[...Rural areas,
sparsely populated though they are, are more vulnerable to coronavirus than you
might think, says Carrie Henning-Smith, a professor of health policy at the
University of Minnesota who studies rural communities. Many in the outsize
rural elderly population depend on children and other family caregivers who
must also work at jobs outside the home. Unlike city-based finance, software
and media jobs that readily move online, rural jobs tend to be in industries,
many of them designated “essential,” that require showing up and working at
close quarters: agriculture, manufacturing, fishing, mining, retail, tourism
and recreation. Even before Covid-19 hit, Henning-Smith’s research found that
“rural caregivers were dramatically less likely to be able to work at home”
than their urban counterparts. “And they had less access to sick leave and time
off.” All this makes it harder for them to safely distance themselves and
protect their families.]...
Letter from Washington:
‘It Really Is the Perfect Storm’: Coronavirus Comes for Rural America
In rural Washington,
hospitals are faltering, stores can’t get supplies and people are staying
closer to each other than you’d think.
In Washington state, a
medical professional wearing gear tests an elderly patient for coronavirus.
AP
By ERIC SCIGLIANO
04/15/2020 04:30 AM EDT
Eric Scigliano is a
POLITICO Magazine contributor.
Dr. Howard Leibrand has
had two very different medical careers—29 years as an emergency-room physician,
then 12 as an addiction therapist. The challenge he’s facing now, as the novel
coronavirus slams bucolic Skagit County, Washington, where he lives and works,
is like both rolled into one. Covid-19 has struck fast and hard, like the car
crashes and mishaps that send victims to the ER. And like opiate addiction, it
has spread stealthily through the heartland, even as it was dismissed as a
distant, urban problem.
“One of the negatives of
living in a rural community is you think it protects you somehow,” says
Leibrand, who for years has also been the health officer—a sort of local
surgeon general—of the county, a sprawling expanse of rich alluvial farmland,
exurban bedroom communities, and steep Cascade peaks midway between Seattle and
Vancouver, British Columbia. “We get a little bit cavalier, a little lazy about
social distancing.” On April 1, Governor Kristi Noem of South Dakota—one of
five states, all in the central heartland, without stay-at-home orders—defended
her decision to leave South Dakotans “free to exercise their rights to work, to
worship, and to play” by saying, “South Dakota is not New York City, and our sense
of personal responsibility, our resiliency and our already sparse population
density put us in a great position to manage this virus” without resorting to
the “draconian” measures taken elsewhere.
Complacency is fast
fading, however, as rural residents realize that, far from being immune, they
may be uniquely vulnerable when the epidemic reaches them. Even as Noem spoke,
Covid-19 was spreading at a Sioux Falls meatpacking plant that subsequently
closed after more than 300 workers fell sick, and local officials across the
state begged her to issue shut-down and shelter-in-place orders.
As of press time, all
but one of Washington’s 39 counties, most of them rural, had reported Covid-19
cases. Nationwide, more than two-thirds of rural counties had confirmed cases
as of April 6, a New York Times analysis found, and across rural America, the
per capita infection rate “was more than double what it was six days earlier.”
That’s as fast as or faster than recent increases in Chicago, Miami, Boston,
Los Angeles and New York.The country’s highest Covid-19 rate is in Blaine
County, Idaho, home to 22,277 residents and the Sun Mountain ski resort.
Most rural infection
rates still fall far short of Blaine County’s, and of the rates in cities like
Seattle and New York where the pandemic first hit. But rural doctors and
emergency managers watch the wave of contagion rippling out across the country
and figure it’s just a matter of time—and not much time—before it hits them
hard too.
They’re also afraid
their communities aren’t ready to face a pandemic—and acutely aware of the
handicaps they bear as this one arrives. Rural residents tend to be older, less
affluent and less healthy than the national average, and fewer of them have
health insurance. Long distances to hospitals and labs can spell the difference
between life and death with an unpredictable disease that can rapidly turn
critical. Rural grocery stores, pharmacies and even hospitals are last in line
for supplies that chains and big box stores have special access to.
Most worrisome of all,
many of the rural hospitals that are the first line of defense as coronavirus
goes country were already on the critical list. An average of a dozen a year
have folded over the last decade, and many more were on the brink when Covid-19
arrived. Before, if a local disaster or disease outbreak overwhelmed their
resources, they could turn to neighbors and big-city medical centers for
relief. Now they find themselves competing, at a disadvantage, with their
larger counterparts for scarce test kits and protective gear.
