Coronavirus in rural America (Part VIII): Indian Country

The Los Angeles Times reported from the Navajo nation a few days ago under the headline "No running water. No electricity. On Navajo Nation, coronavirus creates worry and confusion as cases surge."  Kurtis Lee writes from Cameron, Arizona, population 885:

Lisa Robbins runs the generator attached to her family’s mobile home for just a few hours most mornings. With no electricity, it provides heat in this rural high-desert stretch of the Navajo Nation where overnight temperatures often linger in the low 30s this time of year. 

Robbins first started hearing the whispers earlier this month — the fever, that sickness, something called coronavirus — but most people in this town of about 900 didn’t seem too worried. It was far off, neighbors told her, a world away in the big cities. 

So, Robbins, who rarely has access to the internet or TV news, continued with her daily routine, which includes helping her mother, who sometimes suffers from side effects of a surgery years ago to remove a cancerous stomach tumor.

Then came the bang on her door and a stark warning from local leaders. 

“They told us to stay inside … don’t come out because people could die,” Robbins said one evening last week. “It hit us so fast, no one knows what to do.”

The story tells of the likely spread of the virus from an evangelical church rally in Chilchinbeto, Arizona on March 7.  The Navajo Nation reported its first coronavirus case on the reservation on March 17, but within a few days the number jumped to 115.

The Navajo nation includes 175,000 residents spread over an area larger than West Virginia and served by just four inpatient hospitals.

Postscript:  Here is a hard-hitting NPR story on the coronavirus' impact on the Navajo Nation. Note the focus on water.  Forty percent of the Navajo reservation doesn't have running water, which means hand-washing is a luxury for them. 

Coronavirus in rural America (Part VII): ecological measures of rurality in a pandemic

An interesting metric for measuring the concentration of coronavirus incidence came to my attention yesterday when I was studying the New York Times Upshot chart re: the highest concentrations of the pandemic in the United States.  The chart the NYT published is here:

What jumps out at me is that places like Show Low, Arizona and Mount Vernon-Anacortes, Washington are being "measured" based not on the municipality or metropolitan area, but based on the entire county in which the municipality or metropolitan area sits.  So, Show Low, Arizona is actually a municipality of about 10,000 folks, though this table shows the population for all of Navajo County, which covers nearly 10,000 miles.

Similarly, Mt. Vernon-Anacortes, Washington is shown with a metro area of 129,000, but that is actually the population for the entirety of Skagkit County, which stretches far to the east of Mt. Vernon, and even farther to the east of Anacortes.  It's total land area, though, is a fifth of Navajo County, Arizona, at just under 2000 square miles.  My point here is that this isn't really "apples to apples" with New York, New Orleans, or Seattle, all densely populated cities--at last relatively speaking.  (By the way, here is the Los Angeles Times story by Richard Read on the spread in Mt. Vernon-Anacortes, a spread that accelerated with the help of a choir.  I've not read any coverage on the details of the spread in Navajo County, Arizona).

Another interesting example of the apples-to-oranges phenomenon here is Pittsfield, Massachusetts, with a population of less than 50K, the seat of the County of Berkshire, which has a population of about 130K (as suggested by the table), in Western Massachusetts.  The entire county, at 960 square miles, has less than half the land area of Skagkit County, and less than a fifth that of Navajo County, Arizona.  This well illustrates disparities in land area between counties in the Eastern U.S. and the Western U.S.--bearing in mind that Berkshire County, MA covers a great deal of land area as New England counties go.

So, the question arises:  Which is the more appropriate measure--for policy makers considering the situation or in a graphic like this?  The population of the city or municipality where the coronavirus is concentrated, e.g., Show Low, Mt.Vernon-Anacortes?  or the entire county, e.g., Navajo, Skagkit, Berkshire, which is sometimes vastly greater than the city in territory, as shown in this?  And of what salience to this question is the very different situation of New York City, with its five urban boroughs and very high population density?

Coronavirus in rural America (Part VI): Small-town grit and preparedness in Oklahoma

Annie Gowan and Juliet Eilperin report for the Washington Post out of Bristow, Oklahoma under the headline, "Small town battled coronavirus on its own, as outbreak spread in a red state."

Epidemiologist Mark Brandenburg saw the threat months ago: The data coming out of China signaled that this could be "the pandemic we had feared for a long time."

The chief medical officer of a small hospital in this town of 4,200 people, Brandenburg didn't wait for orders from the federal government or direction from the statehouse. By mid-February, he had launched a citizens' response team to prepare the community for the novel coronavirus's arrival. Local leaders organized a phone chain. Teams of teenagers and college students were formed to deliver groceries to seniors.

Long before schools around the country started closing their doors, the Bristow school system readied a program to feed kids if it shut down — a must in a city with a 25 percent poverty rate.

Meanwhile, Oklahoma Gov. Kevin Stitt (R) was resisting health officials' recommendations to close schools and restaurants and was allowing medical centers to continue elective procedures, even as other hospitals reported shortages of masks and protective equipment.

The story quotes Brandenburg, a veteran of Hurricane Katrina and the Oklahoma City bombing:

There was no guidance on how small towns should prepare well in advance. And my experience allowed me to know this and get in early and get our town up and running.

Bristow is in Creek County and part of the Tulsa Metro area. 

Other stories about small towns and small cities being hit hard by the coronavirus crisis are here (noting Greenville, MS and Pine Bluff, AR, among others), here (Springfield, Oregon), and here (Albany, Georgia).

Coronavirus in rural America (Part V): So much rural coronavirus news, so little time to blog

In light of the fire hose of rural coronavirus news, I'll collect just some headlines and short excerpts here. 

First, on the healthcare front:

Here is a story from the Billings, Montana newspaper on the healthcare challenges facing rural hospitals.  Here's the lede:

As the number of cases of coronavirus escalates in Montana, hospitals are preparing for more patients while also working to protect staff and others from exposure. 

Even the smallest hospitals in rural Montana are preparing to possibly screen and test everyone who comes through the door, while continuing to care for their older, long-term patients. 

Roundup Memorial Healthcare is just now recovering from an outbreak of influenza B in the town’s elementary school, where about 25% of the students were infected, according to Roundup Memorial Healthcare CEO Holly Wolff. 

