"The risk of COVID-19 diagnoses for counties with more black residents is consistent across levels of urbanicity. The risk of COVID-19–related death for disproportionately black counties is significantly higher only in small metro and rural areas. Furthermore, where rural transmission has been significant, it has been in disproportionately black counties. Counties like Dougherty County, Georgia, experienced intense outbreaks among black Georgians a month later than the early wave of infections in large urban areas. In sum, the alignment of individual-level and neighborhood data within urban centers and the county-level data presented here documenting disproportionate burden among black people suggests that the results of the ecologic analyses presented here are not entirely attributable to structural confounding and may hold true at the individual level in at least some cases."