Rural hospitals operate on the very edge of disaster. Two years ago, when I was working in a small community hospital in the Midlands of South Carolina, the region was suffering from a difficult influenza and pneumonia season. Both infections are particularly dangerous to the many people in the region who have chronic lung problems, heart disease, and diabetes, the same preexisting conditions that can make COVID-19 so devastating. Some of the patients needed to be transferred to specialists in a nearby town. And yet, the larger facility we usually referred to had already filled every inpatient bed, and every intensive-care bed. Worse, more than 70 patients were being held in that facility’s emergency department, all waiting to be admitted. Other regional hospitals reported much the same.
Many hospital emergency departments across the country periodically face this scenario, and it results in a catch-22. Physicians recognize that their small hospitals may not have the resources or experience to care for very sick patients. They even fear malpractice litigation for failing to transfer. But there is literally no room on the receiving side. So sick people are held in already busy emergency departments in small towns. And every bed they take means one less available for the next emergency.
Although “surge capacity”—that is, the ability to respond to a large influx of patients or even a few very sick or injured people—is limited everywhere, it’s especially threadbare in hospitals like mine, where one physician sometimes covers the entire facility for 24 hours.
Read: The coronavirus’s unique threat to the South
One train wreck, one tornado, one shooting, and a perfectly functional hospital is immediately overwhelmed. I was working in an emergency department in rural Georgia when a rush of people came in injured from a bus accident at the same time that a car crash knocked out the hospital’s phone and internet. The nurses and I all scrambled on our personal cellphones to talk to staff at centers nearby. I have worked in critical-access hospitals that had just two units of blood on hand. It doesn’t take much bleeding to go right through that supply. The number of physicians and beds, ventilators, and other equipment is fixed. But the number of patients can always increase.
It’s possible that this crisis will pass over us. Perhaps low population densities, warmer weather, minimal mass transit, and social distancing will help slow the spread of COVID-19 in the rural South. But what about the next pandemic? And what will happen when a disaster comes that cannot be relieved by a medication or vaccine: a hurricane, civil unrest, or a terror strike could render hospitals overcrowded and desperate, and not just in New Orleans, Seattle, Atlanta, and New York.
Citizens in the rural South deserve the same quality of care that urban citizens do. The government needs to see rural hospitals not as financial problems to be solved, but rather as strategic assets—a string of small medical facilities, like forts across a frontier. And they have to be funded, stocked, and staffed (or have staff credentialed and ready to come in as needed). Right now, too few hospital beds and ventilators are on hand, even in the best of times, and staffing is difficult because of the challenge of recruiting physicians to rural areas. But coming to a smaller hospital is not a step down. The difference a doctor can make in a town like mine is life-changing for patients. Besides, robust small and critical-access hospitals are important for visitors too. Just consider: A 2008 study found that up to 55 percent of urban residents planned to leave cities for rural areas in time of disaster.