You are on your own. This is the first line from a document entitled, “Advice for low income countries on managing COVID-19.” The document is the one table from a correspondence piece in July in the New England Journal of Medicine. It was written by a group of physicians fighting COVID-19 in Haiti, but as someone who has lived several years in the developing world as a Peace Corps Volunteer and who is now a rural physician in New York I think the same advice could easily be given to any medical provider fighting COVID-19 in rural America. I am struck, in fact, by how much of this table is directly applicable to the pandemic in rural areas. It reads as follows:
1) You are on your own. Pool resources and expertise from public and private institutions.
2) Work with your ministry of health so that successful interventions can be shared and scaled up.
3) Prevention messages must consider socioeconomic context.
4) Grassroots community engagement is essential to gain public trust and fight stigma.
5) Screening, testing, and care guidelines must be developed early and adapted rapidly as the pandemic evolves.
6) Guidelines and training videos can be put online and rapidly distributed on social media.
7) Suspect tuberculosis and Covid-19 coinfection in patients with chronic cough and sudden deterioration.
Let’s break this down point by point. Number one - You are on your own. Pool resources and expertise from public and private institutions. Rural America’s patchwork and very fragile healthcare system (and rural America in general) has long suffered from a lack of money and attention. Now, as medical staffers (physicians, advanced practice providers, nurses, phlebotomists, front office staff, all of us) fighting the pandemic in rural areas, pooling the limited resources we have is of critical importance. These resources include public ones, such as our hospitals and local health departments, and private ones, such as community members who help us in preventing the spread of the virus by building community understanding of the virus itself. I’ll talk some more about this as we go along.
Number two - Work with your ministry of health so that successful interventions can be shared and scaled up. The analogy to the ministry of health in the case of rural America includes national public health organizations (such as the CDC) but above all it includes local health departments in rural counties. As rural medical providers, we tend to know and work closely with the other providers in our areas. The president of my own local board of health is a friend and colleague with whom I’ve worked closely over the course of the pandemic on issues ranging from community outreach measures to allocation of testing resources to the procurement of promising medications for COVID-19. This kind of strong local organization and communication has been one of the essential elements of my county’s ongoing response to the virus and will likely be an essential element in rural counties everywhere.
Number three - Prevention messages must consider socioeconomic context. Rural America is an incredibly diverse place. We are many people, many groups, many regions, each with its own struggles and culture. This is why prevention messages need to come from our national public health leaders but also and even more importantly from our own community leaders. To make this point I’ll ask a question. Have you ever read a news story about a place you know well? We all have, and most of us have probably had the experience of seeing a detail or even a critical aspect of such a story misrepresented. The point I’m making is that understanding a place is hard. It can never be done very well by those who don’t live locally. Prevention messages must, in turn, start both with local people and with context. Who is getting the message? Who is delivering it? How can it be delivered in a way that doesn’t feel insulting or politically motivated? Even if the message is received, is it practical to accomplish? As an exercise, think about how you would deliver a pandemic prevention message in your own community. In my work as a rural health researcher, this is one of my biggest challenges (to sign up for an upcoming webinar that will better illustrate this, click here). This goes back in part to number two. Work with your local health department. Messaging needs to come from within rural areas, and to do this right community members will ideally work alongside their physicians to make the messaging right. I believe that a lack of such messaging is one of the biggest tragedies of the pandemic in rural America. It is now known that in many conservative rural areas people are still not wearing masks (the simplest and most effective of all prevention measures) to the same extent as people in many urban and suburban areas. And yet, rural America is now the hardest hit part of the nation and the world in the pandemic. Much of the solution will come from hearing more from reliable local voices, and this will involve a tremendous and unified effort by local people everywhere. There are about 2000 rural counties. There should also be 2000 messages, each one spread like a counter-virus by its own people, each one similar but still apart. This is going to be very hard, but to beat this thing it’s likely the way it will have to be.