As of Saturday evening, at least 30 people in Montana have tested positive for the coronavirus and numerous state and county officials have declared a state of emergency.

Roundup, the town featured in the story, has a population of just 1,788, and is not far west of Billings; it is the county seat of Musselshell County, population 4,538.

A story out of neighboring Wyoming, specifically Sublette County population 10,000, is here.  Thanks to WyoFile.

And here is a map of where the Intensive Care Unit (ICU) beds in the United States are--at the county level.  As the map-makers observe, less than half of U.S. counties have a single ICU bed. Needless to say, this has enormous public health and spatial inequality implications--most notably for where people are most likely to survive the coronavirus.

A just-off-the presses policy brief by Shannon Monnat of Syracuse University is titled "Why Coronavirus Could Hit U.S. Areas Harder."  It touches on many of the demographic and resource issues I've covered on the blog in recent days.  A short excerpt follows:

As rates of coronavirus (COVID-19) infection and death continue to rise, it is important to consider how rural areas may be differentially affected. On the one hand, rural parts of the U.S. may be comparatively better off than urban places due to lower population density in rural areas. Lower population density reduces opportunities for virus spread. On the other hand, there are several features of rural populations and places that increase their risk of coronavirus-related mortality and other long-term health impacts.

These include the realities that rural populations are older and have higher rates of several chronic health conditions, and rural areas have a less robust health care infrastructure to deal with coronavirus cases. Rural economies may also be affected in different ways than their urban counterparts, which has implications for long-term rural population health outcomes.

Second, on the "culture" front, here is a March 20, 2020 piece from the Sacramento Bee, but with dateline Fort Scott, Kansas, on rural resistance to the reality of the coronavirus.  The headline is "‘People need to wake up.’ A skeptical rural U.S. lacks resources for coronavirus fight."  An excerpt follows:

Roxine Poznich says she won’t close her used book shop in Fort Scott, Kansas, until someone makes her. 

The 73-year-old proprietor worked in the lab at the town’s hospital for decades. But that job vanished when Mercy Hospital closed its doors two years ago. She now relies on the bookstore income for grocery money, she said. 

Like many who live away from the country’s large population centers, Poznich says she isn’t too worried about the coronavirus. But she said the lack of a hospital in the southeast Kansas town of 7,800 will exacerbate any local outbreak.

“I think it will make a big difference,” she said. “It just depends on how hard it hits our county.”

As U.S. cities virtually shut down and brace for an influx of coronavirus infections, the story in rural America is a different one. From small-town Florida to Georgia’s central peach region, from southern Mississippi to the Kansas and Texas plains, some residents say the threat is overblown. Others worry about how they will face the pending crisis with a widespread lack of resources, supplies and preparedness.

Third, here is a story out of New York that implicates both culture and health.  As in California--year-round residents of rural parts of New York are tired of week-enders/second home owners converging on these enclaves in order to avoid the "plague" ravaging New York City.  The headline is "The Wealthy Flee Coronavirus. Vacation Towns Respond: Stay Away."  Once again, the story is one of rural gentrification and the tensions created--here, those tensions heightened by a pandemic and a competition for scarce resources.  An excerpt follows:

This clash between year-round residents and those with the means to retreat to vacation homes intensified on Tuesday as White House officials advised anyone who had passed through or fled New York City to place themselves in a 14-day quarantine. 

“They’re pumping gas. They’re stopping at grocery stores,” said Kim Langdon, 48, of Ashland, N.Y. “If they’re infected and they don’t know it, they’re putting everyone at risk.” 

The expletive-filled commentary on a Catskills Facebook page was less subtle.
“The only cases in Greene County were brought here from downstate people so stay down there,” one man wrote. “Just because you have a second home up here doesn’t mean you have the right to put us at risk.” 

Mayors, town supervisors and the governors of at least two states have warned part-time residents of tourist destinations to stay away.

Fourth, here is a New York Times piece on the importance of broadband access when it comes to defeating the coronavirus.  The author is FCC commissioner Geoffrey Starks, and the opening paragraph follows:

One instruction remains consistent and clear during the coronavirus pandemic: Stay home. For many of us, that means taking our daily activities — work, school, medical care and connecting with loved ones — online. But not for everyone. The coming weeks will lay bare the already-cruel reality of the digital divide: tens of millions of Americans cannot access or cannot afford the home broadband connections they need to telework, access medical information and help young people learn when school is closed. When public health requires social distancing and even quarantine, closing the digital divide becomes central to our safety and economic security.

I'm sure I'll have more to report from the frontlines of rural America as the coronavirus advances in the coming days.   

Where are rural women in the latest abortion case heard by SCOTUS?

I've written a lot about rural women's access to abortion over the years--academic writing (here, here,  and here) and once in an op-ed as the case that became known as Whole Woman's Health v. Hellerstedt was argued to the Fifth Circuit in 2015.  All of these writings implored advocates and courts to pay more attention to the burden of abortion regulations on rural women seeking abortion.  

That finally started to happen in Whole Woman's Health v. Hellerstedt, decided by the Supreme Court in June 2016.  I believe rural women finally got on the radar screen in that case because Texas provided such a great context for talking about the extraordinary distances so many women have to traverse in order to reach an abortion provider.  After all, once numerous Texas abortion providers were shuttered because of inability to comply with (then) new state regulations, women in west Texas had to travel hundreds of miles each way to reach abortion providers in major population centers like Dallas-Fort Worth, Austin, and Houston.  Few other providers remained available elsewhere in the state, with  services in the impoverished Rio Grande Valley particularly hard hit.

In the end, advocates before the Supreme Court and, eventually, the Court itself wound up spending more time, energy and ink (well, toner cartridge) on rural women in Whole Woman's Health than in any other case to make it to the Supreme Court.  As one who has advocated for more than a decade for courts to attend to the particular circumstances of rural women, I was pleased at this turn--though admittedly also a bit frustrated that my (yes, germinal) work on the issue was not acknowledged by advocates or the Court.  When I appeared on Sacramento's NPR affiliate just after the Supreme Court decided Whole Woman's Health and suggested that, though women's right to abortion was much safer as a consequence of the decision, I added the caveat that a state less spatially and geophysically vast than Texas might present a tougher case for the Court.  In other words, if the distances to the abortion providers were not as great as in the Lone Star State, the Court might conclude that the regulations and consequent provider closers did not rise to the "undue burden" legal standard.

