The Great Divide

A little over five years ago, I left my rheumatology practice in Seattle to become the first rheumatologist in St. Lawrence County, the largest and one of the most rural counties in New York. I saw patients from across Washington state and even Montana and Alaska when I was in Seattle, and perhaps because of this I had the feeling that I at least partially understood the demands of rural practice. But I was wrong. I needed to be here to understand. I needed to be in a place where there were no consultants to help me through some of my hardest cases and I needed to be in a place where I saw firsthand what it meant to have neighbors, patients and friends live with the consequences of being second class citizens in the American healthcare system. With the COVID-19 pandemic now ravaging rural America, many of the health and healthcare disparities that have long plagued rural areas are getting worse. What’s even worse than this, however, is that there still seems to be no clear national plan to fix things. To achieve parity with urban medicine, many things will need to change, but to start I’ll just mention three. The first is that rural America must have a louder and clearer voice. The second is that this voice must come from within rural America itself. The third is that this voice must now be heard.

One of the first things that any rural physician learns is what it feels like to have no network. Good medicine means good networks of care, and this is still lacking in the rural U.S. Medical providers still often work alone, without a reliable network of consultants and sometimes without even basic resources. As swamped small rural hospitals across the country now struggle to transfer COVID-19 patients to larger centers which may or may not be able to help them, we are seeing firsthand what happens when adequate care networks aren’t in place. The answer is that care does not always get delivered, and where there is inadequate or absent care there is more sickness and death.

American rural medicine has long been at a point of arrested development. Here are a few facts. It is still not uncommon to find rural counties without a single physician, and during the COVID-19 pandemic it is even more common to find rural counties with either no hospital or insufficient local resources to handle the pandemic. There is a large community of rural physicians and advanced practice providers in the rural U.S., but relative to non-urban areas there remains a large gap in the number of primary care physicians per capita and there remains a rarely discussed but much larger gap in the number of medical subspecialists per capita. Many rural hospitals have closed, and many more are in financial danger. And so, some basic questions. First, how does one build a healthcare system without hospitals? Second, how does one build a healthcare system without subspecialists? Rural primary care providers are famously versatile, but any system without subspecialists will crack whenever disease becomes particularly rare or complex. Third, what about research? Clinical research is rarely done at rural sites, and for many rural COVID-19 patients there is a lack not only of hospital beds and physicians, but also of the expensive medications (such as remdesivir) and the clinical research opportunities that can make the difference between life and death with COVID-19. Fourth, why are so few of the people who are talking about rural America now in the pandemic actually from here? And finally and perhaps most importantly, I’ll return to what I asked above - how do we use this moment to give rural healthcare the attention and the unifying voice that it needs?

I’ll conclude this essay with some hope. I believe that, with the right resources and the right partnerships, rural America’s healthcare system can be deeply improved. Network building is something we know how to do in medicine. We can, with time and money and a lot of effort, train more medical providers for rural practice and connect these providers to larger medical centers in a structured way. We can work with our partners in government to pass legislation such as the Save Rural Hospitals Act that will help save existing and develop new rural hospitals. We can develop national and integrated rural clinical research networks that will help us learn more about and deliver more care options to rural communities. We can continue to improve rural broadband access so that telemedicine becomes more reliable for our patients and so that more businesses can invest in our communities. We can focus more on reducing poverty, including development of local businesses and recruitment of new ones. And as we move down this path and succeed, we can convince investors from our own government to corporate America to major foundations that rural America is not only worth investing in but that it must be invested in. All of these things will be necessary to improving health outcomes in rural America, and they must start with the voice I mentioned above. It must be louder and clearer, and it must come from those who live and work in rural places.

Rural America needs partners, and its healthcare system has been unseen for too long. The COVID-19 pandemic can help us change this, but only if we stand together and only if we have the will to try.

References:

1) https://www.usatoday.com/story/money/2020/04/23/coronavirus-pandemic-218-us-rural-counties-without-a-single-doctor/111582818/

2) https://www.npr.org/sections/health-shots/2020/10/22/926264615/covid-19-surges-in-rural-communities-overwhelming-some-local-hospitals

3) https://www.ruralhealthweb.org/about-nrha/about-rural-health-care