A Doctor’s Warning From the Rural South

Small community hospitals already operate on the very edge of disaster every day.

A sign for a shuttered rural hospital in Georgia.
KEVIN D. LILES / The New York Ti​mes / Redux

About the author: Edwin Leap is an emergency physician and columnist who lives in rural South Carolina.

Life in the rural South is tied closely to nature. Live here long enough and you can tell that a storm is rising by the way the leaves roll in the wind. A strange silence can precede bad weather, as the birds shelter on the ground and the air pressure changes throughout the house. In my part of rural South Carolina, we are experiencing a new kind of silence: a kind of breath-holding, sky-watching, prayer-whispering pause as we wait for COVID-19 to arrive in earnest. My county has 15 official cases so far.

I see the news reports and shudder. If the virus has crushed New York City despite its remarkable influence and resources, how will people here fare? A city with so many physicians, nurses, hospital beds, and ventilators is nearly depleted. What hope is there for rural southern hospitals, which have enough problems already?

The struggles of rural southern hospitals—and their patients—manifest themselves every single day. Since finishing my emergency-medicine residency in 1993, I have spent my career in smaller community hospitals, including critical-access hospitals, which serve rural areas and receive federal aid. Typically, these hospitals have about 25 inpatient beds and are located at least 35 miles—15 miles in mountainous areas, which take longer to drive through—from larger facilities. They exist to serve people who would otherwise be too far from medical care. America has 1,350 such hospitals, but many have closed because of economic pressures associated with low patient volume, the lack of highly reimbursed procedures, and an uninsured, or underinsured, patient base. Hospital closings go hand in hand with the loss of clinics and local businesses, which then makes attracting new industries—and jobs—difficult. Problems here tend to be cyclical.

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.

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.

If COVID-19 strikes rural America with the fury it has unleashed in more populous places, many more lives will be lost, especially if the resources are already committed elsewhere. If this happens, rural southerners will do what they always have done in times of trial: Band together, do their best, and try to survive. Then bury the dead in family plots, weep, and carry on.

Rural hospitals have been limping along for decades. The rural South—rural America in general—deserves a robust medical system, including a series of small hospitals intentionally located to mitigate disaster and save lives. Pandemic or not.