Somewhat extraordinarily, just four years on, that is precisely what is happening.  A Louisiana statute virtually identical to the Texas one struck down in Whole Woman's Health is under scrutiny by the Supreme Court.  The oral argument in the case, June Medical Services, was heard on March 4.  With the help of the (fabulous) UC Davis law librarians, I've perused the briefs and oral argument transcript and found far less attention to rural women--or the burden of distance generally--in June Medical than in Whole Woman's Health.  What follows are the sum total of mentions of distance in the June Medical SCOTUS pleadings and oral arguments.

First, from the petitioner's brief (June Medical Services):

pp. 12-14: 

Much like H.B.2’s effect in Texas, the district court found that two of Louisiana’s three abortion clinics (Hope and Delta) would close. Pet. App. 254a.  [a clinic in New Orleans, in the southeastern corner of the state, would be able to remain open]

“If Act 620 were to be enforced, three of the five doctors”—Does 1, 2, and 6—“would not meet the admitting privileges requirement.” Id.; see also JA 704, 1315 (Doe 1); JA 377, 1318-19 (Doe 2); JA 1311 (Doe 6). Doe 5 would not meet the requirement in Baton Rouge but would in New Orleans. Pet. App. 244a- 45a, 253a-55a. And Doe 3, despite having privileges in Shreveport, would stop performing abortions because Hope [operated by June Medical] would not be a “viab[le]” going concern once Doe 1 (who provided over 70% of its abortion services) could no longer work there. Id. 156a, 256a. All told, only one provider (Doe 5) at one clinic (Women’s) would remain, to provide services for the approximately 10,000 women per year seeking abortions. Id. 255a-56a.

Just as in Whole Woman’s Health, the district court found that “fewer physicians” meant women will encounter “longer waiting times for appointments” and “increased crowding” and “will have to travel much longer distances”—burdens “which will fall most heavily on low-income women.” Pet. App. 258a, 274a. That would lead to “delays in care, causing a higher risk of complications, as well as a likely increase in self-performed, unlicensed and unsafe abortions.” Id. 260a. [emphasis added by L.R. Pruitt] 

 pp. 29-30:

The district court here made findings showing that Act 620’s burdens would, if anything, be more severe than the Texas law in Whole Woman’s Health imposed. While the Court found that the Texas law led to the closure of about half of the state’s clinics, see Whole Woman’s Health, 136 S. Ct. at 2312, the district court found [Louisiana] Act 620 would force two of Louisiana’s three abortion clinics to close, leaving only one physician in the state who could provide care, Pet. App. 273a-74a. Consequently, 70% of women who currently obtain abortions in Louisiana would no longer be able to do so. Id. 256a.

The district court also found that the Act would impose burdens on women beyond clinic closures, including longer wait times and greater driving distances, which would lead to delay in obtaining abortions and therefore a higher risk of complications, as well as increased risk of self-performed, or unsafe abortions. Pet. App. 258a, 274a. Compare, e.g., Whole Woman’s Health, 136 S. Ct. at 2313 (relying on increased distances of 150 to 200 miles); with Pet. App. 262a (citing increased distance of 320 miles for some Louisiana women).  (emphasis added) [bold emphasis added by L.R. Pruitt]

What is more, the district court noted several ways in which Louisiana women were less able than Texas women to overcome barriers to abortion access. Those included that Louisiana is the third poorest state in the country, and likely has a disproportionately higher percentage of women seeking abortion care who are living in poverty. Pet. App. 261a. Additionally, 75% of women seeking abortion in Louisiana—higher than the national average—already have at least one child, meaning a greater proportion would struggle to make childcare arrangements while juggling long-distance travel for medical services. Id. 261a-62a. And, unlike in Texas, where women living more than 100 miles from an abortion clinic are excused from the state’s otherwise mandatory two-trip law, Louisiana law has no such exception; it requires all women to make at least two trips to a provider before they can obtain an abortion, regardless of how far they have to travel. Id. 262a-63a. Compare Tex. Health & Safety Code § 141.012(a)(4); with La. Rev. Stat. § 40.1061.17(B)(3) (imposing 24-hour mandatory delay which necessitates two trips to clinic).

So, the June Medical petitioners are painting a picture of the burden of travel that focuses more on the overall loss of capacity in the state than it does on distance.  That said, distance does matter, as indicated by that last point about the waiver of Texas's two-trip requirement--a waiver that is not part of Louisiana law.

Second, from the respondent's/opponent's brief (State of Louisiana):

pp. 34-35:

Then there is the extensive lower court record on clinic capacity and patients’ travel distances. Because of the small number of Louisiana abortion providers, that record is far more clinic- and doctor-specific than the record in Hellerstedt. App. 40a. The panel did not need to reach that subject in detail, and Plaintiffs leave it unaddressed. But if Act 620 might lead to clinic closures, that evidence would be crucial to analyzing any resulting burdens.

In short, the error-correction Plaintiffs request would require a massive commitment of resources to a case-specific record with little clear significance beyond the facts.

I admit I don't understand the State's argument that the trial court's record on clinic capacity and "patients' travel distances" is not a matter that should draw the Supreme Court's attention, but then this is an advocacy document. 

And finally from the March 4 oral arguments:

MS. RIKELMAN [litigation director for Center for Reproductive Rights, representing  petitioners June Medical]:  And, of course, the finding of every district court that has held a trial on a similar law has been that these laws will restrict access to abortion. And here the district court found that this law would leave Louisiana with just one clinic in one state to serve about 10,000 people per year.

And that would mean that hundreds of thousands of women would now live more than 150 miles from the closest provider. And the burdens were actually more severe than this Court found in Whole Woman's Health. 

JUSTICE SOTOMAYOR: Can we go to Doe 3, the doctor who had the active OB-GYN practice? He's only a part-time doctor in Hope [the name under which the June Medical Clinic operates, in Shreveport, in northern Louisiana]  

MS. RIKELMAN: That's correct.

JUSTICE SOTOMAYOR: There's been much talk about his statement or findings by the district court that he was a superseding cause to the Act because he, on his own, will not practice in that -- in Hope if this law goes into effect because he would be the only doctor.

But putting that aside, he also testified -- I'm sorry -- the Hope manager testified that he only does a limited number of abortions, and without the other doctor, that
clinic would have to close.