Skagit County, which
with 187 cases and six deaths has one of Washington’s highest Covid-19 rates,
is used to disasters; crippling floods periodically inundate its flatlands and
river towns. But “floods and other disasters are immediate,” says Bryan Brice,
fire chief in the county’s largest town and incident commander for its Covid-19
response. “With this pandemic, three people get sick, I treat those three and
four more are. You treat those four and have five or six more. …. A flood or
other disaster is localized. When you have a flood in Skagit County, there’s no
flood in Vancouver so you can turn there for help. But this is everywhere.”
Rural areas, sparsely
populated though they are, are more vulnerable to coronavirus than you might
think, says Carrie Henning-Smith, a professor of health policy at the
University of Minnesota who studies rural communities. Many in the outsize
rural elderly population depend on children and other family caregivers who
must also work at jobs outside the home. Unlike city-based finance, software
and media jobs that readily move online, rural jobs tend to be in industries,
many of them designated “essential,” that require showing up and working at
close quarters: agriculture, manufacturing, fishing, mining, retail, tourism
and recreation. Even before Covid-19 hit, Henning-Smith’s research found that
“rural caregivers were dramatically less likely to be able to work at home”
than their urban counterparts. “And they had less access to sick leave and time
off.” All this makes it harder for them to safely distance themselves and
protect their families.
Those in more remote
areas may also have limited access to information, leaving them exposed to
dangerous disinformation. In 2016 the Federal Communications Commission found
that 39 percent of rural residents, versus just 10 percent of the general
population, lacked access to 25 mps broadband; 200,000 in Washington, by
another estimate, were shut out.In such a vacuum, “radio—farm radio, talk
radio—becomes really important,” says Henning-Smith. And listening, like social
media, has its risks: “They might be getting really bad information. People can
think this is a hoax, that it won’t affect them.”
Until it does.
South Bend, Washington,
population 1,637, is the picturesque seat of Pacific County, at the state’s
southwest corner. Until March 13, the local buzz was that the coronavirus
threat was “being hyped up to make Trump look bad,” says longtime resident Jan
Davis. “That flipped around as soon as Trump declared an emergency. The next
day[Pioneer Grocery, South Bend’s only food store] was cleared out. It still
is. There’s still no toilet paper, baking stuff, rice, beans, or ice cream,”
though produce and meat are readily available, says Davis.“It’s a terrible
situation. What are poor people [who can’t afford to stock up] going to buy?”
“It’s frustrating,” says
Rick Manlow, who owns and operates Pioneer Grocery with his brother. “We run
right out of toilet paper and flour, and of course hand sanitizer and wipes the
very few times we’re able to get hold of them. You throw them on the shelf and
they’re gone in 10 minutes.” His bare shelves don’t just reflect panic buying,
however. “We’re ordering 800 cases and getting 400. Our supplieris operating at
way over capacity. They’ve been having challenges getting adequate staff,
supply, even drivers for the trucks.” (The large chains by contrast purchase
directly from manufacturers and have their own warehouses and truck fleets, so
they’re protected from such problems at the wholesale level.)
Other small towns are in
the same fix, says Jan Gee, the president of the Washington Food Industry
Association, which represents independent grocers and the wholesalers that
supply them. “I’m getting repeated reports like this from our members,” says
Gee. “It appears the large manufacturers are favoring the chains and big box
stores.”
Independent pharmacies,
which fill a vital role in towns too small to attract the chains, face similar
disruptions.“We cannot get hydroxychloroquine, face masks, hand sanitizer,
isopropryl alcohol, 70 percent ethanol or wipes,” says Rob Slagel, who operates
the only non-tribal pharmacy in Ferry County, Washington’s most remote
district; big box stores lie more than an hour away over mountain passes.“We’re
allocated two Z-paks”—an antibiotic to treat the pneumonia that often follows
Covid-19—“a day.”
Slagel is now retiring,
and the county hospital is buying him out so the 4,000 people it serves won’t
be left without a pharmacy. The hospital, which has already treated one
Covid-19 patient, also finds itself at the tail end of the supply chain. It
ordered a ventilator last fall because those it had were outdated; CEO Aaron
Edwards says the manufacturer finally sent one, the wrong model, in January.
