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LA CRESCENT, MINN. – Juggling waitressing and motherhood one morning last week at Kaddy's Kafe, Amy Jore had one eye on her customers and another on her 10-year-old son, Henry, as he tackled his homework in the restaurant's storeroom.

It's a balancing act forced on Jore by COVID-19, which is rapidly spreading across the countryside near this southeastern Minnesota river town and which prompted the temporary closing of Henry's school.

"My main concern is the lack of control we have as people of the community, and the lack of protection I can provide for my family," Jore said. "This has had an impact on my family — financially, mentally, emotionally."

As the deadly virus rolls through the Midwest, case counts are surging in rural communities like never before. Once considered a more serious threat in urban areas, where social distancing and avoiding crowds can be more difficult, the virus is now hitting many small towns and hamlets that had previously dodged some of the worst of it.

Since the beginning of October, the 10 Minnesota counties with the fastest case growth are all in rural parts of the state. And Houston County, where La Crescent is located, has had more new cases in the past six weeks of the pandemic than it reported in the first six months.

"It's very striking that the greater part of the state has just lit up with cases in the last number of weeks and months," said Kris Ehresmann, director of the infectious disease division at the Minnesota Department of Health (MDH). "If you think about the cases that we were seeing early in the pandemic, they were focused quite a lot on the metro area and the population centers."

Early on, many outbreaks in rural areas stemmed from infections at a workplace, school or long-term care facility, where residents tend to be older and more at risk for infection.

Now, health officials say, the spike in COVID-19 cases is coming from scattered transmission across communities as cooler weather pushes more people indoors for gatherings with friends and family.

Adjusted for population, the rate of new cases across 56 counties in greater Minnesota has tripled between early September and early October, according to a Star Tribune analysis of MDH data, compared with only a doubling of the rate across the seven-county metro area during that time.

The analysis lines up with other data showing cases growing faster than the statewide average in central, northwest and west central Minnesota. The regional growth rate is highest in the southwest part of the state, Ehresmann said.

Bar closing in Nevis

Why the rural surge?

Ehresmann suggested it could stem from fewer people in more sparsely populated areas wearing masks, maintaining physical distance and following other public health guidelines to slow the spread.

Other health experts suggest rural Minnesotans are influenced by the example of neighboring states where public health responses, such as mask mandates, haven't been as aggressive. And there's the possibility that people in border communities, such as La Crescent, could become infected by travel to Wisconsin and North and South Dakota.

Houston County sits across the Mississippi River from La Crosse, Wis., one of the nation's COVID-19 hot spots.

"A good number of our population commutes to La Crosse on a daily basis for work, for shopping, for other things," said John Pugleasa, Houston County's director of public health and human services. "That's a population that's had a significant increase, and our folks are in and out of there a lot. That's the definition of community transmission."

Last week, the spike in COVID-19 cases in northwest Minnesota prompted drastic measures in the town of Nevis, where the City Council closed the municipal bar to help contain virus spread. Rich Johnson, a council member in the town of 400 in Hubbard County, said he voted for the temporary shutdown as a safeguard for the community.

Even with the influx of people driving north from the Twin Cities this spring and summer to visit cabins, Nevis and the surrounding area didn't see much coronavirus, Johnson said. Early on, someone even had a bit of fun with the pandemic by fashioning a mask out of a bed sheet and placing it on the city's 30-foot sculpture of a tiger muskie.

But on Thursday, Hubbard County reported 346 confirmed coronavirus cases — a huge jump from just 56 in mid-September.

"People have the fatigue," said Marlee Morrison, the county's community health director. "So, they still want to have their events and they want to have weddings and want to have craft fairs and those kinds of things. ... Everyone just needs to be so careful because it's really spreading."

Other health officials agree.

"I think people have become complacent in not following the recommended guidance," said Jennie Lippert, director of health and human services in central Minnesota's Kandiyohi County, which added 186 new cases last week. "I think everyone is getting tired and weary of COVID-19, especially going into the winter months."

The president of the hospital in the Hubbard County seat of Park Rapids posted a letter on Facebook last week urging residents to stay home when sick and avoid gatherings. Nearly 200 new county cases were reported in October alone, wrote Ben Koppelman, president of CHI St. Joseph's Health. And the county's share of positive coronavirus tests is running much higher than the statewide average.

"Things have shifted dramatically," Koppelman wrote.

Surge in southwest

Case growth in southwest Minnesota is due to a number of factors, said Carol Biren, public health director with Southwest Health and Human Services, an agency that serves six counties. They range from transmission at weddings and group gatherings to an outbreak at a long-term care facility. Her agency is drafting a letter to churches that highlights the importance of wearing masks and seating families at a distance from one another.

Liz Auch is the administrator at Countryside Public Health, an area health agency serving five western Minnesota counties. Over the past seven days, Chippewa County, one of those Auch administers, has reported one of the fastest-growing rates of COVID-19 in the state.

Her agency is paying special attention to schools, holding weekly calls with the superintendents of every district in the five-county area. And it's not just for the sake of the students' health — it's also because high schoolers make up a big chunk of the workforce in the area's nursing homes.

If the kids get sick, there won't be enough people to care for the older people, Auch said.

A big jump in cases this fall in Rock County, in Minnesota's southwest corner, is putting a bit of pressure on the Sanford Health hospital in Luverne, the county seat.

For months, the medical center didn't see any patients stricken by the virus, and the count grew to just one or two at a time starting in July, said Dr. Diane Kennedy, a family practice physician. Last week, as the state reported three of the county's first four deaths from COVID-19, the medical center was treating five or six coronavirus patients per day.

"It definitely feels like we're surging," Kennedy said. "I'm worried about what the next month or two will be like, just because people are indoors and people are sharing COVID more."

Sanford Health is careful to make sure workers don't contract the virus at the hospital or the clinic, Kennedy said, but that doesn't protect them when they're out in the community. For now, there's the capacity in the hospital and enough staff to care for patients, yet she worries about the future because "we don't have a long list of people that we can just call in."

Luverne is located just 15 miles from Iowa and South Dakota, states without mask mandates. As Kennedy goes about town, she's routinely disappointed by how many people aren't wearing masks.

"We're in it every day — we're taking care of sick patients, and we're taking care of people who are afraid of getting sick," she said. "Then you leave the clinic and you leave the hospital, and it almost seems like people don't think it's happening."

"If you don't work in it all day long," Kennedy added, "maybe you don't realize how real it is."

Across the state, in Houston County, that reality is setting in, too, along with a sense of resignation.

"It's here. Let's face it," said David Tessmer who farms corn and soybeans outside Caledonia. "Once it's here you don't stop it — you just deal with it best you can."

Staff writers MaryJo Webster and Leila Navidi contributed to this report.