no place to get sick

“We ask, Father God, that you bless the administration of this hospital—our CEO, our VP,” he said. “We ask, Father God, that you bless this board of commissioners …”

The opening prayer at this particular meeting carried a little more urgency than usual, because Greenwood Leflore Hospital faced a financial reckoning.

When the prayer was done, the chief financial officer took her seat at the head of the table and projected a PowerPoint slide on the wall. She reviewed a list of recent credits and debits: the income from Covid federal aid payments, capital expenses, debt repayments, revenue. “So,” she said, “that gives us a loss of $3.3 million for the month of June.”

No one seemed surprised. “And what did we lose last month?” someone asked.

“Let me find that …” The CFO reached for a stack of papers, but another board member had committed the figure to memory: “$2.6 million,” he said.

The stats had been grim for years in Greenwood, and at rural hospitals all over the country. From 2010 to 2020, more than 130 of the 1,800 rural hospitals in America went out of business. At the start of 2020, almost half of the rest were at “high risk” of closure, according to the nonprofit Center for Healthcare Quality and Payment Reform. The situation grew even worse as the pandemic diminished the frequency of money-making elective surgeries and a growing demand for health-care workers caused hospital payrolls to soar. Many hospitals were kept open only by infusions of federal money.

When the delta variant emerged in mid-2021, it zeroed in on the poorest pockets of the rural South. By late summer, the Covid death rate in Mississippi was higher than anywhere else. Cash reserves at the most vulnerable hospitals were bleeding out, and the delta variant felt like a shark going in for the kill. Nurses and doctors, and state health officials, urged patients to get vaccinations, but the issue had become as politically charged as anywhere in the country. In the middle of the delta variant surge, the state’s governor, Tate Reeves, warned that vaccine mandates amounted to “tyranny,” calling vaccination requirements for workers “an attack by the president on hardworking Americans and hardworking Mississippians who he wants to choose between getting a jab in their arm and their ability to feed their families.” Mississippi had one of the nation’s lowest vaccination rates, and it remains in the bottom four of all states.

In the Mississippi Delta—the poorest region in the poorest state—the doctors, nurses, and administrators have sacrificed and improvised, month after month, exhausting themselves to keep their hospitals afloat. Many are filled with a profound sense of duty. But they’ve come to accept the unease that comes when an institution’s survival feels arbitrary—when all the planning, thrift, and professional savvy in the world feels less important than chance. They fear the worst, do their best, and pray for miracles.

Two at-risk rural hospitals in Mississippi, including one that had declared bankruptcy months before the emergence of Covid-19, kept providing services during the pandemic by forging staff-sharing agreements with another hospital to reduce overhead costs. For others, emergency aid—like the $7.5 billion earmarked for rural providers in the American Rescue Plan last November—helped them forestall closure, but it didn’t lift them out of crisis mode.

At the Greenwood Leflore board meeting, the CFO said the hospital was given about $11 million in Covid relief funds in fiscal year 2021. But during that same period, she said, even with the help, the hospital was about $10 million in the red.

The members approved a motion to go into a closed executive session. For the next 86 minutes, they reviewed and debated a recommendation from the administrators to plug one small hole where the hospital was leaking money. Greenwood Leflore boasted the only neurosurgery unit in the Delta. The unit had a full slate of surgeries scheduled, yet it was losing money. The administration suggested the surgeon’s contract be allowed to expire. That wouldn’t stop the hospital’s financial slide, but it might slow the pace of the fall.

The board called a vote, and the ayes had it: The Mississippi Delta would go without neurosurgery as of Sept. 17, 2021.

He was spending much of his time working the phones. In late July he canceled the 20 surgeries he had on the books, knowing he couldn’t provide the necessary follow-up care. “I set about trying to find these people somewhere to go, and I was completely unsuccessful,” he said, leaning in over his sandwich. “I called up people I knew in Jackson, and they said, ‘Nah, man, I’m covered up—I don’t need any more patients.’ For most of the people, I ended up telling them, ‘You’ll have to go back to your primary-care doctor and have them try to find you a spot.’ So now the primary-care doctor will do what I just did—and may or may not be more successful.”

