Many rural communities have resisted masks and calls for social distancing during the coronavirus pandemic, but now many of them are experiencing record-high infections and deaths.
Critically ill rural patients are often sent to city hospitals for high-level treatment, and as their numbers grow, some urban hospitals are buckling under the added strain.
Registered nurse Pascaline Muhindura has spent the last eight months treating COVID-19 patients at Research Medical Center in Kansas City, Missouri. But when she returns home to her small town of Spring Hill, Kansas, she’s often stunned by what she sees — as was the case during a recent stop for carryout.
“No one in the entire restaurant was wearing a mask,” Muhindura says. “And there’s no social distancing. I had to get out, 'cause I almost had a panic attack. I was like, ‘What is going on with people? Why are we still doing this?’”
Kansas City has a mask mandate, which isn’t the case in many smaller nearby communities that don’t require masks or where mask orders are routinely ignored. In the last few months, a lot of rural counties in both Kansas and Missouri have seen some of the highest rates of COVID-19 in the country.
Yet about three our of four counties in Kansas and Missouri don’t have a single intensive care unit. So when people from these areas get critically ill, they’re sent to city hospitals.
A recent patient count at Saint Luke’s Health System in Kansas City showed a quarter of COVID-19 patients had come from outside of the metro.
“Not only are we seeing an uptick in those patients in our hospital from the rural community, they are sicker when we get them because [providers in smaller communities] are able to handle the less sick patients, and we get the sickest of the sick.” says Dr. Marc Larsen, who leads COVID-19 treatment at Saint Luke’s.
Larsen says that two-thirds of patients coming from rural areas need intensive care and stay in the hospital for an average of two weeks.
Dr. Rex Archer, head of the Kansas City Health Department, warns that capacity at the city’s 33 hospitals is being put at risk by the influx of rural patients.
“We’ve had this huge swing that’s occurred because they’re not wearing masks and, yes, that’s putting pressure on our hospitals, which is unfair to our residents — to our residents that might be denied an ICU bed,” Archer says.
Hospital officials have pleaded with Missouri’s Republican Gov. Mike Parson and with Kansas’ Republican-controlled Legislature to implement statewide mask requirements, but to no avail.
Parson, who was just elected governor by nearly 17 percentage points, accused critics of “making the mask a political issue” at his COVID-19 briefing on Nov. 5.
Many health care experts, however, say that the rural COVID-19 crisis involves far more than masks.
Both Kansas and Missouri have seen rural hospitals close year after year, and public health spending in both states, as is the case in much of rural America, is far below the national average.
Rural populations also tend to be older and suffer from high rates of chronic health conditions, including heart disease, obesity and diabetes, which can make them more susceptible to severe illness when they contract COVID-19.
As Shannon Monnat, a rural health researcher at Syracuse University, explains, the coronavirus has basically caused the rural health crisis to spill over into cities.
“It’s not just the rural health care infrastructure that becomes overwhelmed when there aren’t enough hospital beds, it’s also the surrounding neighborhoods, the suburbs, the urban hospital infrastructure starts to become overwhelmed as well,” Monnat says.
Unlike many parts of the U.S., where COVID trendlines have risen and fallen, Kansas, Missouri and several other Midwestern states have never significantly bent their statewide curves.
While individual cities, such as Kansas City and St. Louis, have managed to curb the spread of cases, the continual emergence of rural hotspots across the state has driven a slow and steady increase in overall case numbers and imposed an unrelenting strain on the states’ hospital systems.
The months of slow, continuous case growth have also primed these states for the kind of case explosion that is now taking place.
“It’s sort of the nature of epidemics that things often look like they’re relatively under control, and then very quickly ramp up to seem that they are out of hand,” says Justin Lessler, an epidemiologist at the Johns Hopkins Bloomberg School of Public Health.
Now a recent spike in Kansas City is adding to the statewide surge.
An average of 160 people with COVID-19 are being admitted to hospitals each day. And the number of people hospitalized throughout Missouri increased by 40% in just the last two weeks.
Some Kansas City hospitals have had to decline patients at times, and some are considering stopping or slowing elective procedures, according to Dr. Steven Stites, the University of Kansas Hospital's chief medical officer.
But bed space isn’t the only hospital resource that’s running out. Forty percent of area hospitals say they are expecting “critical” staffing shortages in the coming week.
And as patient counts continue to rise, nurse Pascaline Muhindura says that's not the only problem hospital workers are confronting. They're also struggling with anxiety and depression.
“The hospitals are not fine because people taking care of patients are on the brink,” Muhindura says. “We are tired.”
