In the past several weeks, as metro Kansas City began working to avoid being overwhelmed by Covid-19 like big cities elsewhere, rural places like Wright County in southern Missouri have been barely touched by the disease.

But Wright County family physician Dr. David Barbe, along with other health care providers who work in remote parts of the state, have been pleading with Gov. Mike Parson to force their patients and neighbors to shelter in place.

Im worried about them, Barbe says. There are individuals in my practice, and certainly in my community, that would be at great risk if they were to get Covid-19.

Last week, the Missouri State Medical Association sent Parson a letter requesting a statewide order to implement the same kind of stay-at-home requirements already in place in Kansas City or St. Louis.

Parson has so far refused to do so, repeatedly citing the importance of personal responsibility as he encourages individuals to take their own measures to prevent the virus from spreading.

Wright County currently has four Covid-19 patients, whose cases are believed to be related to travel or contact with other known cases, according to Barbe. Health officials say they have no evidence of community transmission in the county of close to 19,000 people.

Barbe says that some of his patients are already staying at home, but he acknowledges that for others in Wright County, Covid-19 still seems like a far-away threat.

Its mixed, Barbe says. I would say there is a lot of concern, but often people in rural areas think that, Thats going to me something that only involves urban areas. Thats not going to affect me.

However, new cases are being identified in new counties almost every day. Jeff Howell, general counsel and director of government relations for the Missouri State Medical Association, says Missouris patchwork approach to keeping people at home wont be effective when many residents routinely cross county lines for work, shopping or entertainment.

You dont want to have people who want to go to Applebees driving from Sikeston all the way to Poplar Bluff and possibly infecting a bunch of people, Howell says.

And residents of Wright County and similar rural counties could be especially vulnerable to a Covid-19 outbreak. More than a quarter of Wright County residents are over 60 years old; about a quarter are in poor or fair health; and the county has one of the states highest rates of premature death.

However, Wright County doesnt have a hospital. Like dozens of counties in the state, it doesnt have a single intensive care unit bed.

The shelter-in-place orders can be especially important in areas like Wright County, according to Claire Standley, an infectious disease researcher at Georgetown University.

We know that the elderly and (people) with underlying health conditions are particularly vulnerable to Covid-19, and particularly to severe infection, hospitalization and even critical conditions or death, and so in that case, we really do want to be protecting those vulnerable portions of our population, Standley says.

And I think part of the shelter-in-place scenario is not just to stop transmission, but also to really reinforce protection for those groups.

While shelter-in-place orders have most often been implemented in the U.S. in areas that have identified community spread, Standley says they may be most effective before that takes place.

China actually implemented quite severe lockdowns and movement restrictions with only 30 deaths, Standley says. Of course, weve far exceeded that in many parts of the U.S., and so I think were seeing there can be really big benefits to trying to be proactive.

Standley says that if rural communities dont yet have community spreading, it still may be possible for them to achieve the goal that most cities have abandoned weeks ago: to contain the spread of the disease, rather than just mitigate its effects.

Of course, stay-at-home orders are only effective if residents choose to follow them, and given the skepticism that many rural residents have about the threat of Covid-19, Barbe acknowledges that many of his neighbors might chose to disregard an order.

However, based on his conversations with patients, he thinks a statewide order would send a powerful message. And he doesnt think such orders would face any more resistance in Wright County than they have in other parts of the state.

Thats human nature and human behavior Barbe says. I think theres relatively little difference between Wright County and Springfield or even Kansas City. There will be some people that will pay attention and do the right thing and there will be others that will think that theyre bullet proof or invincible, and they are going to go out no matter what.

Alex Smith is a health care reporter for KCUR. You can reached him at alexs@kcur.org.

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So Far, Much Of Missouri Seems Untouched By Covid-19 So Rural Docs Want Aggressive Action Now - KCUR