Clark tried to envision what would happen to patients who’d need emergency neurological care in the coming months. Most would have to travel an hour or two longer for treatment than they had before. That extra distance, he believed, might be the difference between a full recovery and a permanent disability, or worse.

A series of studies analyzed by the Centre for Economic Policy Research last year found that when a rural hospital closes, the median distance for residents to access basic health services jumps by about 20 miles, and ambulance travel times increase an average of 76%. The death rate for time-sensitive conditions increases by 8.7%. The mortality increase is even higher for rural racial minorities and the rural poor—11.3% and 12.6%, respectively. The Mississippi Delta’s population is majority Black, and there’s no poorer place in America.

Clark, who’s 72, plans to seek another job elsewhere, likely outside the Delta. He grew up in Macon, Ga., where as a preteen he played bass guitar in a church band whose drummer was Otis Redding. Until his late 20s, when he turned to medicine, he’d been a session bassist at studios throughout the South—Muscle Shoals in Alabama, MasterSound in Atlanta, a few others in Nashville. These days, he connects to music in his workshop, where he crafts replicas of Gibson electric guitars.

“It’s something to do,” he said. “A hobby.”

He rose from the table after finishing lunch, but he didn’t plan to go back to work, even though the need for his services hadn’t changed. In the waning days of his contract, his afternoons were mostly idle.

Mississippi ranks dead last in doctors per capita, but it has more Dollar Trees, Dollar Generals, and Family Dollars per person than any other state in the union. They’re the most conspicuous of the region’s economic indicators, flashing by along with the other roadside snapshots: brick houses with sagging roofs and boarded-up windows; a Ford Taurus on a weedy lawn, no wheels, cables spilling out of the hood like a gutted fish; a couple walking on the shoulder of the highway between a cash advance store and a LoanMax.

The median wage here is the lowest in the country, but health insurance is expensive, with higher deductibles than in far more affluent regions. The average person in Mississippi spends more than twice as much on insurance, relative to total income, as someone in Massachusetts, the state that also has the most doctors per capita. The combination of low wages and expensive health care has saddled Mississippi with yet another dubious distinction: Almost 40% of adults under 65 carry medical debt, according to the Urban Institute, and that figure, too, is the highest in the U.S. In the Delta specifically, a 2020 survey by the national health-care nonprofit Altarum showed that 7 in 10 residents had reported problems in paying medical bills over the past 12 months.

Hospitals are often left with those unpaid bills, which they categorize as “bad debt,” a leading culprit for putting them at risk of closure. Since 2010 the amount of bad debt at rural hospitals has jumped 50%, according to the nonprofit National Rural Health Association. It sets a vicious cycle in motion: A depressed economy leads to unpaid bills; unpaid bills lead to hospital closures; the closures strip the local economy of higher-wage jobs; and the economy gets more depressed. The National Institutes of Health estimates that when a rural hospital closes, per capita income in the surrounding county dips an average of 4%.

Mississippi is one of only three states that lost population from 2010 to 2020, and the outward migration was most intense in rural counties, a couple of which suffered losses of more than 20%. Hospital workers, in high demand almost everywhere, have been among the most likely to leave. Since the start of the pandemic, more than 2,000 Mississippi nurses, for example, have either left the state or quit. This has created yet another challenge for the state’s rural hospitals and local economies: How can you find people to work in communities where the standard of living, by nearly every measurable standard, lags so far behind?

Cassie Oglesby isn’t among them. She’s a traveling nurse from Nashville who early last year threw a couple of tote bags in the back of her Honda Civic and drove to the Delta for the first time, taking a temporary assignment at a 16-bed intensive care unit in Greenville. The water turned her stomach. It was an introductory lesson in the sort of comparative geography implicit in American health care: Things considered intolerable in one place can be easily overlooked, even accepted, in another.

