Small, rural counties struggle with COVID-19 in ways big counties don't

2020-04-19 | The State

April 19-- Apr. 19--In rural Marlboro County, the coronavirus can seem like an insurmountable problem for some people who call the area home.

The eastern South Carolina county, a one-time tobacco-farming community that borders the Great Pee Dee River, has more than 100 suspected cases of the coronavirus that is spreading across South Carolina.

But to some folks, it's a disease they can't do much about.

Hampered by spotty internet service, many can't get the telehealth screening they need to follow through with a coronavirus test, the county's top official said. Others lack the transportation to reach the closest hospitals, located outside the county.

"Access to healthcare is always a challenge to rural residents, particularly here with no hospital," Marlboro County Administrator Ron Munnerlyn said.

Marlboro's obstacles are among the struggles rural South Carolina communities face as the coronavirus envelopes the state.

A lack of adequate testing and protective equipment, poverty that discourages trips to the doctor, relatively few doctors and nurses, higher percentages of people in poor health and limited information about the dangers of COVID-19, the disease caused by the novel coronavirus, are among the issues affecting rural areas dealing with the coronavirus.

But as the disease takes its toll, these challenges need addressing, say advocates for the state's rural areas. Often neglected, rural South Carolina faces a problem like none it has seen before.

The impact of the virus, increasingly well documented in bigger counties like Richland, is now being felt in rural, smaller counties that in some cases are underequipped to handle the crisis. Three of the top five counties in rates of infection have populations of under 70,000, according to the S.C. Department of Health and Environmental Control.

Those are Clarendon, Lee and Kershaw, where the outbreak first was identified in large numbers. Sumter County, also in the top five, has just over 100,000 people, but large swaths of rural areas. The only large county among the top five in case rates is Richland.

In the 27 counties under 70,000 in population, the coronavirus has infected more than 700 people since it was first identified in South Carolina in early March, DHEC data show. That's about 18% of the total cases verified in South Carolina.

DHEC projects, however, that there are likely more than 4,400 unconfirmed cases in those counties. Unlike Richland and metropolitan Columbia, some of those counties don't even have hospitals to care for coronavirus patients. And those with hospitals have limited ability to deal with the coronavirus.

Limited beds

Experts say health care in rural areas, even in normal times, is far behind that offered in South Carolina's major cities, which have well-financed, well-equipped urban hospitals.

"Rural hospitals have very limited beds, so when a virus does begin to take hold in a rural community, the hospital can be very quickly overrun," said Jan Eberth, associate professor of epidemiology and biostatistics at the University of South Carolina Arnold School of Public Health.

Nor do many rural hospitals have intensive care units or the trained staff for those units, said Eberth, whose studies include public health issues in rural areas.

Jason Cummings, assistant professor of Sociology and African American Studies at USC, said people in rural areas often have to travel long distances to seek treatment. In rural and low-income areas, many people lack reliable transportation or the financial resources to travel, leading to delays in health care that often result in the progression of more severe health problems or premature death.

Many rural South Carolinians lack health insurance and consequently don't have a regular doctor or a consistent history of preventative care, he said.

"So if there was a mass spread (of COVID-19) in a rural area where there's already a lack of care, and especially a lack of emergency care, it would overwhelm that area," Cummings said.

Rep. Lonnie Hosey, D-Barnwell, said the coronavirus crisis has again focused attention on the health care needs of poor, rural communities in South Carolina. Hosey said rural areas need help getting more tests, more supplies and more access to health care.

Barnwell and other nearby counties have poverty rates exceeding 22%, well above the state average of about 15%, Census statistics show.

"Do you want us to give up our territory and move to metro Columbia, Charleston or Greenville?" Hosey asked. "No? Then why don't you help us? We don't have the amenities you have. But we are still part of America."

Sen. Kevin Johnson, D-Clarendon, said the area he represents has plenty of challenges that the coronavirus is exposing. Much of his district includes Clarendon and Sumter counties, which have some of the highest per capita coronavirus case rates in the state.