When Edwards tried to exchange it, after the coronavirus appeared, he says the
manufacturer told him the one he’d ordered had been allocated to FEMA instead.
When even entire states
are bidding against each other for ventilators and personal protective
equipment, tiny hospitals can be at a particular disadvantage, says Jacqueline
Barton True, the Washington Hospital Association’s vice president for rural
health programs: “When they go to buy 11,000 masks, the supplier says, ‘I have
an order for a quarter million. I don’t have time for you.’”
Many rural hospitals
were in dire financial straits even before the virus appeared. Buffeted by
rural flight, rising costs, state budget cuts and restricted Medicare and
Medicaid reimbursements, more than 170 nationwide have closed since 2005, 128
of them since 2010 and eight since January. Most were in the South and lower
Midwest, particularly in states that did not expand Medicaid coverage under the
Affordable Care Act; Texas lost 24, Tennessee 13, and Alabama 7. (Those are
also states with high shares of uninsured rural residents.) Some hospitals are
now reopening to deal with Covid-19.Washington state will take over one that
closed in January in Yakima, a major agricultural hub, and reopen it for
coronavirus care.
Many more rural
hospitals in Washington are tottering and hoping this crisis doesn’t overturn
them. A state-ordered moratorium on elective surgeries and other non-urgent
procedures has choked off their largest source of revenue; many deferred them
to conserve precious supplies even before the order came down.Emergency-room
visits and the income they bring have also plummeted.Insurers pay less for the
telemedicine that has replaced traditional office visits. These losses affect
all hospitals, but urban ones, with their efficiencies of scale,are better
insulated, with bigger cash buffers and more in-patient and critical-care
treatment, which continues despite the moratorium.
The quickest way to
rebalance hospitals’ books would be to do what so many businesses have done:
trim staff. But the hospitals are loath to do that in the face of a pandemic,
though many have been sending hourly workers home at reduced pay and letting
salaried employees take unpaid days off. “You’re doing crisis prevention,” says
Shane McGuire, CEO of the Columbia County Health System, the only hospital in
nearly 1,000 sparsely inhabited square miles of southeastern Washington. “You
need to keep your staff. So you have a high cost of operation and low revenues.
It really is the perfect storm.”
Rural hospitals across
the state have seen their revenues fall by a third to more than half since the
emergency began.“We’re essentially equivalent to grounded airlines,” says Rod
Hochman, the CEO of Providence Washington, a nonprofit network of urban and
rural hospitals, one of which treated America’s first Covid-19 patient. “We’ve
grounded the economic activity that sustains the rural hospitals.”
As part of a large
network,Providence’s hospitals enjoy access to resources, supply chains and
lobbying clout that their independent and county-operated counterparts can only
dream of. “We see our rural hospitals as mission-critical,” says Hochman.“What
I’m worried about are those who aren’t connected, who don’t have support” from
a network like Providence.
That would include Three
Rivers Hospital in Brewster, which serves 15,000 residents spread across 5,000
square miles of Central Washington scrub and prairie. Three Rivers went from
running a small surplus in December to six-figure deficits in the ensuing
months. “We’d been positioning to grow in 2020,” says Jennifer Best, its
business development director. “Then we got blindsided.” Now Three Rivers is
one of five rural hospitals the Washington State Hospital Association warned
faced “imminent closure” in a March 20 letter to Governor Jay Inslee pleading
for state relief. They have less than two weeks’ cash on hand, says the
association’s Barton True; 15 more have less than 45 days’.
All those hospitals are
still hanging on, with a little help. The state kicked over $2 million in
emergency funds—about $140,000 for each eligible hospital, enough to keep the
doors open for a week or two. Because of the lag in insurance reimbursements, they’re
still receiving payments for procedures performed in the halcyon days of
January and February. And they’re anxiously peering through the murk of the
federal coronavirus response to discern what share they will receive of the
$100 billion designated for hospitals and other care providers in the $2
trillion coronavirus relief package signed into law March 27. Clarity is slow
in coming.
That act also authorizes
Medicare to send hospitals three months of “accelerated payments” (six months
for small, rural critical access hospitals) based on what they billed last
year. These are not grants, however, but loans against future earnings. Some
rural hospitals are grabbing for this lifeline. Others view it warily, fearful
of incurring debts they can’t repay.
