Health

Coronavirus Is Bad in the Cities. It Could Be Even Worse Outside of Them

Shortages in hospital staff, equipment, and space could force doctors in rural regions of the U.S. to begin the kind of unthinkable rationing decisions that have been reported in Italy.
March 23, 2020, 7:00pm
coronavirus-triage-tents
Nurses adjust protective masks inside a coronavirus testing tent at St. Barnabas hospital on March 20, 2020 in New York City.  Photo: Misha Friedman / Getty Images

Whether you live or die from the new coronavirus may depend on where you get it. That’s because the resources you may need to survive a severe case—an intensive care unit, a ventilator, doctors to operate it, and nurses to care for you—are concentrated in metropolitan areas, and the lack of a national healthcare system means these resources are frustratingly difficult to share.

Rural areas, where 20 percent of Americans live, are the most vulnerable, because people both have more of the chronic heart and lung issues that make coronavirus extremely dangerous and fewer doctors and hospitals.

Shortages in staff, stuff, and space could force doctors in rural regions of the United States to begin the kind of unthinkable rationing decisions that have been reported in Italy far sooner than in major cities with academic hospitals—unless we act to break down the silos and create a way to share lifesaving resources.

But this sharing will be far more difficult than it should be, because we do not have a universal healthcare system and the Trump administration dismantled our pandemic response team two years ago, pushed out the national security adviser who replaced them, and ignored a 2018 letter from Senators Elizabeth Warren and Patty Murray who called for a global health security expert on the national security council—all despite the Department of Health and Human Services conducting exercises last year that demonstrated how fatally unprepared we are.

Of course, urban areas aren’t immune to major concerns around resources. New York City’s world-renowned hospital system, which has more than 20,000 hospital beds and 5,000 ventilators, may soon be under water, with more than 12,000 cases as of Monday. The chair of Columbia University’s department of surgery reported that its intensive care unit will be full in three to four weeks. But as ambulances carry the sick to increasingly full city hospitals, the President rejected pleas from major medical organizations to use the Defense Production Act, a 1950 law that allows the government to force private companies to make war supplies, to rapidly manufacture the supplies and equipment that might save their lives.

Major urban hotpots aside, surviving the worst pandemic in a century will require surviving not only a deadly virus but surviving a healthcare system that works better for some zip codes and tax brackets than others. “Our healthcare system is not designed for what is happening at all,” said Emily Sydnor Spivak, an infectious disease doctor at the University of Utah School of Medicine.

Every state is at risk of running out of ICU beds, but most rural areas never had them to begin with

In the United States, intensive care beds are concentrated almost exclusively in metropolitan areas—94 percent are there, according to an analysis by the Society of Critical Care Medicine—leaving rural areas with a mere 1 percent of the total beds needed to care for the most severe patients.

“The short answer for surge capacity in our state is that there isn’t any,” said Joshua Gentges, associate professor at the Oklahoma University School of Community Medicine in Tulsa. “Large hospitals in metropolitan areas are full or nearly full year-round, and at our shop we are on full-capacity protocol at least part of the day every day. The situation for rural hospitals is worse.”

Spivak sees the same problem in Utah. “Outside of the Salt Lake City area, I would suspect most people are not prepared,” she said. “The bulk of the ICU beds are going to be concentrated in Salt Lake City and Salt Lake Valley.”

But the number of beds available in some rural places, such as South Dakota, don't tell the whole story: People may simply live too far away to reach them. “We might look like we have more beds but people can’t get there, they’re hours away,” said Susan Strobel, a nurse and assistant professor of public health at the University of South Dakota.

Many spaces that did exist for treatment in rural areas have been shuttered—19 rural hospitals closed last year and six have already been shut down in 2020, the byproduct of Republican-led states refusing to expand Medicaid.

“Rural hospitals have been closing at an alarming rate here in the past few years, which resulted in several counties in Alabama having no hospitals at all,” said Anand Iyer, a pulmonologist at the University of Alabama.

Seven counties in Alabama do not have a hospital; in North Dakota, the number of counties without a primary or acute care hospital is 19. According to 2018 data, in nearly 10 percent of all rural areas, there are not only no intensive care units, but there are no physicians at all.

Just because there is a hospital doesn’t mean there is the stuff needed to treat patients for coronavirus

Because rural areas lack hospitals and physicians, they also lack the ability to test for coronavirus. This has led to what many doctors suspect is a potentially deadly circle of logic: Most testing is only happening in areas currently in an outbreak, but we don't know which areas are in an outbreak if they don't have tests. In Kentucky, there are 28 cases confirmed in Jefferson County, where Louisville is, but this is likely because most of the state's 1,866 tests have been done there.

