Eric Annis, owner of Lary Funeral Home, is pictured at the Dover-Foxcroft location on April 16.

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Any other spring, Lary Funeral Home would be busy organizing graveside services for people who died during the winter and couldn’t be buried in the frozen earth. Now, the dead rest in tombs, and mourning rituals have to wait as the pandemic upends life across Piscataquis County, which on Sunday became the last Maine county to confirm a case of the coronavirus.

In a sign of how seriously some people have been taking matters, more Piscataquis County residents have been making funeral plans for themselves because they believe the pandemic is “bringing on the end for them,” said Eric Annis, the owner of the funeral home, which has locations in Dover-Foxcroft, Milo, Guilford and Greenville.

[Our COVID-19 tracker contains the most recent information on Maine cases by county]

“I’ve made quite a few arrangements with people who I think were scared to the point where they needed to come do it,” he said. “In the past it would be, ‘Dad’s going to go in the nursing home, and we should probably set things up.’ Not the urgency that I’ve seen this last month. It’s like, ‘No, I need to come in.’”

So far, isolation has largely protected rural places in Maine. But as the virus has traveled out of cities to adjacent locales and rural vacation destinations, it has continued a steady march, day by day, into smaller communities.

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If it spreads in a meaningful way in rural Maine, the death rate would likely be higher than in metropolitan areas, if only because there are more older people susceptible to falling gravely ill.

“The risks to rural America based on age are higher, and there are a lot of other factors like access to health care that make rural areas vulnerable as well,” said Kenneth Johnson, a senior demographer at the Carsey School of Public Policy in New Hampshire.

The Maine Center for Disease Control and Prevention has reached this conclusion as well. It estimates that roughly half or more of all Maine adults, particularly those who are older and in rural places, are at risk of becoming seriously ill if they contract COVID-19.

So far a disproportionate number of cases and deaths have been in urban areas nationwide. In Maine, no one from the state’s rural rim counties has died. But rural places are more prone to “super-spreading events” where all it takes is one funeral with an infected person, and “you could have most of the town infected within a couple weeks,” said Dora Mills, chief health improvement officer for the MaineHealth hospital system and a former Maine CDC director.

In fact, despite some prominent reports to the contrary, it was vast and agricultural Aroostook County that saw the highest death rate in Maine from the 1918 flu pandemic, according to information published by the Maine CDC.

Maine is not the same now as it was in 1918, but many factors work against rural places, which have less health care infrastructure and more poverty. With poverty comes a greater likelihood of poor health, Mills said, which puts people at greater risk of COVID-19.

In fact, Aroostook still appears to be at greatest risk from COVID-19, according to a tool created by the media company STAT that outlines each U.S. county’s preparedness. Washington and Knox counties also received ratings of “extremely low” preparedness. Piscataquis County received a rating of “medium,” or 40 out of 100.

The model is based on several variables such as the number of licensed hospital beds within a 40-minute drive, the number of critical care staff within a 40-minute drive, the percentage of the population age 65 and older and the county’s score on the U.S. Centers for Disease Control and Prevention’s Social Vulnerability Inde x.

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Maine has 16 critical access hospitals, which are located in rural areas and may operate up to 25 beds. They would handle patients with COVID-19 as they would patients facing any type of disease, and follow normal transfer protocols for people with medical complications who require specialists, said Jeff Austin, with the Maine Hospital Association.

“If they feel they can handle it in house, they do and they have,” he said.

People in rural places may be more vulnerable, but with age also comes wisdom, said Dan Morin, with the Maine Medical Association.

“As long as people keep doing what’s recommended by the Maine CDC, we’re not anticipating a big spike, especially in the rural areas,” Morin said. People who are older have “experienced or at least heard about transmittable diseases including polio. They’re old enough to remember stories about the last flu pandemic. I think they’re going to be more careful.”

Based solely on their age structure, Lincoln, Knox, Washington, Aroostook and Piscataquis counties have the greatest potential for high death rates compared with the country as a whole, according to an analysis by Johnson, with the Carsey school, who applied mortality estimates from new research on the epidemic in China.

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Maine public health officials have similarly found that Lincoln and Piscataquis counties are at highest risk when accounting for their older age and prevalence of chronic health conditions, but all parts of Maine have vulnerabilities. And a lot depends on whether and where the virus infiltrates.