Providence’s Hochman
sees another source of emergency funds for hard-pressed hospitals: “Private
insurers have cash sitting in the banks—essentially all the elective surgery
they would pay for isn’t happening.” Why not advance that cash to hard-pressed
hospitals? he asks. “We’re pushing on that.”
He offers one more blunt
piece of political advice: “Very quickly, rural hospitals have to figure out
who their friends are.”
A sizable share of rural
Washington lies within its 29 Native reservations, which cover 6 million acres
spread around all but the state’s southeast quadrant. Covid-19 could hit Indian
Country especially hard. The tribes have limited medical resources; none have
their own hospitals, and some don’t have clinics. That’s one reason many have started
early and worked hard to keep the coronavirus out of their communities, or
contained once it’s in.
A little south of the
Canadian border, the Lummi Nation, with 20 confirmed Covid-19 cases, has
installed a 21-bed care center next to its clinic to absorb any overflow from
the nearest hospital, in Bellingham. Thinking ahead, the Lummi stocked up on
medical and safety supplies in January and declared an emergency on March 3, 10
days before Trump did. The smaller Suquamish Tribe, which lacked a clinic, is
now building one.
“We have a population
with adverse underlying conditions,” says T. J. Greene, chairman of the Makah
Tribe. “Nationwide, Native populations have higher rates of diabetes and heart
disease.” He figures that between elders and those with compromised health, a
sixth of the 1,800 residents would be especially vulnerable if the virus
reaches the isolated Makah reservation at the state’s westernmost point.
It hasn’t, as far as
anyone knows. To keep it that way, the Makah have installed a 24-hour
checkpoint on the only road into their village, excluded visitors, closed their
popular (and spectacular) oceanfront hiking trails to outsiders, and urged
residents to leave only for emergencies.
The tribes along more
densely inhabited Puget Sound, especially those with intermingled
“checkerboard” territories, don’t have the option—another big source of
concern. The Tulalip Tribes abut the blue-collar town of Marysville in
Snohomish County, where America’s first Covid-19 case appeared. They have 10
active cases, with two more suspected and 12 test results pending, but until a
few days were able to obtain only 50 test kits at a time. Thanks to the
community grapevine, “we’d hear if a native person got sick,” says chairwoman
Teri Gobin. “But most people living on the reservation are nonnative. On most
reservations, we don’t know who’s sick [among nonmembers] unless they
self-report.”
Thirty miles up the
Sound, the smaller Swinomish Tribe has seen just one Covid-19 case, in a young
nontribal resident. The Swinomish could follow the Makahs’ lead and close the
bridge connecting their reservation to the mainland, but that would compound
the disruption the epidemic has already brought. “We’ve talked about it, but
not yet,” says deputy tribal chairman Joseph Williams. “We don’t have a grocery
store, so we’d have to get all that stuff delivered. And over half the
population is nonnative”—and, presumably, more likely to resist.
The tribes have taken a
heavier economic hit than other communities, even as they struggle to get
emergency funds and medical supplies from the federal government. Local cities
and counties, which have ongoing tax revenues, have retained all or most of
their employees. With limited taxing authority, most tribes depend on their casinos
and hotels, which closed in early or mid-March. “We’ve furloughed 95 percent of
our gaming staff and 85 to 90 percent of government staff,” says Gobin. The
Makah depend on fishing rather than chips, but with the restaurants and
processors who buy their catches shut down, their boats sit as idle as the
casinos to the east.
Unemployment and forced
isolation fray the social fabric. “We’d had a pretty good stretch since we
opened our wellness center,” says Williams. “We didn’t have any overdoses for a
couple years. Since then we’ve seen extra drug problems. We’re seeing a rise in
alcohol and marijuana sales” at nearby stores.
Down at Tulalip, Gobin
hasn’t seen a rise in alcohol problems or domestic abuse, but the local
cannabis shop “spiked to its highest sales ever.” What saddens her is the way
cherished traditions must yield to public safety. “Our funerals are not one or
two days,” she says. “We’re there for the family all week.” When a beloved
elder died of Covid-19, “we could not do that. The family couldn’t be there at
the cemetery when they put her in the ground. They had to do it with the nurse
putting them on FaceTime.
“I can’t imagine burying
my mother without being there.”
Filed Under: Letter From
..., Coronavirus
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Farmers & Ranchers Trade Association
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Washington, DC
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628-8833
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393-1816
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