"This is a prime example of why we need to have better access to better health care," Johnson said. "When you don't have transportation and you are lower income, and you have to travel more miles (to a doctor), people just can't do it. "

This past week, Republican Gov. Henry McMaster and state health department officials acknowledged the problems rural areas encounter, but offered few details on how the state was specifically working to help rural communities deal with the coronavirus. The governor did say that the state was working to provide broadband access to areas with spotty internet service, while DHEC officials said they are trying to increase testing in at-risk communities and also trying to engage high-risk communities about the dangers of COVID-19 through outreach to churches and media campaigns.

Graham Adams, chief executive at the S.C. Office of Rural Health, pointed out that people from rural areas who are seriously ill can get hospital care. But they sometimes have to get it in another county, he said.

"That same mindset and that same practice will play out here" with coronavirus, he said. "It's just exacerbated by the number of patients and level of care that they may require."

Testing challenge

One of the biggest concerns these days is where to get tested for the coronavirus, particularly in rural areas.

State Rep. Wendy Brawley, D-Richland, worries that a lack of testing in out-of-the-way communities gives the impression that COVID-19 is not a problem, when it may be more prevalent than people suspect. She represents rural eastern Richland County, as well as Pinewood, Horatio and Dalzell in rural Sumter County.

"A low number of positive test results does not mean that the virus is not vastly prevalent in certain zip codes, but most likely means that fewer tests are being offered to residents in those zip code areas," she wrote in a letter Friday to McMaster, requesting more rural testing. "It is important that citizens in rural communities throughout our state have this information to exercise the precautions necessary to prevent the spread of the virus and not rely on the false impression that the virus is not a serious threat in their community."

The state is working to provide more tests, including rapid testing kits that can tell people within a short time whether they have the disease, said Nick Davidson, a leader in DHEC's effort to fight the coronavirus.

"We want these testing devices to be in areas where there are higher risk populations," he said Friday.

Officials in Allendale County, one of the poorest in the state with a poverty rate of 37%, say more testing is badly needed. Because so few places in Allendale provide tests, people are asking to get checked in the local hospital emergency room, said Lari Gooding, who heads the Allendale County Hospital.

But that's not a good idea, he said. The hospital doesn't have the capacity to do widespread public testing, he said. And it also has limited emergency staff to care for patients who get sick, meaning testing at the emergency room needlessly exposes doctors and nurses, he said.

"The problem is I don't want to expose my ER physician and my nurses any more than we have to, because they're the ones we're going to need in the hospital when we do get a surge and have these patients coming in," Gooding said.

And if someone comes in showing symptoms, and a test takes place, the person is still generally told to go home for 14 days, unless conditions get worse, Gooding said.

Clay Lowder, a doctor and partner with Colonial Healthcare, said his offices made an effort to obtain and provide testing to people in Sumter and Clarendon counties, both of which have plenty of remote areas with sparse but needy populations.

Still, that's not the case in a lot of communities, he said.

"We have not had adequate testing, except for the hot spots. To me in my opinion, that's not logical. We need to be testing areas that are not hot spots," Lowder said. "If you live in New York City, you know that it's a hot spot and you don't dare go out of your house. We need to apply testing to areas that could be future hot spots and it's just not available right now."

Access to coronavirus testing also has been an issue in some of the state's middle-sized counties that have large segments of rural areas.

Among those is Oconee, a county of about 80,000 people with small, remote communities in the southern Appalachian Mountains.

Oconee County's local hospital, part of the Prisma Health hospital system was sending many patients to Greenville for testing, rather than doing it locally, Westminster physician Billy Campbell said. That left some residents in the county's mountainous areas with a drive of 70 miles to Greenville, he said.

"The number one thing is that barrier of having to drive an hour or more each way to be tested," Campbell said, explaining why he thinks many people are undiagnosed. "If someone doesn't feel good, they are not exactly wanting to do that."

The system initially planned more extensive drive-through testing in the Upstate but had to scale that back because of a shortage of testing supplies, Prisma spokeswoman Sandy Dees said in an email.

Prisma changed the policy this past week with testing in Oconee County that Campbell said the area needs. Still, many people who may have needed tests never got them, including one of Campbell's patients.

