Recently the warning I give my son changed. Usually, I tell my adventurous nine-year-old, who is high-energy and prone to stunts: I don’t want to take you to the hospital. Since the coronavirus pandemic, I have had to say: there is no hospital. Even before the governor of our state, Ohio, issued a shelter-in-place order, my son’s pediatrician sounded a warning: they were shutting down the surgery centers of the local hospital and the three closest medical facilities, to save protective gear for coronavirus cases. This means if my family gets seriously injured, we may have to drive an hour and a half for care.
We live in a remote, rural area in central Appalachia. I joke darkly that everything is wonderful here except there are no jobs and no healthcare. The pandemic is exposing these sizeable gaps—who has care, who has nothing—compounded by race, class, and geography. But it’s also reinforcing for me why I have lived where I do for so long: in the face of the pandemic, my small community has supported each other, stronger than ever. With inequitable access to resources, we have always had to.
Where I live, in southeastern Ohio, the largest health providers are the hospital and a nonprofit rural clinic (where the CEO made a half a million dollars in fiscal year 2017, and one doctor made more than a million). At the clinic, the waiting area is one huge room, with ill patients sitting next to newborns. This situation concerned me enough a decade before the pandemic that I would wait with my child in our car before appointments. And after repeatedly having to wait months for appointments for illnesses, I decided a few years ago to become a patient of a primary care physician who works out of Columbus, the closest major city. It’s a three-hour round trip, but at least I can get appointments.
It’s not uncommon for people across America to have to endure long waits for medical appointments, and to have difficulty accessing or affording them, but Appalachia is a region where the population is especially vulnerable to illness. We have higher rates of hunger, and all the illnesses of poverty, like poor nutrition and diabetes. And, over the past decade, we have lost access to medical care at an alarming rate.
More than one hundred rural hospitals have closed since 2010, according to NBC News, including a twenty-five-bed hospital near me, in Nelsonville, Ohio, which was once one of the largest employers in town. From 2012-2013, only 45.5 percent of rural hospitals had an intensive care unit (ICU), based on data from the Rural Health Information Hub. The hospital closest to me has eight ICU beds. It is unclear how many ventilators rural hospitals have, but the equipment is expensive enough to be prohibitive. And it is not clear that the CARES act will help rural residents or our “financially troubled” hospitals as much as metro areas with five hundred thousand or more people.
Just before the first cases of COVID-19 were announced in my county, two giant bright yellow tents appeared in the hospital parking lot, a spot where, last year at this time, my son and his friends raced in the annual bike derby. The tents were being pitched as practice for triage, to prepare for an influx of coronavirus cases. But to be tested locally for COVID-19, you must have a referral from a doctor—otherwise, “people will be turned away.” This is a major issue of equity, because a lot of people in my area don’t have primary care physicians and must use the ER. And with a lack of public transportation options, low incomes, and a low rate of insured, the care we do have is inaccessible for many.
Groups for mutual aid—the voluntary exchanges of services and goods—have sprung up across the country in response to the pandemic. But in Appalachia, those networks and exchanges were always here. Strangers cooked food for me when my son was a baby, and I was a new single mom. Neighbors still leave hand-me-downs and books on our porch. A friend who forages drops off my favorite mushroom. Often gifts appear on our porch without attribution.
In small towns, you know who is in need. And so in my community, which doesn’t have the internet connectedness of an urban area, people are calling senior citizens to check on them. The libraries left their wireless networks on and freely accessible from parking lots, though their doors have shuttered. My neighbors have disinfected board games, bikes, and children’s books, and set them out for free. On my community’s mutual aid group, gardening tools are available for use, sewing and washing machines. People give rides, offer to do shopping, to cook, even offering up their spare rooms or empty apartments for others—strangers to them—in need. My favorite bakery drops off food to medical providers; an artist neighbor sewed a hundred and fifty masks.
It’s wonderful that my neighbors give so much, but they shouldn’t have to. My state, Ohio, ranks 48th in the nation for emergency preparedness dollars per capita, after decades years of public health disinvestment. Only Missouri, Nevada, and Arizona spend less on public health per resident. Public health in Appalachian areas, like parts of Ohio and Kentucky, has also lost funding due to population loss, the death of the older generation, and people in younger generations moving elsewhere.
The more things change in the nation, the more Appalachia stays the same. Schools just started remote learning in my county, lagging behind most of the nation, because a large number of students in my area don’t have internet or internet-accessible devices at home, according to the local school superintendent. The school has delivered nearly two thousand Chromebooks free to students and has begun the slow process of setting up mobile hot spots for them.
It’s been said the world will never be the same, even after the shelter in place orders end, the schools return to session, and a vaccine is widely available. It is my deepest hope that some of these emergency changes—like getting more medical supplies and care to the poorest people—stay in place. I hope these previously unconnected children can keep their computers. If landlords can lower rent and utilities and not shut off essential services during the pandemic, why not all the time? I hope more hospitals are built, equipped, and staffed in rural places like my own. I hope the internet stays on.
And when you look for a model on how to remake the world after the pandemic? Make it a place where strangers care for strangers without expecting anything in return. Make it a place where the community is only as strong as its weakest member, and where help is given, as much and as often as it can be. Make it like Appalachia—but don’t forget us this time.