Number four – Grassroots community engagement is essential to gain public trust and fight stigma. Much of my response to this lies in the paragraph above, but one additional point I’ll make surrounds stigma. In my own area, I know many people who are scared to wear a mask for fear that they will be ridiculed by friends and family. The only way to erase stigma is from within. In my community, one way in which we are trying to do this is through a grant from the Patient-Centered Outcomes Research Institute (PCORI) to develop a program for community education about COVID-19. This program involves partnering with a committee of community members from different backgrounds in order to design a practical outreach and educational program for our county (to learn more about this, click here). When the committee meets, one of the things we invariably talk about is where and how to reach people. We talk about meeting them everywhere from online to dollar stores to gun shows. We talk about who can and who can’t (there are many people in our county and in all rural areas who lack both internet service and any form of transportation) likely be reached. And we talk about gaining trust and fighting stigma. Our conversations are both difficult and excellent. Above all, they feel more than just useful. They feel like the only real way forward. The last point I’ll make in this section is an obvious one. Changing any ingrained idea can be done, but doing so will also take a long time. This is why it’s so important in my opinion that the COVID-19 pandemic serve not only as a catalyst for change now in rural American healthcare, but as a catalyst for ongoing change in the future, too.
Number five - Screening, testing, and care guidelines must be developed early and adapted rapidly as the pandemic evolves. In my county, this goes back to the work of our local inpatient COVID-19 treatment team and its ongoing regular communication with our department of health. As a result of this work, we now have clear and continually adapting guidelines for screening, testing and treating potential COVID-19 patients in my health system. We also have guidelines for communicating with quarantined COVID-19 outpatients about everything from adherence to quarantine measures to identification of red flag symptoms to clinical trial opportunities. The theme here remains largely the same - local medical providers working together, pooling resources and communicating with the community. And yet, let me ask now a different question that I could have asked at various points in this essay. What about the over 200 rural counties (over 10% of rural counties, which is a staggering number) which don’t even have a single physician? Who will design screening, testing and care guidelines in these areas? What about the many other rural counties where there are far from enough hospital beds and testing capacity to adequately treat all COVID-19 patients? I like number five, but I am also practical. Until there are sizable new investments in rural American healthcare, I think that for many rural areas designing strong guidelines and for that matter following much of the advice given in this essay will be much easier suggested than done.
Number six - Guidelines and training videos can be put online and rapidly distributed on social media. This goes back to the PCORI research grant as well as the collaboration with our department of health that I discussed above. On this point, I will simply say that I agree. No further comment.
Number seven - Suspect tuberculosis and Covid-19 coinfection in patients with chronic cough and sudden deterioration. This will be irrelevant to most rural areas in the U.S., but there is a point to be made here. In every community there are local patterns of infection and local sources of possible coinfection of which medical providers are aware. These can range from the flu to tuberculosis to fungal infections such as coccidiomycosis (in the Southwest) and histoplasmosis (in my county) to many others. Again, a similar theme emerges. Local expertise matters. Rural medical providers must lead the way in fighting COVID-19 in their communities.
Rural America is a diverse place. Some of us even refer to it as its own nation. I like to believe this is true. I feel a kinship with all rural Americans, even the many who live in places that I don’t know. And so, if we are a nation, let me put forward an idea. The idea is just, from a healthcare standpoint at least, that we are a developing nation within America. We have fewer doctors, fewer hospitals, fewer resources to pool. In much of our nation there are no doctors at all. We are often ignored and unseen. The advice that is given by physicians in developing nations to other physicians in developing nations applies very directly to us. And so, if we are a developing healthcare nation, then what does this mean? It means that our healthcare solutions will need to come from working with national leaders to improve our resources, infrastructure and visibility but also and most critically by working together to solve our problems from within.
May the pandemic serve as a message to all who are watching. Rural healthcare systems must have more attention and more resources. As it stands, rural healthcare looks more like the healthcare system of a developing nation than a developed one. We are, in turn, a developing healthcare nation, but we must not remain one forever and we must not remain one for much longer.
No group anywhere and certainly no group in any wealthy nation should be ignored. For now at least, we in rural America are on our own, but we are not alone.
1) Rouzier V, Liautaud B, Deschamps MM. Facing the Monster in Haiti. NEJM July 2020;383:e4.