Alec Soth / Magnum

A popular T-shirt in my home state proclaims West Virginia: COVID-19 National Champions, Self-Isolating Since 1863. Until yesterday, West Virginia was the only state not to have a reported case of COVID-19.

I’m a West Virginia native who has been working in public health in the Army for 15 years and back home for the past five. Our status as an isolated region of the country comes with some irritating stereotypes, but we can also poke fun at ourselves. Under the humor of that T-shirt lies some truth. West Virginians feel very protective of our state.

And right now, I am concerned. West Virginia and other parts of rural America may be somewhat less exposed to the virus. But the infrastructure required for a pandemic response has been hollowed out.

A recent study by the Kaiser Family Foundation indicated that West Virginia is the state with the highest share of adults who are at risk of serious illness if infected by COVID-19 (51 percent) compared to the national average (41 percent). Like much of rural America, our state is plagued by a declining population, fewer social-support structures, lack of access to nutritious foods, and lower educational achievement, all of which hamper resilience to both man-made and natural disasters.

Rural America is already dealing with many other infectious diseases: hepatitis B and C, HIV due to needle sharing from injection drug use, and chronic diseases like obesity, cancer, and diabetes. A 2014 study demonstrated the widening health disparity between rural and urban areas, showing a life expectancy of 79.1 years in large metropolitan areas, 76.9 in small urban towns, and 76.7 in rural areas. The opioid crisis has disproportionately driven down life expectancy in the rural U.S. because of drug-overdose deaths. Other “diseases of despair,” as described by the Princeton professors Anne Case and Angus Deaton in 2015, including heart and lung disease, stroke, Alzheimer’s, diabetes, and suicides, have been on the rise in the rural heartland as well.

In our clinics in Kanawha County, we see people from every walk of life. We have many elderly patients with chronic illnesses and conditions such as obesity and heart, lung, and kidney disease. We also have a large and growing medication-assisted treatment program for people in recovery from opioid use. We see the homeless and the working poor. We provide a pulmonary rehabilitation center for coal miners who have black lung and other occupational lung diseases. Our school-based health staff help children afflicted by the opioid crisis. All of our providers also advocate for those without adequate transportation and for children who rely on schools to keep them fed. We provide this care even as the system as a whole faces cuts.

While West Virginia ranks among the highest in the number of hospital beds per 1,000 people in the nation, several rural hospitals in the state have closed. In late February 2020, Fairmont Regional Medical Center, an acute-care facility of 207 beds in my hometown, announced its closure. Across the country, a record 18 hospitals in rural areas shut down in 2019, and 161 rural hospitals have closed since 2005.

Public-health systems in rural states like West Virginia also rely on financial backing from the federal government that is not always forthcoming. Through the Prevention and Public Health Fund, the Centers for Disease Control and Prevention funneled roughly $625 million a year to state and local initiatives, such as immunizations for children, grants for local needs, and programs to respond to infectious diseases. However, according to a Trust for America’s Health report, from 2013 to 2027 the fund will receive nearly $12 billion less than the law had promised. Also within the CDC, a program that helps state and local health departments prepare for and respond to emergencies has lost nearly 30 percent of its funding since 2002, except for a short-term increase in funds to address the Ebola and Zika outbreaks.

Sixteen states have decreased their public-health budgets over the years. According to a 2016 analysis by Trust for America’s Health, the median state funding for public health was $33.50 a person in the 2015 fiscal year. Nevada was the lowest, at $4.10 a person, while West Virginia spent the most, at $220.80. But the report notes, “Only 7.1 percent of adults have diabetes in Utah compared to 14.1 percent in West Virginia, and only 10.3 percent of adults in Utah are current smokers compared with 27.3 percent in West Virginia.” Shrinking local health-department budgets compound the problem. In 2016, the state government proposed cutting aid for local health departments by 25 percent.

Not everything is broken. Federally Qualified Health Centers in our community serve one in four West Virginians, more than 450,000 patients, and one in 12 Americans nationwide. Like all community health centers, we see anyone regardless of ability to pay. Free and charitable clinics fill the gaps for underserved populations in our state and across the nation. Another bright spot: The Affordable Care Act Medicaid expansion has helped address pressing needs in our population. There was a 55 percent reduction in the uninsured rate in West Virginia from 2013 to 2018.

At Cabin Creek Health Systems, we are preparing for the worst, knowing time isn’t on our side.  We are already segregating people with respiratory illnesses from other patients, deferring unnecessary clinic visits, adapting to more telemedicine and telephone triage, and conducting business meetings over the phone. We’ve also begun testing a handful of patients at risk of the coronavirus. We’re doing all of this while maintaining a growing medication-assisted treatment program for people recovering from opioid addiction. I assume that many health-care systems across much of rural America are doing the same.

Rural communities are accustomed to shortfalls and doing more with less. Despite the lack of access to required resources, communities and organizations find ways to carry on, and that will be the case whatever comes with the COVID-19 pandemic.

Most of us who live in West Virginia knew it was just a matter of time before it arrived. We deal with the uncertainty with typical self-deprecating humor. A new T-shirt embraces social distancing: You stay in your holler and I’ll stay in mine.

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