Dr. Michael Brumage, MD, MPH, FACP, FACPM is the Medical Director, Cabin Creek Health Systems, West Virginia and the Program Director, Public Health/General Preventive Medicine Residency, West Virginia University School of Public Health

As the first wave of the coronavirus tsunami crests, communities across Rural America are experiencing the consequences in different ways. Rural southwestern Georgia has been especially hard-hit as they begin to reopen businesses. West Virginia, where I live, has escaped the worst while we remain under a stay at home order from the Governor.
Rural America was at a disadvantage even prior to the pandemic. A 2014 study demonstrated the widening health disparity between rural and urban areas, showing a life expectancy of 79.1 years in large metropolitan areas, 76.9 in small urban towns, and 76.7 in rural areas. The opioid crisis has disproportionately driven down life expectancy in the rural U.S. because of drug-overdose deaths. Other “diseases of despair,” as described by the Princeton professors Anne Case and Angus Deaton in 2015, including heart and lung disease, stroke, Alzheimer’s, diabetes, and suicides, have been on the rise in the rural heartland as well.
Public-health systems in rural states also rely on financial backing from the federal government that is not always forthcoming. Through the Prevention and Public Health Fund, the Centers for Disease Control and Prevention funneled roughly $625 million a year to state and local initiatives, such as immunizations for children, grants for local needs, and programs to respond to infectious diseases. However, according to a Trust for America’s Health report, from 2013 to 2027 the fund will receive nearly $12 billion less than the law had promised. Also within the CDC, a program that helps state and local health departments prepare for and respond to emergencies has lost nearly 30 percent of its funding since 2002, except for a short-term increase in funds to address the Ebola and Zika outbreaks.
Sixteen states have decreased their public-health budgets over the years. According to a 2016 analysis by Trust for America’s Health, the median state funding for public health was $33.50 a person in the 2015 fiscal year. Nevada was the lowest, at $4.10 a person, while West Virginia spent the most, at $220.80. But the report notes, “Only 7.1 percent of adults have diabetes in Utah compared to 14.1 percent in West Virginia, and only 10.3 percent of adults in Utah are current smokers compared with 27.3 percent in West Virginia.” Shrinking local health-department budgets compound the problem. In 2016, the West Virginia state government proposed cutting aid for local health departments by 25 percent.
Across the country, a record 18 hospitals in rural areas shut down in 2019, and 161 rural hospitals have closed since 2005. Just in the past 2 months, two hospitals closed in West Virginia in the middle of the pandemic.
West Virginia was the last state to report a case of COVID-19 with the first instance reported just as I was writing an article published On March 18, 2020 in The Atlantic. When the article ran, I was worried, and for good reason. A study by the Kaiser Family Foundation indicated that West Virginia is the state with the highest share of adults who are at risk of serious illness if infected by COVID-19 (51 percent) compared to the national average (41 percent). Like much of rural America, our state is plagued by a declining population, fewer social-support structures, lack of access to nutritious foods, and lower educational achievement, all of which hamper resilience to both man-made and natural disasters. West Virginia was already dealing with many other infectious diseases: hepatitis B and C (the number one infectious killer in America), HIV due to needle sharing from injection drug use, and chronic diseases like obesity, cancer, and diabetes. We were dealing with a syndemic of overlapping epidemics prior to the arrival of SARS-CoV-2.
Despite all that, we have fared relatively well. Governor Jim Justice acted rapidly relative to many other rural states, closing schools on March 14, shuttering all but essential services on March 24, and issuing a stay at home order on March 25. The models continued to revise down estimates of anticipated ICU bed requirements and deaths. Relative to our 5 surrounding states, we have exceeded expectations, with the lowest case fatality rate and the lowest percentage of population positive despite having tested a greater proportion of our population.
The attention on the pandemic has robbed air from our other pressing issues, where they will ferment until we can refocus on them. Still, we count our blessings as we hope to transition to a looser set of restrictions to help revive a declining economy and the public health problems associated with that. In the meantime, we take our surfboard back out to face the next wave.

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