MS. RIKELMAN: That's absolutely right, Your Honor. The district court found
that without Doe 1, the primary provider at Hope, Hope would not be a viable going concern.

So regardless of Doe 3's testimony, Hope would have to close because Doe 3 was providing fewer than 30 percent of the abortion services of that clinic.

The primary provider was unable to get privileges, and Hope would close, meaning that women living in northern Louisiana would now have to travel hundreds of additional miles, for a law that has no benefit, in order to access abortion services.
JUSTICE KAVANAUGH: Could I -- 

JUSTICE SOTOMAYOR: There's no dispute here about Doe 1.

More from the oral argument transcript at pp. 27-29: 

MS. RIKELMAN: They [the restrictions on abortion providers] serve no valid state interest. And, in fact, the district court here found that this law was a solution for a problem that didn't exist and would actually jeopardize this -- health and safety of people –

JUSTICE SOTOMAYOR: Would this be –

MS. RIKELMAN: -- in Louisiana.

JUSTICE SOTOMAYOR: -- different if --if they did something as limited as, for example, you have to be admitted somewhere, because some -- being admitted somewhere does further credentialing benefits? But this was you have to be admitted within 30 miles. Some of these doctors were admitted further away, but
they still were credentialed by someone, correct?

MS. RIKELMAN: That's correct, Your Honor. If credentialing were the true goal of this law, the 30-mile limit would make no sense. And one of the practical real-world impacts, if this law were to take effect, is that women in the Baton Rouge area would now have to travel miles back and forth to New Orleans to see the same exact physician that they previously could have seen –

JUSTICE SOTOMAYOR: How many –

MS. RIKELMAN: -- in Baton Rouge.

JUSTICE SOTOMAYOR: -- miles from the northern -- from the Hope area?

MS. RIKELMAN: It's 320 miles, Your Honor, from Shreveport to New Orleans. And from Baton Rouge back and forth, because of the two-trip law, it's 320 miles. And, again, they would be making that trip to see the same exact physician who had been previously providing services in Baton Rouge. And that has no benefit to women's health. It will only hurt their health, which is exactly what the district court found here.

JUSTICE GINSBURG: You haven't mentioned, and it's odd, the 30 mile from the clinic, when most of these abortions don't have any complications and the patient never gets near a hospital, but if she needs a hospital, it's certainly not going to be the one near the clinic. She will be home.

MS. RIKELMAN: That –

JUSTICE GINSBURG: And so –

MS. RIKELMAN: That's exactly right, Your Honor. That's what this Court recognized in Whole Woman's Health and one of the reasons why it concluded the law is medically unnecessary, because the -- the complication rate is extremely small to begin with, but when complications do occur, it's almost always after the woman has been left the clinic.

[emphasis added by L.R. Pruitt]

I hope, in a future post, to write more about how commentary on the case has addressed the issue of distance--or not.  For now, it is worth noting that rural women were not mentioned in these pleadings and oral arguments in June Medical though distance and travel made at least cameo appearances. 

Coronavirus in rural America (Part IV): California

The Los Angeles Times and Sacramento Bee both ran stories yesterday about the implications of the coronavirus for rural California.  Both discussed health care issues (the subject of recent posts here and here), but health care access in rural parts of the Golden State was the focus of the Bee story by Ryan Sabalow and Jason Pohl.  The headline proclaims the bad news bluntly:  "California’s rural hospitals can’t handle a coronavirus wave. ‘People will die,’ doctor warns."

Mammoth Hospital’s chief medical officer Dr. Craig Burrows didn’t hold back as he urged the 8,234 people living in his Sierra ski-resort town to stay home and avoid crowds. 

“Try to imagine 100 people getting sick all at once tomorrow,” Burrows said in an unscripted video message the Mono County hospital posted on YouTube. “If that happens, our small hospital, our small community, will be completely overwhelmed and people will die. 

“Let me say that again: People. Will. Die.”

Mammoth Hospital has 17 beds. If COVID-19 sweeps through that community, there won’t be room to treat everyone and doctors will have to make hard choices. It’s a grim reality that Mammoth shares with 33 other federally designated “Critical Access Hospitals” in California that have 25 or fewer beds.

The story goes on to list many of those other 33 "Critical Access Hospitals" in the Golden State.  They are in places like Fortuna (Humboldt County), Fall River Mills (Shasta County), Surprise Valley (Modoc County), Lone Pine (Inyo County), Tehachapi (Kern County) and Gridley (Butte County).  Here's more of the Bee story:

In 2015, officials from across California conducted a “tabletop exercise” designed to simulate the impacts of a major flu pandemic. Local emergency planners were given various projections of how many people would get sick and die and how many ventilation machines each county has to keep severely ill patients breathing. 

The results were sobering for Shasta County (population 180,000) and its county seat Redding, a regional medical hub: Anywhere between 39 and 445 people would need ventilators. 

State figures show that Shasta County hospitals have 86 ICU beds equipped with ventilators, including beds for newborns. Most beds are in Redding, home to two regional hospitals that receive patients from across the rural north state. 

The numbers are even bleaker at the three hospitals along the foggy north coast in Humboldt County, population 136,754, said Rex Bohn, a county supervisor. 

“We’re very fortunate (the hospitals) all work together really well, but with that, I think we have a total of maybe 22 ICU beds and 250 beds total,” Bohn said. “So if it comes time for us to push that red button (and request help from regional hospitals) … there’s no guarantee they’re going to answer because they’re already stretched.” 

He said the county is trying to prepare by renting rooms at local motels to house and isolate COVID-19 patients who don’t require critical care.

As with my last "health" post re corona virus, this one demonstrates the relationship between rural and urban, with the former at the mercy of the latter.  That's a reversal of the normal state of affairs, when urban folks rely on rural folks--for food, minerals, fish, timber and other products of rural-based extractive industries.

The Los Angles Times story also mentions Mammoth Lakes, but in this case as a destination urban folks are escaping to as they seek to avoid the densely populated areas where coronavirus is quickly spreading.  Here's the paragraph most salient to what is happening in the Eastern Sierra:

In Mammoth Lakes, a small Eastern Sierra town that survives primarily on skiing at Mammoth Mountain, the tourism board this week told nonresidents to keep out. “The reason is simple,” the board’s website announced. “As a small, remote mountain community our healthcare facilities lack the capacity to handle a widespread outbreak of COVID-19.” 