“It might be more micro than macro. It’s not like urban Maine gets hit, and then rural Maine gets hit. It’s, ‘Do you have a nursing home that gets hit?’” Austin said. “It might be more facility- and housing-based than economic, or urban versus rural.”

Despite the heartache that delaying services causes family members, Annis does not want a funeral to be the reason people in Piscataquis County get sick. Some bodies in the tomb will need to be buried this spring, but he doesn’t yet know whether he will be able to hold services with the burials.

He has not been able to hold standard funeral services for six weeks or so, he said, but has been allowing five people at a time into his funeral parlors to view their loved one’s remains.

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“We know it’s here,” he said in an interview on April 14. Five days later, officials confirmed the dreaded eventuality: The virus had officially reached Piscataquis. Previously, it had been among 14 percent of counties in the United States with no confirmed case.

Across Maine’s rural landscape, people’s homes are already largely separated from one another, but that doesn’t mean they don’t go to the grocery store or the post office, or sometimes work in close proximity to others, such as in processing plants, Johnson said.

Even if the virus does not spread, life has still changed in ways that would have been unfathomable several months ago.

For most of her 77 years, Patricia Sutherland has been attending the annual town meeting in her hometown of Chapman, in Aroostook County. On March 23, she and the other selectboard members spaced the chairs six feet apart in the local snowmobile clubhouse, and then waited for residents to arrive to conduct the business of the town, which has fewer than 500 residents.

For the first time, no one showed up. The selectboard carried on, on its own.

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Aroostook County’s trademark is its small towns where many families have been neighbors for generations, Sutherland said. That connectedness has helped communities get through many challenges. Chapman, Mapleton and Castle Hill, for instance, operate their towns on a joint budget, which lets them share town employees and volunteer firefighters, maintain facilities, and bid on projects together to get the best price.

“We get queries from all over the state saying, ‘How do you guys do that?’” said Sutherland, who has been serving on community boards in Chapman for 46 years, 25 of them on the selectboard. “My first answer when people ask me how it works is, ‘We all trust each other.’”

Now, people are showing their trust in a different way: by staying away. “People haven’t gone to visit. I have a neighbor with a new baby. I’ve been waiting to go see her. I’m still nowhere near going to see that baby. I think people are being careful,” Sutherland said.

There are too many unknowns to accurately predict when the outbreak will peak in rural counties. And even when the number of cases begins to fall, people should still remain cautious.

“You can be past peak and still get an outbreak that provides a localized surge scenario,” said Austin, with the hospital association.

Regardless of how the virus spreads, the effects could be long-lasting because of a reduction in the number of births, Johnson said. People are likely to put off having children during this time of economic uncertainty. That could hasten population decline, especially in Maine’s outer rim counties where deaths exceeded births every year of the last decade.

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The unknowns are alarming to many, particularly to those with immediate basic needs: families who are hungry and people trying to feed them.

These days Dixie Shaw is having to meet challenge after challenge to figure out how to keep the only two food banks north of Hampden going amid an unprecedented spike in demand for food. She has worked for Catholic Charities Maine for 32 years, most of them helping to alleviate hunger, and she has never seen such a need for basic sustenance, she said.

Aroostook County’s 26 food pantries typically come to the food bank warehouses in Caribou or Monticello once per month to pick up items to take back to their local communities, she said. Now many are coming once per week or even every other day.

She worries about how long the food banks can keep going without revenue. Normally they rely on the income generated by four thrift stores, which have shut down.

At 66 years old, Shaw is supposed to be isolating herself. She has also been experiencing vision problems, which means others have to drive her places. But she has spent decades making sure her fellow Aroostook County residents have food, and she isn’t going to stop now.

“In lieu of flowers, please bring a can of beans,” she said, her grim humor intact.

Even if the operation runs out of money, Shaw said she will find a way to continue to feed people. That determination helped her build the food bank infrastructure in Aroostook and is now a driving force behind her, and many others, who continue on in the face of a pandemic. “I will never stop working,” she said. “I will never stop working unless I’m dead.”

BDN writers Josh Keefe and Matthew Stone contributed to this report.

Watch: Nirav Shah talks about the impact of coronavirus on rural Maine

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Erin Rhoda

Erin Rhoda is the editor of Maine Focus, a team that conducts journalism investigations and projects at the Bangor Daily News. She also writes for the newspaper, often centering her work on domestic and...