“We are doing almost no tests [in Tulsa, Oklahoma],” Gentges said. “I'm seeing lots of fairly ill, viral respiratory infections. We are showing no outbreak because they are not doing adequate testing. It's heartbreaking and infuriating to me.”

But even if the tests are provided to rural areas, they would face the challenge of processing those tests, something that larger academic hospitals can do but rural hospitals cannot.

“There is no way these small communities have their own lab-testing capabilities,” said Spivak, in Utah. That places these hospitals and their patients at the mercy and speed of the state health lab or a commercial reference lab.

With less of virtually everything in rural areas, including air-filtering N95 masks, doctors worry that they will run out faster than in other areas of the country and be forced to make desperate and dangerous decisions to save lives.

“I worry our hospital and others across Alabama will run out of these specific masks,” Iyer said. “A surge will strain supply chains, and I really worry about our state’s smaller hospitals and the EMS going out to rescue patients across the state who may have to reuse supplies.”

With fewer intensive care beds, there are also fewer mechanical ventilators, which anywhere from half to three quarters of severely sick patients will need to help them breathe. Some smaller number of patients, 3 to 12 percent, will be so critically ill that they need more advanced life support in order to survive. This is called extracorporeal membrane oxygenation (ECMO), a system that pumps blood outside a patient’s body in order to oxygenate it and then pumps it back in.

“That is a particularly specialized form of life support that really is only done in sizable centers,” said Dee Ford, a critical care doctor at the Medical College of South Carolina in Charleston. “There are only a certain number of devices and staff trained to manage patients receiving that therapy.” Many people in rural communities would have to travel one or two hours by ground or air, when they are more sick than they’ve ever been, in order to reach an ECMO machine, assuming one is available for them.

There are not enough specialists in rural areas to treat this disease, and those specialists are likely to get sick themselves

Even if patients are able to reach the hospital, get tested, and admitted to an intensive care unit, that still doesn't mean the hospital has a provider with the expertise necessary to treat the novel coronavirus.

Nine out of ten rural hospitals do not have an intensive care specialist doctor on staff. In metropolitan areas, there is also a shortage, but not as severe: two thirds of hospitals in those places have intensivists. “It may or may not be the beds available per se, but do you have the right providers in place to care for patients,” Ford said.

Even when there are the right providers in place, and even when personal protective equipment like masks and gowns is available to them, it is expected that these doctors will get sick and need to be quarantined and temporarily replaced.

“If we have a limited number of pulmonary and critical care doctors and they are doing the most high-risk procedures, then the chance that some of them will need to be quarantined gets pretty high,” said Michael Niederman, clinical director of pulmonary and critical care at New York Presbyterian/Weill Cornell Medical Center.

Right now, Joshua Denson, a pulmonary critical care doctor at the Tulane University School of Medicine in New Orleans, is quarantined. “We are frontline providers for this disease,” Denson said. “I’m on a quarantine right now, that takes out one. We have 10 to 11 providers covering three or four hospitals.”

To solve the staff, stuff, and space problem, we need to break down the silos and shift resources

The problem, when viewed at 35,000 feet, is not necessarily a lack of resources, but a spatial mismatch between where the resources are and where they need to be—and a lack of a national healthcare system that could coordinate and move these resources fast and without bureaucratic red tape.

“If Philadelphia had a disaster and Temple and Penn were overwhelmed and we were not yet hit, it would make sense to deploy some resources to help them deal. And then they would ship them back,” explained Robert Reed, a pulmonologist and associate professor at the University of Maryland School of Medicine in Baltimore, pointing out that this would be virtually impossible given the current bureaucracies at work. “What hinders everything across the U.S. is the inability to break down all of the silos and move the resources around in a way that only the federal government could.”

Right now, what we have are many institutions making individual decisions rather than a bigger coordination of how to allocate resources. “It is a symptom of not having a national health system,” said Ford, in South Carolina. “Everything is quite siloed fundamentally. It impedes the ability to have a truly nimble regional response to something like this.”

The solution to the problem of a lack of staff, stuff, and space, experts told VICE, is a mobile response system and a federal pandemic response team, which the Trump administration eliminated two years ago. That response team could lead the effort to build temporary hospitals, and identify and move critical stuff and staff—doctors, nurses, respiratory therapists, and custodial staff—without worrying about licensing, credentialing, and insurance.

Otherwise, the siloed nature of our healthcare system and response may prove as deadly as COVID-19 itself.

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