In a normal year, hospitals in rural southern Missouri see a lot of snake bites and rolled ankles.
They’re ailments you acquire canoeing in the early autumn sun or “hold-my-beer-and-watch-this-ing” at night, as an emergency doctor in the area who requested anonymity because he had not been given clearance to speak on behalf of his hospital told The Daily Beast.
“Obviously, this year is really different,” said the doctor, who noted that he contracts out to several hospitals in the area, sometimes driving three hours from his home to serve rural communities coping with COVID-19 outbreaks. Although New York and Washington were dealing with overflowing hospitals and piles of body bags in March, the Missouri doctor told The Daily Beast he didn’t treat a coronavirus-positive patient until May.
Things increased slowly at first, but the past six weeks have been a test of fortitude for the doctor, his nurses, respiratory therapists, and their facilities staff. And regardless of who prevails in a presidential election that saw little campaigning in this erstwhile swing state, the scale of the suffering and loss of life here—coupled with lingering pandemic skepticism—demonstrates the size of the hole out of which the country must still dig itself.
“I get dirty looks going into the gas station wearing a mask,” said the doctor. “It’s just unfathomable the disconnect between being one of the worst areas for COVID, while people who are not necessarily healthy at a baseline are still just acting like there is absolutely nothing going on.”
As of Tuesday, Missouri had reported a total of 190,424 cumulative COVID-19 infections and 3,064 deaths. About 16,111 of those cases had been recorded in the past seven days, according to the state’s coronavirus dashboard. Though there have been significant improvements in the state’s ability to test for the virus, its positivity rate measured over the past seven days was a staggering 28.6 percent. A popular threshold for a percent positive being “too high” is 5 percent.
A number of other largely rural states in the Midwest were struggling on Tuesday, with North and South Dakota in particular emerging as nationwide hotspots. North Dakota has seen a 167-percent increase in cases in just one month. Nationwide, on Tuesday alone, at least 540 new deaths and 93,581 new cases were reported. Those numbers are even more concerning when factoring in the 232,529 Americans who’ve already lost their lives from the virus—an amount some experts see doubling by the end of February 2021.
And the pandemic picture is a disastrous one even in rural areas that have failed to capture much of the national spotlight.
Missouri hit a record number of COVID-19 hospitalizations for the fourth day in a row on Sunday, when the health department reported a total of 1,649 patients hospitalized with the virus. According to reporting from the St. Louis Public Radio, the rise in rural cases have driven the state’s numbers. When smaller rural hospitals must refer a majority of patients to larger ones in other parts of the state, things get overrun quickly, said Steve Edwards, CEO of Cox Health in Springfield.
“It’s gone up exponentially like we had worried about,” Edwards told the radio station.
Even when there isn’t a pandemic ravaging the state, “it’s not unusual for people to drive 30 to 45 minutes without a hospital,” the rural doctor told The Daily Beast, noting that the problem isn’t just the distance between the facilities, it’s their size, their resources. As the virus has spread, more and more patients have severe cases, meaning they need more and more care.
Dr. Jennifer Horney, founding director and professor in the University of Delaware’s epidemiology program, said that years of federal and state healthcare policy changes have weakened an already fragile health-care infrastructure in many places around the country.
Missouri is among them.
“In all kinds of disasters and emergencies, there’s kind of this perceived wisdom that somehow rural people are more resilient—and that when there’s a problem they can band together and help one another,” said Horney. “But resilience can’t overcome not having access to healthcare.”
“Since 2010, 133 rural hospitals have closed,” added Horney, referring to a study by the University of North Carolina’s Center for Health Services Research. Seven of those closures were in Missouri alone, and a back-of-the-envelope analysis of the UNC’s study’s map shows that those hospitals contained a combined 348 beds.
The National Rural Hospital Association has said the closures were a result of the state’s decision not to expand Medicaid, a common political move in states dominated by the GOP in the Obamacare era. Notably, in August voters in the state passed a ballot initiative approving Medicaid expansion to about 230,000 of their lowest-income residents.
As for those rural hospitals left to contend with the unprecedented and deadly pandemic: “We’re seeing sicker and more intensive patients,” the emergency doctor said.
“The problem with these little hospitals is not the number of people coming in—it’s that if we have one really sick patient, all of my resources are tied up there,” he continued. “If I have to put somebody on a ventilator, everyone else gets put on the backburner. That puts a strain on the system by clogging things up.”
“I have seven rooms in my ER, and only three are set up to handle potential COVID patients, with doors that will close all the way,” he added. “I have to put anybody who has any of those symptoms in those rooms.” Aside from rooms, there’s no cardiologist or trauma surgeon at the small, rural hospitals, either, he said.
“Anyone who needs to go to the ICU needs to go to another hospital down the road,” but it has become harder and harder for the doctor and his staff to spend hours on the phone finding beds for transfers, he said. “It’s extremely hard to find a place for those people. We’re looking at sending them four, five, six, or seven hours away.”
Sure enough, Richard Liekweg, president and CEO of BJC HealthCare in St. Louis, said there were “basically no beds” available for patients to transfer to across its hospital system, which on Monday had 205 COVID-19 patients, per the St. Louis Post-Dispatch.
“We’re in the process right now of reassessing whether we’re going to need to start to cancel elective procedures (again) in order to accommodate what we think is going to continue to be a gradual increase in COVID patients at a time when our staff, like everyone else, is completely exhausted,” Liekweg told the paper.
In another tragic milestone, officials in Franklin County said on Sunday that an eighth-grade boy had died of complications due to the virus, making Peyton Baumgarth the first minor in the state to be killed by the disease, as the Post-Dispatch reported.
Baumgarth, a student at Washington Middle School outside of St. Louis, last attended school on Oct. 22 and began quarantining last week, according to the newspaper. His family asked district officials to remind the public “to wear masks, wash hands frequently and follow guidelines. COVID-19 is real and they want to remind students and parents to take these precautions in and outside of school.”
Despite GOP Gov. Mike Parson getting COVID-19 himself, his state has no mask ordinance. And with many local governments refusing to impose their own, it’s hard to imagine residents in many counties following those guidelines.
At least some of the data shows the consequences for that lack of compliance. About 40 percent of those hospitalized in Springfield are residents of the city’s surrounding county, St. Louis Public Radio reported. But the other 60 percent, according to county data, were transferred from all over southern Missouri—a region that largely recommends, but does not require, face masks and sees limited compliance.
“This just isn’t going to get fixed until more people take it seriously,” said the emergency doctor. “When you know the consequences of that action and you keep carrying out that action anyway, it just makes me want to scream.”
Horney echoed many other experts in arguing that the studies by now are crystal clear on the effectiveness of mask orders, even in rural areas where officials may worry about compliance.
“Counties in Kansas where they had mask mandates, they had fewer cases,” said Horney. “And they’re similar in every other way.”
But there has to be a willingness on the part of local leaders to impose such orders—it’s unlikely to happen overnight, even if a new president is elected, and even if Democratic presidential nominee Joe Biden has said he supports a national mask mandate.
It’s also far from clear that the politicization of such public health measures, and the erosion of trust in institutions like the Centers for Disease Control and Prevention, can even be reversed.
For his part, the emergency doctor thrusted blame for at least those two hurdles on President Trump’s pandemic leadership, despite his popularity in rural America, including in rural Missouri: “Unfortunately, we elected a sentient copy of The Power of Positive Thinking for president.”
Late Tuesday, it was not yet clear whether the country had re-elected him.