Another in-demand "rural" location (well, I'd say a form of rural gentrification) is Joshua Tree, in the Mohave Desert of San Bernardino County.  Louis Sahagun writes:

As the coronavirus pandemic tightens its grip on California’s largest cities, some residents are fleeing urban sprawl and seeking shelter in isolated communities in the Mojave Desert or rugged Sierra Nevada. Their hope, they say, is to avoid possible public unrest and limit their exposure to the virus. 

These new urban immigrants are not entirely welcome, however. Locals fear their arrival could overwhelm the public health systems of small towns already struggling to cope with the growing crisis, and public health officials worry the movement will lead to greater spread of the highly contagious virus. 

In Los Angeles, Mayor Eric Garcetti announced Thursday night that residents were forbidden from moving to or from vacation homes outside the city, along with a number of other health and safety restrictions aimed at fighting contagion. 

And that will stem the flow of people from urban to rural, and vice versa.  No doubt, this will not be the last post in this series on coronavirus' impacts on rural places and on the relationship between rural and urban.

P.S.  The story discussed above re: California's rural hospitals is the top item in Sacramento Bee print edition on the morning of March 24, 2020. 

Also from the Sacramento Bee online as of March 24, 2020:  "California Tourist Towns Demand Outsiders Stay Home:  'Someone is going to get shot.'"  Again Ryan Sabalow and Jason Pohl report, including from Mono County, population 14,168.

Coronavirus in rural America (Part III: More on health)

A few days ago, the Washington Post published an important story by Dan Keating and Laris Karklis comparing flu deaths in rural America to what we might expect from COVID-19 as it spreads to rural places.  The points are mostly that rural America has a higher proportion of elderly and vulnerable populations and less well resourced health care.  Still, not all rural places/regions are "created equal," just as the same is true among urban areas.  Here's an excerpt from the story:

Covid-19 may pose the greatest risk to Americans in rural areas if deaths from the coronavirus pandemic are similar to those from the standard flu. Other concentrations of sick and old people may also be at risk. 

With more than 100 Americans already dead, scientists project the future by measuring the people at greatest risk and deaths from similar threats. 

Biostatistician and infectious disease specialist Nicholas Reich from the University of Massachusetts is participating in the White House Coronavirus Task Force modeling efforts. He said the death rates from flu for people over 50 could be a good indicator of vulnerability for covid-19. He said flu death rates are “probably not a perfect measure but a good place to start.”

The story also offers some interesting comparisons among urban places, and then among rural ones, including this information about the flu:

Rural and small city areas in Iowa and Missouri, around the Missouri River and Mississippi River, have had high death rates. Kansas, Nebraska, the Dakotas, Indiana and New England show rates higher than any of the big cities. 

The push for social distancing and isolation make dense crowds and public transportation in big cities seem like the deadliest environment. 

The pattern of flu deaths over the past five years, however, shows that big metro areas are not hot spots for high flu death rates. Most of the deaths are among the large population in big cities, but the risk for any individual person goes up dramatically where homes are sparse. 

Very rural areas have a 60 percent higher death rate from flu than the big metro areas, according to analysis of CDC death records.

See the story in WaPo to look at the infographics.

And here is today's National Public Radio story on the threat of rural hospital closures, reported by Lauren Weber.  The lede follows:

Rural hospitals may not be able to keep their doors open as the coronavirus pandemic saps their cash, their CEOs warn, just as communities most need them. 

As the coronavirus sweeps across the United States, all hospitals are facing cancellations of doctor visits and procedures by a terrified populace — profitable services that usually help fund hospitals. Meanwhile, the institutions also find themselves needing to pay higher prices for personal protective equipment such as face masks and other gear that's in short supply. 

* * * 

The American Hospital Association ... on Thursday [asked] Congress for $100 billion for all hospitals to offset coronavirus costs, citing rural hospitals' inability to withstand huge losses for long.

Alan Morgan, head of the National Rural Health Association, which represents 21,000 health care providers and hospitals, is quoted:

If we're not able to address the short-term cash needs of rural hospitals, we're going to see hundreds of rural hospitals close before this crisis ends. This is not hyperbole.

A March 17 story from In These Times/Pew Charitable Trust's Stateline is here, and an excerpt (focusing on West Texas) follows:

If you’re exhibiting coronavirus symptoms and meet the criteria, you should get tested.

But if you live in rural Presidio County, on the western end of the Texas-Mexico border, be prepared to travel. County residents who are severely ill are being told to go to Big Bend Regional Center in Alpine, Texas, which is nearly 90 miles away from the city of Presidio. The hospital will stabilize those patients before sending them nearly 200 miles to El Paso, according to a hospital spokeswoman.

Patients in the region seeking test results should be prepared to wait. The 25-bed hospital in Alpine takes samples and sends them to the nearest testing site, also in El Paso. Those tests are reported in a day or two. Three local clinics also have a handful of coronavirus tests, but those are taken by a courier to El Paso on weekdays, and then flown across the state to a lab in Dallas. The turnaround time is three to four days, said Dr. Adrian Billings, with Preventative Care Health Services in Alpine. 

“People who live out here in West Texas, we’re used to it,” said Gary Mitschke, emergency management coordinator of Presidio County. “If you don’t have 100 miles — well, you really haven’t gotten anywhere.” 

As in the rest of the country, most of Texas’ coronavirus cases have been in its largest cities, including Austin, Dallas, Houston and San Antonio. But the virus is moving toward less populated areas.  

Another recent Legal Ruralism post (collecting sources) about rural health care challenges in the era of coronavirus is here.  A New York Times story about the significance of population density to spread, specifically in the NYC context, is here. 

Financial Times on novel and successful approach to coronavirus containment in small Italian city

Here's the lede from the story by Donato Paolo Mancini and Clive Cookson in the Financial Times on March 17, 2020: 

An infection control experiment that was rolled out in a small Italian community at the start of Europe’s coronavirus crisis has stopped all new infections in the town that was at the centre of the country’s outbreak. Through testing and retesting of all 3,300 inhabitants of the town of Vò, near Venice, regardless of whether they were exhibiting symptoms, and rigorous quarantining of their contacts once infection was confirmed, health authorities have been able to completely stop the spread of the illness there. 

