By Lois Parshley
Rural communities “tend to be older, with more chronic illness,” making people more at risk of severe Covid-19.
Early this week, Kodiak Island, part of an archipelago in southwest Alaska, issued a “hunker down” proclamation, asking residents to stay at home as much as possible. In the Covid-19 pandemic, the remote island, known for its brown bear population, might seem well-positioned — travel on or off the island is limited to the water or air. But Elise Pletnikoff, a family physician and the medical director of the Kodiak Area Native Association, says the same physical remoteness which may help protect rural communities from infection will become a liability if — and, more likely, when — the novel coronavirus arrives.
“Our capacity will be the limiting factor,” she says, “meaning not just equipment, but also staff.” Her organization provides care for 5,000 patients on Kodiak; while there is a hospital on the island, it has limited resources for critical care and usually flies patients needing that kind of medical attention to Anchorage. But Pletnikoff says when Covid-19 cases surge, “we’re worried about how busy everyone will be.”
Many small communities around the United States don’t have a full-time doctor — and in Alaska, many aren’t connected by road. Instead, they rely on community health aides, a physician who visits a few days out of the month, and either commercial or medevac flights to larger urban centers during emergencies. Already because of the outbreak, health workers are forced to disrupt this limited care even further, transitioning to telemedicine when possible. “We’ve stopped traveling to remote villages to reduce exposure,” Pletnikoff says, and staff currently in each village are staying, “until … we don’t know when.”
Even though small towns like these may be thousands of miles from Covid-19 hotspots like New York City and New Orleans, there’s good reason for the 60 million Americans in rural areas to worry.
A new map of confirmed cases and deaths nationwide from the University of Chicago’s Center for Spatial Data Science shows a disturbing trend:
While New York state still has the highest per capita rate — 1,995 cases per million people as of March 26 — there are also significant clusters of Covid-19 in rural areas in the Midwest and South, including Arkansas, Mississippi, Georgia, and South Carolina. Every US Health and Human Services region also has shown a sharp uptick in non-flu-related influenza-type illness.
On Friday, Alaska reported 85 cases and its first Covid-19-related death. Shana Theobald, another doctor on Kodiak Island, explains the grim calculus for her state: Given that experts from the CDC estimate 40 to 70 percent of the state’s 737,500 people may eventually contract Covid-19, at least 295,000 Alaskans could get sick. Based on initial reports, 20 percent, or 59,000 people, will need hospital care.
Alaska only has 1,500 general hospital beds. And even if as few as five percent of Covid-19 patients become critically ill (a conservative estimate), that’s a minimum of 14,750 people needing ICU beds. And Theobald estimates that Alaska only has around 200. If that many people get sick over the next one to three months, only one in 25 people who need intensive care will be able to get it. Even if you halved the number of Alaskans infected with Covid-19 to 20 percent, the system will still be over capacity — by thousands of people.
It’s these kinds of equations that make epidemiologists particularly concerned about rural America. “If we believe that the way seasonal flu spreads through the country is likely similar to Covid-19, the rural eruptions tend to be later and briefer, but more impactful than in big urban areas,” said Roger Ray, a retired neurologist, physician executive, and physician consulting director with The Chartis Group.
Far apart, but far from safe
Remote Alaska is an extreme example of rural health care, but even in the state’s comparatively large urban centers — like Fairbanks, the second largest city— physicians are worried.
“Today I’ve been at the office for 12 hours on the phone or video conferencing, doing everything I can to keep my patients from the ER or urgent care clinics,” says Jenny Lessner, a family doctor in Fairbanks. She’s had many patients she suspects of having Covid-19, but says due to limited testing availability, “we have no idea how many people in this town have Covid right now. We’re walking in the dark.” In what has become a familiar refrain, Lessner’s clinic currently has four doctors, 16 masks, and thousands of patients.
She and other doctors in the state recently put together a petition asking the state to institute a travel ban and shelter in place order. On Friday, state officials ordered shelter at home, closure of all nonessential businesses, and a ban on nonessential travel between communities in Alaska, effective Saturday.
In rural areas, social distancing can be the normal way of life, delaying the arrival and spread of disease. But once people get sick, “I am absolutely concerned about capacity,” says Ray. Overall, rural communities “tend to be older, with more chronic illness,” he adds, making people more at risk of severe disease. This includes millions of Americans with heart disease, diabetes, and asthma — all risk factors for the novel coronavirus.
Various models predict slightly different rates of Covid-19 transmission, but Robert Siegel, a professor of immunology and microbiology at Stanford University, says they all “dramatically illustrate the importance of intervening early and hard, in terms of saving lives.” Density of population has been closely linked to transmission, he says, “but I wouldn’t leave people in rural communities thinking they’re safe.” He adds, “If they don’t do anything, the virus will arrive there — it might arrive slower, but it will arrive.”
You can see detailed projects for transmission rates around the country at CovidActNow, a prediction tool created by a team of data scientists, epidemiologists, and public health officials to help people understand how Covid-19 will affect their area. It predicts that, with the current amount of limited action some states are taking to curtail transmission, Kansas will have more sick people than hospital beds by April 16 and Oklahoma by April 19 — in short, even states with low population densities will soon be overwhelmed. Leo Nissola, an immunologist at the Parker Institute for Cancer Immunotherapy, who was not involved in the design, says, “When I look at that model, I trust the data and the source.”