A fast-food worker, she had been sick for weeks and wanted to get tested in Oconee County. But she received a "complete runaround" when she tried to find out how she could have a coronavirus test, Campbell said. The woman was never tested.

Campbell said his office, which has a tent set up to screen patients with possible COVID-19, said he isn't offering tests because a private lab he deals with takes up to 10 days to send results back.

Threats to African Americans

Supplies also have become an issue in some rural areas.

Faith Polkey, chief clinical officer at Beaufort Jasper Hampton Comprehensive Health Services, a network of community health centers with nine locations in the Lowcountry, said shortages of protective equipment hit the health centers hard.

During the early weeks of the outbreak, Polkey found supplies diverted to hospitals or harder-hit areas. The clinics would get a quote for masks from a supplier in the morning and by the afternoon stocks they thought they had secured would be depleted, she said.

The clinics turned to other suppliers and community donations, receiving donated masks from a local pillow manufacturer. The network consolidated patient care to four locations. "We've just had to piece it together," said Polkey. "In order to continue to run we have to be able to protect our employees."

The health centers are testing for COVID-19 on a limited basis. The private labs they contracted could only send five to 10 swabs for collecting samples to each clinic and, lacking a complete supply of N95 masks, Polkey doesn't want to risk the health of her staff.

In Hampton County -- a tiny slice of South Carolina between Augusta, Georgia, and Hilton Head Island -- a top official said that while tests are available, people aren't taking advantage because there is no cure for the coronavirus.

"A lot of people tend to just tough it out," County Administrator Rose Dobson-Elliott said. "We tend to go to the doctor when it's really bad. When I walk in, they know I'm half dead."

One thing that may contribute to that mentality is that doctors can only treat the symptoms of COVID-19, much like the flu, Dobson-Elliott pointed out.

Fairfield County Councilwoman Bertha Goins and Johnson, the state senator from Clarendon County, said they are noticing people in their communities who aren't paying attention to social distancing recommendations.

Johnson said he saw a group of 30 people at a rural convenience store congregating just last week, which is a concern because Clarendon County has had plenty of people infected by the disease already.

"That is the exact opposite of what we are being asked to do," Johnson said. "A lot of folks just don't seem to get it."

Counties such as Fairfield and Clarendon have particular concerns because many of their residents are African American with underlying health conditions.

Many black residents have high rates of diabetes, high blood pressure and heart disease, which can, in turn, increase their risk of kidney failure, according to the National Kidney Foundation. The foundation says African Americans make up about 13% of the U.S. population, but 35% of all patients receiving dialysis.

Researchers like USC's Cummings said poor health conditions among black people that make rural communities susceptible to the coronavirus are largely a result of poverty and lack of opportunity.

"Research has consistently shown that where you live is a strong predictor of health and well-being," he said. "Tell me your zip code for instance, and I can tell you your potential exposure to water, air pollution and lead-based paint, your access to nutritious foods, your educational opportunities and job prospects. In concert, each of these factors plays an important role in shaping both the length and quality of one's life. '

In Fairfield County, where 23,000 people live and more than half the county's population is black, the coronavirus threat is real, statistics show.

COVID-19 is suspected of sickening more than 150 people in the county, according to DHEC, which says it has confirmed 25 cases. Fairfield has one of the highest case rates in South Carolina, agency statistics show.

Access to care in the county took a hit two years ago when its local hospital closed. There was an effort to help fill the gap as a free standing emergency room operated by Providence Health was opened the same day the hospital closed. The county also recently started drive up testing for the virus.

Even so, residents must trek about 30 miles to Columbia to reach a hospital.

It's the kind of thing Goins is well aware of. Her husband, who is 69, has kidney disease and a variety of ailments that make him particularly susceptible to the coronavirus. On Friday, she had to leave her home in Jenkinsville for a trip to a doctor's office in Peak, a community in Newberry County.

"We are not exempt from this and it's not over," she said of the coronavirus threat in rural communities like Fairfield. "We just don't know what the outcome will be."