Andrea Crisanti, an infections expert at Imperial College London who is taking part in the Vò project while on sabbatical at the University of Padua, urged countries that have been limiting virus testing, which includes the UK and US, to learn lessons and ramp up the numbers of people being screened. “In the UK, there are a whole lot of infections that are completely ignored,” Prof Crisanti told the Financial Times. “We were able to contain the outbreak here because we identified and eliminated the ‘submerged’ infections and isolated them,” he said of the Vò approach. “That is what makes the difference.”

In other words, broad testing was effective in that context. This seems like the sort of experiment that would be hard to do in a larger population cluster, if only because it would be more costly and harder to control the movement of people to and from the place.   

Coronavirus in rural America (Part II): Education

Following up on Part I regarding health care, here is Part II on the impact that the coronavirus is having in rural America, this time on educational access.

First up is this story from last week by Nicole Gaudiano for Politico, published under the headline "Coronavirus quarantines could rob poor, rural students of access to education." It suggests that 12 million students live in homes without broadband, which is complicated when the whole country--virtually--has moved to online learning.  Here's an excerpt from the Politico story:  

If the coronavirus forces schools to shut down for long stretches of time, millions of students will struggle to keep up because they don’t have broadband to do schoolwork at home. 

What’s known as “the homework gap” could be devastating for students who can't easily use the internet — especially in poor urban areas and rural districts where families don’t have a home laptop or high-speed internet connections. Federal and state officials have long known about the online education gap in America, but spending money to fix the problem wasn’t prioritized. If there are mass school closures, it will be too late.

Nearly 12 million children live in homes lacking a broadband connection, and white residents are more likely to have broadband in their homes than people of color, according to a 2017 report from the Democratic staff of the Joint Economic Committee. 

In 15 states, the majority of rural residents do not have access to broadband, the report says. 

* * * 

Given local control of schools, continuing education amid lengthy closures may look vastly different — and with varying degrees of equity — from place to place. 

“They will rely on e-learning as much as possible, but they have to have a backup plan in place, which could include a more traditional presentation of textbooks, work packets, pen-and-paper-based academics that support learning in a way that makes it accessible for kids that don't have internet at home,” said Noelle Ellerson Ng, of AASA, The School Superintendents Association.

The "too late" part from three paragraphs up is what I'm hearing from my mom, a teacher's aide (now called non-certified personnel) in the rural Arkansas Ozarks.  Kids there went home last Friday with five days worth of homework, but I understand that many are not getting completed homework turned in--and many don't have access to the digital infrastructure to log on for online instruction. 

Another issue re K-12 school closure is how to feed the millions of kids who rely on free- and reduced-price lunches.  Many of those kids are also fed breakfast at school.  It's challenging for urban kids to feed those students--more so for rural districts because of the spatial barriers.

As for higher education, here is a story by Kate Reilly for Time Magazine:

Spring break just began for Kyii Sells-Wheeler, but he’s already wondering how he’ll complete his school work when classes resume in a little more than a week. 

A sophomore at Fort Lewis College in Durango, Colorado, Sells-Wheeler is one of thousands of students who have seen their colleges cancel in-person classes and transition to online learning as a precaution against the coronavirus outbreak, which school leaders have described as an “unprecedented crisis.” And a member of Navajo Nation, he is one of thousands of Native American students who come from reservations with notoriously limited internet access. 

“We still had classes today, so I was asking my professors, ‘What if we come from an area where internet access isn’t readily available or reliable?’” Sells-Wheeler, 20, said Friday, adding that many instructors told him they don’t yet know the answer. 

As the coronavirus outbreak affects people across the United States, educational institutions—including colleges where students live and study in close quarters, and K-12 schools where children roam crowded hallways and cafeterias—have been forced to take drastic measures to prevent the virus from spreading.

Several stories from last week also touched on college students who will be more disadvantaged by online learning--in particular first gen (first generation in their families to go to college) and rural students who depend on their colleges for housing and food.  Many of those students, including rural ones, don't have access to the broadband they'll need to complete online classes.  Two of those stories about colleges going "online" and sending students home are here and here.

In this post yesterday, I touched on the rural-urban divide in California's response to the coronavirus crisis.  Since then, more cases have been reported from rural California, though not nearly as many as from the Golden State's urban clusters.  

California's Governor Newsom on rural-urban difference in coronavirus incidence and response

California Governor Gavin Newsom spoke at length yesterday about measures the State is taking to protect Californians in the face of the quickly spreading coronavirus and COVID-19.  Newsom is continuing to allow local governments to make many decisions about closures for themselves and in doing so, said this on Sunday:

We’re not some small isolated state. We’re a nation-state.  Santa Clara County’s conditions are extraordinarily different than Tulare. Extraordinarily different than Madera. Or Colusa. And so, while it may be fanciful and comforting by perception standards, for some [who want] one size fits all, that’s not the world in which we view the reality on the ground. There’s no community spread in some communities, there [is] significant community spread in other communities.

While he didn't use the word "rural," in mentioning Madera, population 150,865, and Colusa, population 21,419, Newsom certainly implied it.

Also in Sunday's news conference, Newsom mentioned that about half of California's school districts would be closed starting on Monday, but those districts serve about 85% of the state's students.  Newsom commented, "Many smaller districts remain open and for reasons that are perfectly understandable."  I noticed that when many California school districts started announcing closures last week, Modesto in the northern part of Central Valley was not among them.  Modesto, with a population of 200,000 is hardly rural, but it's mid-sized in context of the population behemoth that is the Golden State.  Apparently many smaller California districts also remain in session this week. 

I note that on California's coronavirus map as of today, there appears to be one case in nonmetro Siskiyou County (or perhaps that's Shasta County, but right along I-5) and one in sparsely populated Humboldt County, perhaps in the county seat Eureka.  A few cases show up along I-5 farther south, in the state's great Central Valley (looks like a cluster in Fresno and a smaller number in perhaps Merced County).  At least one case is pretty far east in the Inland Empire, which is mostly nonmetropolitan.  Among counties with "shelter in place" orders, nonmetro San Benito, population 55,269, is new to California's list this morning and the only rural county on it.

