The biggest failure of Putin’s reforms may be one we have only glimpsed so far: the neglect of Russia’s regions.

While cosmopolitan Moscow has suffered the most cases, it’s also home to Kommunarka, a high-quality coronavirus hospital, and it has other top-notch facilities. Beyond the large urban centers and outposts linked to big natural resources companies, much of the rest of the country is less well-equipped. The real pain of reform cuts was felt in these farthest reaches of Russia, where populations are falling fast. In 2016, parliamentary deputies were told that out of 130,000 rural settlements, less than half were within reach of medical assistance. Russia had 42,000 ventilators at the start of the outbreak, several times the size of Britain’s supply, but a quarter were in Moscow.

Left by Putin to keep a lid on things locally, regional governors are struggling. A spike in cases in Komi, in the far north, showed how bad it could get. In early April, a single doctor caused an outbreak by continuing to work while ill, leaving dozens infected. This vast, sparsely populated province soon became one of the worst affected. In the large city of Yekaterinburg, another hospital medic caused 78 cases. Poor southern Dagestan, meanwhile, is emerging as a hotspot. Officials described the situation to Putin this week as “very difficult,” with deaths left unrecorded.