Crisis Capacity in Rural and Remote Communities

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Rural and remote societies depend on healthcare systems which are a part of their communities and their lives. These rural healthcare systems their own challenges since they operate in communities where they are the sole healthcare provider, neighbor, friend, and often family, overlap and intermingle, and where presenting a patient to a different less interested doctor is not possible. Moreover, the rural North America, their populations are more likely to be attacked by the economic and health impacts of any pandemic that may strike (“Status of State Medicaid Expansion Decisions: Interactive Map” 2020). Rural healthcare providers are few in numbers compared to their urban counterparts. More on that, rural healthcare providers have to work in very straining conditions with fewer resources and a system that depends on colleagues for day-to-day management of patients care.

Statewide pandemic planning should include rural and remote communities, who may n other way fear that health care facilities and providers will not have resources needed to provide pandemic care. Fear may also arise that the resources to combat the pandemic may be transferred to hard-hit urban areas, further corrupting the rural capacity. Many rural facilities do not have access to bioethicists, and rural hospitals often lack or underutilize ethics committees (Cook and Hoas 2008). This may affect the ethical choices and deliberations of rural healthcare systems and providers. The lack of timely ethical guidance or expertise is compounded during a pandemic, as smaller systems are at a greater risk of using all of their resources faster, without the financial and political ways of big institutions to replenish them. Regional coordination that allows rural healthcare facilities to work together and pool key resources may be essential.

The implications of any pandemic for rural healthcare systems include an urge to strengthen the already existing social relationships and is true in all health systems, to communicate clearly and early during a pandemic how and why certain decisions are made (e.g., why family members may be no allowed at a loved family members’s bedside, or how the allocation decisions are made and the ethical rationale for the criteria to be selected). Given the lack of ethics expertise in some rural systems, sharing pandemics prevention policies from urban or suburban healthcare systems is important. However, rural healthcare systems must create policies, guidelines and resources that consider and address the rural populations’ circumstances and concerns specific to their community.

Discrimination and Health Equity

Structural inequalities in both the United States and Canada put specific economic, racial, ethnic, geographic, and other marginalized groups at a disadvantage in accessing and using healthcare services, even in times of relative prosperity and calm (Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care 2003). Under the pressured conditions of a pandemic, health differences can be increased. Disadvantaged communities can experience delayed access to testing, problems in transportation to health facilities (especially when people are expected to observe social and physical distancing), lack of insurance, worry about immigration status, and higher burdens to the existing chronic disease (Quinn and Kumar 2014). These patients may also encounter provider bias, such as by having their pain under-treated or complaints minimized or misdiagnosed (Anderson et al. 2009; Hoffman et al. 2016). This partly explains why, for instance, while black residents make up only about 23% of the residents of Cook County, Illinois, they accounted for about 70% of COVID-19 deaths as of this writing (Ramos and Zamudio 2020).

Other ethnic and racial populations, such as Native Americans and Canadian Indigenous people, are also at particular risk (Artiga et al. 2020). In addition, the social pressures of an economic depression, loss of jobs, isolation, and the closing of some services has increased the risk of having no shelter, hunger, and disease among the nation’s poorest populations. Members of low-income communities under quarantine, often suddenly without an income due to joblessness, may be hard for them to buy food, sanitation products, and other resources that might be necessary in the pandemic which can sloe the searching of health care because of financial hardships or fear of losing a job position because of absenteeism. They may also need help settling their electricity water and other bills. Immigrant and undocumented populations, with increased fear of deportation in the current political climate, have also been delay of access to essential services with fear of discrimination or being deported (Parmet and Ryan 2018).

Sometimes a particular group of people might be at a higher risk in case of a pandemic. The elderly who are not under any institutions care, may find themselves forced by circumstances to look after their grandchildren in the wake of school closures, therefore increasing their rate of exposure to the pandemic. There has been concerns on disability rights advocates and their allies that the healthcare system, and proposed policies to aid in the allocation of resources, might discriminate against those with disabilities (American Association of People with Disabilities 2020; Department of Health and Human Services 2020; Disability Rights Washington 2020; Ne’eman 2020). Even in the best of times, navigating the barriers constructed by an ableist society can be hard for people living with disability. In a pandemic, mobility issues, the inability of health providers to report to work, the inability to acquire neccessary supplies, and even the loss of face-to-face contact for those with mental challenges can worsen existing conditions. The Americans with Disabilities Act, the Rehabilitation Act, and the Affordable Care Act all of them are against discrimination of patients, like eliminating disabled patients as a category from medical help on the basis of their disabilities (Bagenstos 2020). Yet, many argue that this is precisely what some triage and allocation policies have done. A study by the Center for Public Integrity found that policies in 25 states that it said would ration care in ways that disability advocates have denounced (Whyte 2020a). A policy in Alabama (since repealed) read in part: “persons with severe mental retardation, advanced dementia or severe traumatic brain injury may be poor candidates for ventilator support” (Weixel 2020). Washington state does recommend transferring of a patient with with “loss of reserves in energy, physical ability, cognition and general health” out of hospitals and into outpatient care (Disability Rights Washington 2020; Washington State Department of Health “Washington State Department and Crisis Standards of Career 2020). On March 28, 2020, the Office for Civil Rights (OCR) within the Department of Health and Human Services (HHS) gave out a bulletin with measures aiming at ensuring that entities under the civil rights laws keep in mind their obligations under laws and regulations that are against discrimination on the basis of race, color, national origin, disability, age, sex, and exercise of conscience and religion in HHS-funded programs. On April 8, 2020, in the wake of protests from disability rights groups, the Utah Department of Health approved an update to its emergency plans to explicitly state that it does not discriminate against people with disabilities in allocating care (Jacobs 2020). Facing a pandemic, the healthcare system cannot remedy the structural inequalities of the social system in the US, but contributes to them. Disability advocates and experts should be active participants in the design of trial and resources allocation. No matter the burdens the healthcare systems is having, care of people with disability should be prioritized.

References

“Status of State Medicaid Expansion Decisions: Interactive Map” 2020

Cook and Hoas 2008

Quinn and Kumar 2014

Parmet and Ryan 2018

Artiga et al. 2020

Bagenstos 2020