Coronavirus impacts in rural America (Part I: Health)

The media are increasingly paying attention to how coronavirus is playing out differently in rural and urban areas.  From the perspective of a ruralist, the news is mixed.  First, commentators seemed to suggest that rural America would fare better than the rest of the nation because it is less exposed--less in contact with the people who would have the virus.  An illustration of this is that as of March 16, West Virginia didn't yet have a single positive test.  Other states popularly thought of as "rural" were slow (compared to other states) to identify their first cases; these include North Dakota, Arkansas, Idaho, Mississippi, Alabama, New Mexico, Wyoming and Maine, none of which had a single diagnosed case as of March 10).  Of course, we don't know whether this is because people there did not have access to testing or whether, in fact, the virus was slow to spread there.

This Washington Post story from today indicates that population density drives the spread of the virus, which helps explain why many rural areas are not as hard hit.  An exception to that "rule" of low incidence in rural communities is here, from the New York Times, out of Cynthiana, Kentucky, population 6,402, where six cases were diagnosed the first week in March.

The media have also shifted some of their coverage to rural deficits, particularly in the health care sector, which will make it difficult for rural hospitals and medical professionals to deliver the standard of care associated with more populous places. 

An example of this is NPR's March 15 story out of Grangeville, Idaho, population 3,141 and the county seat of Idaho County, the largest in land area in the state and spanning the width of Idaho, from Montana to Washington State, just as the state's territory narrows to the panhandle.  Here's an except from the story by Kirk Siegler, a veteran reporter on the American West: 

Syringa Hospital has just 15 beds, an emergency room and a clinic. As is common in rural medicine, the chief medical officer, Dr. Matthew Told, is also a family practice OB and, on a recent evening, the on-call ER doc. 

"We don't have ventilator services, we don't have respiratory therapy," Told says during a break between seeing patients. 

There is no intensive care unit. So when they do get a critically ill patient or trauma victims, it's standard protocol to stabilize and transfer them to a large regional hospital in western Montana or Spokane, Wash. But what if ICUs in those places become overwhelmed with coronavirus patients? 

"The biggest challenge is living so close to a state where there are so many cases, such as Washington, and having that really just across the border," Told says. 

And a few paragraphs later is this related, illuminating comment from Dr. Mark Deutchman, associate dean for rural health at the University of Colorado's medical school.

If the places that you rely on to send your critically ill patients are full, then you're stuck.

In other words, this Grangeville hospital and is at the mercy of larger hospitals in Washington State, or perhaps in Montana or in Lewiston, more than an hour to the north, if a patient needs a ventilator.  Rural hospitals face other challenges:

Told knows that his hospital could soon be completely overwhelmed and unable to effectively treat anyone, coronavirus patient or not. This is the story in many communities right now. But it could have an even more dire effect in isolated rural towns like this that lack the infrastructure or trained staff, especially if they were to get sick and couldn't come to work.

A similar story is reported from nearby Dayton, Washington, population 2,526, by Eli Saslow of the Washington Post.  The themes are the same:  under-resourced facility with few staff, reliant on larger hospitals in the region, in this case Walla Walla and Spokane, if the need arises.  Here's an atmospheric quote from the story, which provides context for both Dayton General and what is happening to rural hospitals across the United States:

[Dayton General] had ... for the past several years [been] somehow keeping the doors open even as America’s rural health-care system collapsed all around them, with 125 other rural hospitals around the country closing for budget reasons and doctor shortages spreading across 85 percent of rural counties. Dayton General could no longer afford to offer obstetrics, endoscopy or surgery of any kind. Its emergency room and nursing home were both losing more than $1 million per year. But the hospital remained the final lifeline for an aging community of about 5,000 people in a rugged corner of southeast Washington state, isolated from all other medical care by 35 miles of barley and wheat.

Noting that Dayton General has not ventilators, Saslow continues:

“This is a virus that can take over and expose your weaknesses,” [Shane] McGuire [CEO of Dayton General] said, and he feared that was true for both rural residents and the beleaguered hospitals left to care for them.

The virus had just arrived in rural America, but already, small hospitals across the country had begun bumping up against the limitations of their resources. A facility in the Berkshires had lost much of its nursing staff to a 14-day quarantine. A critical access hospital in North Texas had only one face shield in storage and couldn’t acquire any others. A hospital in Wisconsin was borrowing sterilized medical gowns from local dentists.

As is typical of Saslow's reporting, the story features lots of great human interest angles, including an aging physician who retired to his hometown a few miles from Dayton, only to become the emergency department director at Dayton General a few years later.

As I write this, I'm listening to Governor Gavin Newsom's long press conference for this afternoon, and he's talking about the President's embrace--finally--of telehealth use by Medicare.  As many rural folks already know, telehealth can be a lifeline--literally.

Here's a much earlier story (relatively speaking in this time when a month seems to pass every few hours), from March 5, by the Center for American Progress.  This excerpt highlights rural demographics and economics--as well as rural deficits--and their salience to the coronavirus outbreak:

The CDC also urges people to contact their health care professional if they believe they may have been exposed to the virus. 

For many vulnerable individuals, following these instructions are not an option. Though government health agencies may instruct the public on how to combat COVID-19, they don’t give them the capacity or tools to do it. For rural America, which has a higher proportion of people vulnerable to the virus—including those who are older and those with disabilities—these resources are sorely lacking. 

As experts have recently noted, many low-income individuals are employed in occupations that do not have health benefits or provide paid sick leave. Rural workers are less likely to have access to paid sick leave than urban workers. Many individuals may be working several jobs so, for them, staying home is not financially feasible. Some companies have encouraged their employees to work from home in order to reduce the chance of transmission, but that isn’t feasible for individuals that don’t have reliable, high-speed internet access at home. Many more Americans work jobs that cannot be performed remotely. 

For many who live in rural areas, including many communities of color, LGBTQ people, and people with disabilities, these factors make it impossible to work remotely. Almost one-third of rural households lack internet at home. Though many conflate the agriculture sector with the entire rural economy, the service sector employs the largest number of workers in rural counties, and many of those are in lower-paid occupations in the education, health, and food service sectors. More likely than not, these workers cannot work remotely—nor can they afford to miss work. Because of the economy that rural Americans face, they do not have the capacity to keep themselves safe from COVID-19 and continue to make a living. 

