimately scared. They’re being very cautious and worried and concerned,” Griggs said.

Angela Spencer is among those who are worried about COVID-19. On Monday afternoon, Spencer was taking advantage of a clear, sunny afternoon to walk around Columbia’s historic district, past the courthouse with its flags flapping in winds lingering behind a storm. Past houses with historic plaques. Past attorney’s and insurance offices with signs warning that service was still available, but nobody would come to the door.

Spencer works at a small daycare center. On a normal day before the pandemic, she said, there would be about 40 kids at the daycare. Now, there’s about 20.

Employees greet children at the door, and parents are not allowed inside, Spencer said. Throughout the day, Spencer and other employees take children’s temperatures several times to make sure none are elevated.

“As an essential worker, it’s a little nerve-wracking going into work,” Spencer said. “You just never know where people have been, parents and all. You just never know their day-to-day, especially with some of them working in places where there are cases, and then they have to come home to little Tyrrell County.”

Around the time Spencer was describing how she has twin boys at home taking care of their little brothers, Tyrrell County was confirming its first case of COVID-19.

Testing in rural areas
Wes Gray, the health director for Martin-Tyrrell-Washington District Health, acknowledges that there are almost certainly more cases than what’s being recorded.

People who have contracted COVID-19 but are asymptomatic are not being tested, nor are people with mild symptoms who are frequently being told to stay at home or those with symptoms who don’t meet testing guidelines. To be tested in North Carolina, someone must have a fever or respiratory symptoms, as well as either contact with a confirmed COVID-19 patient within the past two weeks or a negative rapid flu test.

“Just because there’s no cases does not mean it’s safe to, say, go out to the store or do all those things. It’s really essential that you stay home and do social distancing,” Gray said he told residents before the case was confirmed.

Gray said tests are being conducted at health departments and at hospitals throughout the three-county district. Those providers are no longer required to report how many tests have been conducted; therefore, health officials do not have “a complete and accurate count” of testing.

In rural parts of the state, doctors are likely adhering more strictly to DHHS guidelines, Griggs said.

“They’re really only testing folks who are going into the hospital or close to being hospitalized or if it’s a healthcare worker. In many of the rural counties, you’re seeing really strong adherence to that criteria because it’s been more difficult to get tests and there aren’t as many testing sites,” said Griggs, who added personal protective equipment shortages could also be limiting testing.

Gray, the health director, said he believes the tri-county area has adequate testing kits and supplies. Turnaround times for test results have dropped, he said, from a week to 10 days last month to about 48 hours now.

On the western end of U.S. 64’s trip through North Carolina, health care professionals are also receiving COVID-19 results more quickly, said Antony Chiang, the CEO of Dogwood Health Trust, which was formed to promote public health using proceeds from the sale of Mission Hospital. In the pandemic’s early days, Dogwood established relationships with smaller labs and was able to access test kits for a region encompassing 18 western counties and the Qualla Boundary.

Those tests were particularly useful after a New York state resident who was asymptomatic attended a March 10 contra dance at the John C. Campbell Folk School in Brasstown. After the person tested positive, Dr. Brian Mitchell and officials from the Cherokee and Clay county health departments used kits from the trust to test 75 people who had been at the dance.

Six of those people tested positive.

“Our population may be sparse, but we are not so remote, as this recent experience shows,” said Mitchell, a Murphy physician. “We can have the virus strike, and we can be vulnerable if we don’t have the testing and tracing that we should have. We may be more vulnerable than other communities because of our limited resources and limited staff in our hospital.”

While social distancing seems to be preventing the coronavirus’ spread in much of Western North Carolina, Chiang still echoes Mitchell’s concerns that a smaller outbreak in that area would overwhelm hospital resources and staff faster than those in other states.

It is possible, Chiang warned, to be lulled into “a false sense of security.” He pointed to the Spanish Flu pandemic of 1918, where rural communities largely ducked the first wave during the summer but were severely impacted by a second wave in the fall.

“My caution to all rural communities in North Carolina is: It’s looking good on the first hump,” Chiang said, “but let’s not experience what happened in 1918 by having a much worse second hump.”

This reporting is financially supported by Report for America/GroundTruth Project and The North Carolina Local News Lab Fund, a component fund of the North Carolina Community Foundation. The News & Observer maintains full editorial control of the work.


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