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Rural hospitals were already struggling. Then the coronavirus hit.

Much of what we’ve heard about the coronavirus is from major cities like New York. But what’s happening to hospitals in rural America, where there are more high-risk patients, fewer resources and a smaller safety net — if there is one at all? We talk to two front-line hospital workers in southwest Georgia, and one man in West Texas who has pieced together his own supply chain to get hospitals the equipment they need.

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Rural hospitals were already struggling. Then the coronavirus hit.

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  • Chaplain Will Runyon:

    — everything that we're used to, it is harder to adapt I think as an adult.

    William Brangham

    Chaplain Will, do you ever have moments where you forget?

    Chaplain Will Runyon

    Yeah, I think so. The first couple of weeks that it hit our hospital in Albany, I got to the point where I couldn't sleep. I would sleep maybe til one or two in the morning and then I was up and my mind was racing and it was just the constant replaying of the day before and what's happening and kind of the stress of all that. But I was able to get some medication and help with the sleep, so that helps me a lot. So I'm not so constantly replaying all the visits and all the things that are happening. But it does — it feels so surreal every day when we wake up. It doesn't, you know, the house doesn't look like there's a pandemic and the neighborhood doesn't look any different.And it's beautiful here in Albany, in south Georgia right now. Everything's blooming and it's warm.

    William Brangham

    Spring does have a way of making everything feel new again, but by a lot of actual public health measures — like how many people in Georgia are still testing positive for coronavirus — things are not OK. But, several states, including Georgia, are re-opening for business and Dr. Akers and Chaplain Will are worried it's too soon …

    Chaplain Will Runyon

    It's just insane, to me, to think that we're still having people die in our ICU's every day. But people want to open up the economy again. It just makes absolutely no sense. Because they can't see it face to face and first hand what's happening in the hospitals.

    Dr. Shanti AkersIt's a particular source of stress when you know that you're a resource-stressed area. You know, I have friends at large institutions around the country, large academic centers that have, you know, they have a large pool of critical care doctors. They have a large pool of nurses or just other staff. And we don't have that and additionally, we happen to be one of the only hospitals within — within that area that we live in, that is as large as we are. So there may be some surrounding counties that have no hospitals. There's a few that do have hospitals, but they're 25 bed hospitals. And so we know that they will be overwhelmed as well.

    William Brangham

    But even if cases don't spike again in Dr. Aker's community, there's an underlying problem here — and it's not unique to Georgia: rural hospitals were having a hard time staying afloat before the pandemic. Nearly half were operating in the red and one in four were at risk of closing.And then, the virus came.

    John HendersonHey, this is John Henderson. It's about 4 o'clock on Friday afternoon.

    William Brangham

    John Henderson knows this struggle better than most: for 16 years, he ran the small, rural hospital in his hometown of Childress, Texas. Population: six thousand, forty-five.

    John HendersonHave spent my day delivering about 120 gallons of hand sanitizers to 4 different hospitals in West Texas. I'm just on the highway back home and it's been a pretty day and a pretty drive. There are actually wildflowers blooming here in Texas.

    William Brangham

    These days, Henderson runs the Texas organization of rural and community hospitals. Before the pandemic, his job was pretty 9 to 5, lobbying the Texas legislature in a coat and tie, or hosting webinars — but now he and a small army of volunteers are building their own, homemade supply chain.

    John Henderson

    It's a pallet of hand sanitizer on a pickup that meets another pickup and fans out going, you know, north, south, east and west to make those deliveries.

    William Brangham

    They're logging tens of thousands of miles, hand-delivering protective gear to hospitals across the state. Masks, gowns and even ventilators, or "vents" as he calls them.

    John Henderson

    What we're seeing is a really uneven and unpredictable display of COVID cases in rural counties and hot spots across the state. Happened twice last week, once in a small community in the panhandle of Texas that had a hundred — went from two to a hundred cases in a couple of days and literally couldn't transfer patients and ran out of vents. And so we paired them with another rural hospital in central Texas with some extra vents — and flew those from one site to the other.And then literally trying to meet people at airports and gas stations all over the state has been a wild experience, to say the least.

    William Brangham

    But now, with the usual supply chains so broken, Henderson will follow almost any lead, no matter where it goes.

    John Henderson

    A friend connected me to another friend of his that knew someone at an oil and gas production facility on the Mexico side of the border that had converted all of their production to surgical masks. They got those from Mexico to a warehouse in Austin. I met him and bought all of the supply that he had and started trying to send seventy-thousand surgical masks around the state. And they literally, at the warehouse, asked me if I wanted to sit down and drink some tequila with them, which made me nervous. I said no, thanks. I appreciate the masks. I got go.