This story, by Olugbenga Ajilore, a senior economist for the Economic Policy Team at the Center for American Progress, and Zoe Willingham, a research associate for the Economic Policy Team at the Center, is chock full of helpful links providing detailed rural context re economics and demography.

P.S.  Another resource I just discovered on March 18.

P.P.S.  These projections from March 20 suggest that some rural areas--see north central Montana--will not be hard hit even under the worst-case scenarios associated with no social distancing.  Generally, more sparsely populous areas will be less hard hit--just look at places like California's Inland Empire, West Texas, western parts of Nebraska and Kansas, and the corner of the remote Arkansas Ozarks where I grew up.

How rural America continues to suffer, in particular under the Trump presidency

Here's the story and map from the New York Times Upshot, "Which Areas in America Are Worse Off Since 2016?"  An excerpt from Jed Kolko's piece follows:

Although economists now expect that the coronavirus will lead to a major recession, the American economy improved steadily for nearly a decade, under both President Obama and President Trump. 

Gains have been widespread since 2016, when Mr. Trump was elected, with the lowest-wage industries and workers seeing the biggest wage gains. And yet not all of America is better off. 

Five percent of Americans live in counties where the economy was worse off in 2019 than in 2016, on at least two of three key economic measures.

* * *

Where are these worse-off places? Mostly in rural America, outside of metropolitan areas, though some are in small metro areas or the outer suburbs of the largest metros.

What jumps out visually from the map:  Nebraska is in a world of hurt, especially since Trump became president.  Adjacent parts of the Dakotas and Montana are hurting, too.  Otherwise, the region experiencing most pain is the mid-South:  parts of Arkansas, Louisiana, and Mississippi.  Here's Kolko's analysis:

Worse-off counties have a higher-than-average share of agricultural and manufacturing jobs — despite the manufacturing boom of 2018 — and relatively few tech, arts and media jobs.

Photo essay from the Arkansas Ozarks wins WaPo contest

Here's a link to Terra Fondriest's photo essay in the Washington Post, which chose her submission as one of two prize winners in a contest co-sponsored by Visura.  Fondriest's photos are from Searcy County,  Arkansas, population 8195, and some are from a community in that county called Oxley. 

That's about 40 miles from where I grew up in neighboring Newton County, just to the west.  Searcy and Newton counties are Arkansas's only persistent poverty counties (meaning high poverty rate for each of the last four decennial censuses) that are essentially all white.  The state's other persistent poverty counties have significant African American populations and are in the Mississippi Delta area.

Washington Post photo editor Kenneth Dickerman writes: 

I recognize my own extended family in these photos, and I’m sure many others will, too. Fondriest’s work is a poetic look at how most of us put one foot in front of the other and move forward. It shows that daily life is just as profound and important as any big news event.

Fondriest had this to say about her work: 

One drive on a dirt road through the Ozark hills and you’ll get a taste of this region’s natural features. You’ll cross creeks in your vehicle, stopping in the middle to listen to the water flow, and then head back up the hill on the wash-boarded road. You’ll pass vistas of seemingly endless hills dotted with cattle pastures. You’ll see wild turkeys dash across the road in front of you on their way to the acorns and hickory nuts that are in the forest on the other side. If your windows are open, you might hear waterfalls cascading down the drainages after a hard rain, or the interior might fill with dust and the smell of oak leaves burning during a dry spell. You might meet a truck coming at you on the narrow road and see how it pulls off onto the edge of the woods to let you pass. You’ll begin to collect moments that are unique to this part of the country. And if it so happens that you decide to put roots down and call these hills home, you might start to develop a relationship with certain parts of the creek or different bends in the road. You might start to become familiar with the people nestled in the hills that have been here for generations and those who have arrived recently just like you. You might discover and become part of the cadence of everyday life here.

Nice.  I admit that I still have relationships with certain stretches of creeks and particular bends in the road in Newton County--though I left more than three decades ago. Here, here, here, here and here are some of my more photo-centric posts about the place in the dozen years I've been writing this blog. 

P.S.  According to the map published in this New York Times Upshot analysis, Searcy County, Arkansas is one of just three Arkansas counties where the economy was doing worse in 2019 than in 2016 by three major metrics: fewer jobs, lower inflation-adjusted average wages and a higher unemployment rate.  Only two other Arkansas counties have declined on all three metrics, though many declined on two of the three.

The struggle to serve rural Wisconsin's higher education needs

John Hart reported on February 28, 2020, for The Chippewa Herald in northern Wisconsin, on what's happening to the state's multi-campus higher education system outside the flagship Madison campus, with particular focus on the state's rural reaches.  Here's an excerpt that paints a pretty dire picture, focused on Richland Center, population 5,184, the county seat of Richland County, in southwestern Wisconsin.  The enrollment at that campus has hit an all-time low of 155.  The last time the UW system closed a campus, Medford, in 1980, the Richland campus had an enrollment of 264. Here's more background on the system's declining enrollment:

Seven of the System’s branch campuses this fall, including Richland Center, tallied their lowest enrollment in nearly half a century, according to preliminary data. Total enrollment at the branch campuses, about 7,300 students, marked a 46-year low.

The demographic trend shows little sign of reversing during the next decade. Projections based on the state’s birth rate show the number of students graduating from Wisconsin high schools this spring will be the lowest since 2000, according to a UW-Madison report.

Nationally, the contraction in college enrollment will worsen as an even smaller pool of students born during the Great Recession enters college between 2025 and 2030.

The share of students enrolled at the System’s branch campuses is small — less than 10% of students attending Wisconsin’s public universities. But the campuses play an outsize role in the lives of the students they serve.

Four in 10 students at the Richland campus in 2018, for example, were the first in their families to go to college. Nearly half were eligible for a Pell grant, federal aid that mostly goes to students whose families earn less than $40,000 a year. About 40% of students came from communities with fewer than 5,000 people.

For students like Faith Morga, 19, the prospect of attending a four-year campus was daunting, both personally and financially.

Richland Center’s small classroom setting and lower tuition rate appealed to Morga. She decided to save even more money by commuting from nearby Soldiers Grove, the 500-person village where she grew up. She started classes this fall and plans to eventually complete her degree in elementary education at Platteville [the UW 4-year campus associated with Richland Center].

“I’m not sure why more students aren’t going here,” she said. “It’s a great campus to start out small.”