Nissola agrees rural communities might not ever see rates of Covid-19 as high as New York City, but is concerned about their underlying vulnerabilities. More than half of counties in America have no hospital ICU beds, posing a particular risk for the more than 7 million people over the age of 60 living in those places, who are at higher risk of severe cases of Covid-19.
In February, The Chartis Group released a study showing that more than 450 rural hospitals are vulnerable to closure. “If you’re vulnerable enough to risk losing the ability of making payroll, how valuable can you be to the community in crisis?” Ray asks.
The delay in transmission may be longer in some places than others. Data from Johns Hopkins University suggests that rural areas with popular tourist destinations — like Blaine County, Idaho, home to Sun Valley — actually already have the highest rates of cases outside of New York City and its surrounding areas.
“A different country”: fighting the virus on Native American reservations
Ethel Branch, a former attorney general for the Navajo Nation, says that underlying inequalities in rural areas exacerbate these risks as well. “When I was growing up on the Nation as a little kid, I always felt like I lived in a different country,” she says. “A third of the Nation doesn’t have running water, a third don’t have access to electricity.” Many families live in multigenerational homes, increasing elders’ risk of infection, and risk factors like diabetes and asthma are common. The unemployment rate, before Covid-19, was 42 percent.
In a pandemic, says Joseph Ravenell, a professor of population health at NYU Langone Health, “More vulnerable populations are more susceptible to having worse outcomes.”
Last weekend, Branch set up a GoFundMe to buy supplies for elders who might not be able to stock up to prepare. When buying food for her mother, who lives on the reservation, she says, “I encountered shelves that were empty, really long lines. I thought about how disappointing it would be to spend so much gas money and not even be able to purchase what you need, and have to come back again” — also increasing the risk of infection. Over three-quarters of the reservation’s population have some level of food insecurity; the average resident drives three hours to buy food.
Branch has, so far, raised over $162,000, which she is allocating based on risk. “We have help request forms for people to fill out so we can identify the highest risk folks,” for food distribution, she says. As of March 27, the Navajo Department of Health reports 92 positive Covid-19 cases in the Navajo Nation. But there, as elsewhere, testing has been limited.
Health clinics and hospitals are being forced to turn patients without Covid-19 away, or delay their treatment
The ability to manage crises is also unequal in cities versus rural areas, says Aaron Clark-Ginsberg, a qualitative social scientist who researches disasters at RAND Corporation, the nonpartisan policy research group. Big urban health departments usually have teams whose full-time job is to manage large incidents, but “in rural cases, it’s often a part-time person already pressed and doing other things,” he says.
Many health departments do have disaster plans on file, Clark-Ginsberg says, but “they can be fantasy documents, paper plans that don’t necessarily match the capacity, and that first responders wouldn’t be able to put into practice.”
And the surge of Covid-19 patients is not the only health impact the pandemic will have. “Inevitably, the health care system will have to shift toward Covid-19 patients, and there will be knock-on effects,” Clark-Ginsberg says.
In Fairbanks, Lessner says Covid-19 has already hurt patients with other health concerns. She describes helping the spouse of a patient with very advanced Alzheimer’s find an assisted living facility. Over the past several months, she says, “we’ve been calling, trying to figure out Medicaid, and we finally had a plan with all the boxes checked.” But this week, the facility announced it was no longer admitting new patients because of Covid-19. “Now this poor guy is at home with his spouse, who we knew was too much for him to care for,” she says. “Instead of a full-time care facility, he’s just got me on the phone.” She pauses. “What do I tell him?”
She adds that her clinic has rescheduled or delayed important preventive care for other health conditions, like mammograms, colonoscopies, screening bloodwork, and more. “None of these screenings are considered urgent but they are critical, particularly from a public health perspective, to prevent or detect cancers, high cholesterol, diabetes, etc.,” she says.
On Kodiak, Pletnikoff says she’s very worried about hospital physicians “needing to care for newborns in addition to any surge of Covid-19 patients,” as the same hospital staff there manages standard inpatients, ICU patients, and OB and pediatric patients.
There’s no denying that currently, the projections all look pretty grim. But one thing the CovidActNow model illustrates is the power of social distancing measures. Already, rural communities have been taking steps to minimize their risk.
Checkpoints for the annual Iditarod dog sled race in Alaska, normally held in rural villages along the route, moved to remote locations outside of town to discourage visitors — and potential infection sources. Many people traveling with the race usually sleep in local schools, says Sarah Manriquez, a photographer who traveled with the dog teams to document the race this March — schools some of the villages also decided to close.
Prior to Friday’s shelter-in-place order, Alaska’s hospitals were predicted to be overloaded by May 14 — spiking to almost six times the hospital capacity by early June. Three months of shelter-in-place would move that date beyond the model’s range of prediction. Any extra time that social distancing buys is critical to manufacture or procure much-needed supplies, or innovate new solutions.
As Craig Smith, the surgeon-in-chief of Columbia University, wrote in a memo sent last week to his colleagues, “The next month or two is a horror to imagine if we’re underestimating the threat. So what can we do? Load the sled, check the traces, feed Balto, and mush on. Our cargo must reach Nome.”