    William Brangham

    That's great. I bet you never imagined you'd be this sort of PPE procurements dealer character when you first got into this.

    John Henderson

    Never in my wildest dreams. But the thing that I did know I was signing up for was to do whatever it takes to help these little rural hospitals survive. So, you know, it's not — it's not what I had planned, obviously, but I'm happy to keep doing it if it moves the needle a little bit for those frontline caregivers, especially who are trying to be safe as they care for all of us.

    William Brangham

    Obviously, it's a fantastic service you're providing. But it just seems to highlight the issue that hospitals are having to cobble this together with, you know, hand sanitizer on the back of pickup trucks and ventilators in trucks going back and forth. I guess that's just the world we're living in right now.

    John Henderson

    Well, I think the — the positive aspect of it is that you truly do see the very best in people in challenging times like this. The frustrating part is, you know, we're in the United States of America. And you think to yourself, how in the hell did we let this happen?

    William Brangham

    And how do you answer that question?

    John Henderson

    [Laughs] I don't answer that question. It's probably more accurate to say I wrestle with that question.

    William Brangham

    How the hell did we let this happen? Maybe a pandemic of this size takes everyone by surprise and there's only so much preparation you can do. But one thing we know for sure is that the people Henderson is trying to help — rural Americans — are more likely to have the kind of underlying medical conditions that put them at even greater risk when it comes to this virus.

    John Henderson

    Rural populations generally are older, poorer and sicker. So you have a more poor, poverty population, which is Medicaid and the uninsured. And then you have, generally speaking, more comorbidities like diabetes, more obesity, which can be challenging in normal circumstances, even more challenging during a crisis like we're in.

    William Brangham

    In some ways, it seems like an incredible mismatch — that the uninsured people with really more need and more demand for health care are being served by facilities that may not be as well equipped as larger, better funded places.

    John Henderson

    That's right. Rural Texas hospitals specifically were on the ropes and had had numerous closures prior to the pandemic. We've had 20 rural hospital closures in Texas since 2010, which is double any other state. And you know, the reality on the ground, when you find yourself in a community that no longer has a hospital or a clinic and relies on E.M.S. or ambulance care solely to get to a hospital, when you find yourself 30 or 60 miles away from that, it gets pretty scary pretty quick.

    William Brangham

    So all of these challenges that you're describing of the patient population, rural hospitals struggling just to stay afloat, that's all prior to a global pandemic, then the pandemic comes. That's just got — seems like it's got to complicate things even more.

    John Henderson

    Oh, yeah. It's the same challenges amplified and layered on top of it come the PPE shortages, inability to perform testing and even know how many cases you have in the community you serve. It's — it's near impossible.

    William Brangham

    As if facing a pandemic wasn't enough, this virus is stressing hospitals in a whole new way: since the outbreak, a lot of hospitals stopped all elective surgeries. They wanted less people coming through their doors, and wanted to preserve that protective gear. But elective surgeries are a big money-maker for hospitals and the pandemic cut off that income right when they needed it most.

    John Henderson

    The CEOs I've talked to say that that's as much as 50 percent of their operating revenue.

    William Brangham

    Wow.

    John Henderson

    So we've ground to a halt intentionally. I don't think anyone would say that was a bad decision. It was the right thing to do for those communities. But there are financial, operational consequences to that. A rural hospital CEO recently conveyed to me that the hardest decision of his career was whether to lay off frontline clinical staff so that he can make payroll, or buy masks and gloves and gowns to protect those — those folks.

    William Brangham

    I can't believe a hospital executive is in that position today.

    John Henderson

    Yeah, it's — like I said, it's impossible.

    William Brangham

    Rural hospitals have been on the brink for a decade — and lots of people worry this crisis could push even more of them over the edge. But everywhere you look, people are trying to make the impossible a little less so. Dr. Akers and Chaplain Will in Georgia, helping patients and their families through a heartbreaking, scary time. John Henderson in Texas, getting lifesaving equipment into the hands of caregivers. Each playing their part on the frontlines of this pandemic.

    This episode was created in several living rooms, basements, and any quiet corner of the house we could find. It was produced by Vika Aronson and Gretchen Frazee, and edited by Erica R. Hendry and Emily Carpeaux. Production assistance from Bella Isaacs and Rebecca Oh. Music by Blue Dot Sessions. Thanks to Jason Kane and to Laura Santhanam for their research and guidance, and to Avery Henderson for her technical support. Thanks also to Travis Daub, Vanessa Dennis, and James Williams. Our executive producer is Sara Just.

    And don't forget you can follow all of our coronavirus coverage on air and on our website: PBS.org/newshour. Thank you for listening.