Just as families are gathering for the holidays, many rural communities are dealing with a growing number of COVID-19 cases and deaths.
James Hamilton's life was so entwined with the community in Spindale, N.C. - population 4,200 - that he figured the hour-plus commute to his job as campus police officer at UNC-Asheville was a small price to pay.
He was a town commissioner and a deacon at his church. He coached youth basketball and football. And his wife Sophia said he still somehow found time to mow the grass at the church and at friends' and neighbors' homes.
"They had him more than me," she said. "But I know that was his heart, and that was his calling. So I just had to get over it."
But they don't have him now, and she doesn't either. Hamilton died last month at age 55 after contracting COVID-19.
Many rural areas in North Carolina escaped the worst impacts of the first peak in the pandemic this summer. But the even-stronger second wave is hitting places like Spindale hard.
In November, state health officials found rural counties were reporting nearly twice as many new cases as urban and suburban ones. And rural deaths tied to COVID-19 also have been climbing significantly.
Hamilton's wife said he likely caught it while he was, as usual, looking out for others. He visited a neighbor who was dying of cancer, then got a call. The neighbor's son, who had been present during the visit, had tested positive.
His wife said Hamilton immediately got tested, but the results were a false negative.
"And then when everything started going downhill, they went on and took a rapid COVID test and found out he had double pneumonia," she said. "And he did have COVID."
In North Carolina, the pandemic started in urbanized areas, said Mark Holmes, director of the North Carolina Rural Health Research and Policy Analysis Center at UNC-Chapel Hill.
"It's been spreading to rural, ever since the beginning," Holmes said, "and now we're seeing a larger foothold in rural, which is being more affected in most places than in urbanized areas."
The state recently unveiled a county alert map online so people can get a better sense of how strong the pandemic is where they live. The map color-codes Rutherford County, where Spindale is located, as orange, meaning the level of community spread there is substantial.
In practical terms, the data behind the new county alert map helps residents understand the risks more easily than, say, the total number of cases, which might be small in a county with little population.
"What matters to me is not necessarily how many people in the county have it, but what percent of people in the county are currently infectious," Holmes said. "And that really changes your perspective as to the risk of leaving the house, and do I wear a mask, and do I participate in an indoor-activity-with-15-friends kind of thing."
High infection rates in rural areas are especially troubling, he said, because of the additional challenges people face there.
Rural residents tend to be older and more likely to have underlying health problems. They may hold jobs that require them to show up in person, not work from isolation at home.
Many rural hospitals were struggling financially even before the pandemic. And small rural county health departments were already under serious stress before the latest wave of infections.
"There's challenges because we are such a small workforce," said Leeanne Whisnant, the health director in Alexander County, just north of Hickory. "So for public health, that is very taxing, after you've already had six or eight months of daily extra work."
"I'm not meaning to sound like I'm complaining, but at some point, you get really tired, and your staff just can't keep up," Whisnant said.
Transmission levels in Alexander county are among the highest in the state. Nearly 17 percent of those tested in recent days were found to have COVID-19. On the new alert map, the county is color-coded red because the level of community transmission is critical.
"We have seen that increase all month" Whisnant said. "Actually back into October."
Some of the cases, she said, are from a recent outbreak at a prison in the county, but the numbers would be up substantially even without that.
She said some of that surge probably can be traced back to summer, when state leaders eased restrictions on mass gatherings.
"I think some churches opened up, and that was the first time we had actually had clusters," she said. "I think we're still seeing the ramifications of those clusters. We kind of can't get a handle back on it."
Many people in the county also are back at their workplaces.
"We are seeing that masks are making a difference and helping," Whisnant said, "but when you're standing right beside somebody for eight hours a day, it's hard to keep your guard up for that entire period."
There's also something she thinks of as "COVID fatigue."
"People are just tired," she said. "And so I think we kind of let our guard down."
She said many in the county are taking the pandemic seriously. Some churches, for example, that had restarted in-person services went back to online worship.
"I think I think it could be much worse here if our community hadn't been so agreeable and responsive to do their part," she said.
Not everyone, though, is following public health guidelines. In Spindale, long-time Mayor Mickey Bland said Hamilton and the rest of the town board had always masked up for meetings and had tried to be good role models. But people in the community can be independent, and many haven't paid much attention to the upswing in cases.
"I don't see a lot of change in the way people have been operating in the last eight months," he said. "I feel like if more people were wearing masks, we could probably control this a little better. But you know, it's everyone's individual preference. It's hard to regulate."
And it's especially hard to regulate private gatherings, a fact that has the people like Whisnant who are on the front lines of the fight against the pandemic bracing for the aftermath of Thanksgiving and Christmas.
"That's a big fear, because families are going to gather," Whisnant said.