She’d worked for almost two decades at an ICU in Nashville. But a couple years ago some colleagues began leaving to become professional nomads, capitalizing on the national nursing shortage. “If you get the right contract,” Oglesby said, “you can make seven or eight times your old salary.” That’s how she found herself in Greenville. Rural Mississippi has always had trouble attracting health-care workers, but the pandemic triggered desperation. At the ICU where Oglesby now worked, at least half of the nurses on any given shift were travelers. They warned her shortly after she arrived: Brace yourself.

Oglesby had already begun an assignment at Barnes-Jewish Hospital in St. Louis when the pandemic began; she’d also worked in Texas and Washington, D.C. The work was stressful, but in those places she’d grown accustomed to a standardized set of tools: bedside monitors that continuously report a patient’s temperature, blood pressure, and oxygen level; intravenous pumps that are programmed to deliver timed infusions of pain relievers, sedatives, and fluids; pill-crushing machines that make it easy to administer medications on the spot.

Here, Oglesby had none of that. She witnessed nurses sneaking out to steal IV pumps from other parts of the hospital because the ICU didn’t have enough. “And the IV pumps are so old,” she said. “They don’t even make that kind anymore. They have chambers that just don’t work, and they can’t be fixed.”

“We saw it coming,” Oglesby recalled of the weeks in late summer, before things got really bad. “And every nurse and every doctor in the ICU said, ‘No—I can’t do this. I just can’t.’ ”

But she did. She showed up for every 12-hour shift, month after month. Not once did a single one of those 16 ICU beds sit empty. It took a toll on her. By the time her contract was nearing its end in the autumn, Oglesby was spending most of her downtime in bed. She held out little hope that things would change anytime soon. “I mean, as long as people aren’t getting vaccinated and are still meeting in their clusters,” she said, then let a disheartened shrug of the shoulders finish her sentence. “I sleep all day, and I’m not the only nurse who sleeps all day, I promise you that.”

When the delta surge started to subside last fall, the preliminary data showed that 11 states had experienced higher rates of Covid infection than Mississippi. But none had a higher death rate. The impact on the people working in its hospitals was very clear to Oglesby. She watched other travel nurses cut their contracts short and saw some of the permanent staff join the ranks of the nomads. “Just yesterday,” she said in late September, “one nurse who’d been here for years finally took the leap. He’s going to New Mexico.”

She began to think about where she might go after Greenville. (Ultimately she chose Phoenix.) She’d learned to live with many things over the course of the pandemic’s surges, but there were some things she simply couldn’t abide. Like the water that came out of the hospital’s sinks. It still disgusted her every time she washed her hands. Wherever she ended up next, it would be someplace where the water was clear. “There’s haves, and there’s have-nots,” she said. “And I want to go back to the haves.”

So they pursue specialties, and those jobs are almost always in population centers. Sandquist, however, is that rare breed the Delta desperately needs: a young doctor, drawn to the wide-open nature of a rural practice, willing to live in an underserved region. To make sure rural medicine suited her, she spent last summer in Indianola, Miss., shadowing a local physician, Katherine Patterson.

On a Monday morning in September, the two of them were greeted by a walk-in—a woman who’d arrived at the hospital wildly disoriented. When Sandquist and Patterson examined her, she was hooked up to a ventilator and unresponsive. She wasn’t moving her neck or eyes. She didn’t appear to have Covid, but they couldn’t tell what was wrong. Patterson said she wanted to perform a lumbar puncture, to determine if an infection might be to blame.

Sandquist’s heart lifted. In New Orleans, someone like her would never get the chance to do a spinal tap. “At a big academic hospital, they have neurology residents and internal medicine residents, and basically I’d be at the bottom of the totem pole,” she said. But here she was, watching the needle go in and the fluid come out clear. For the next 36 hours, they monitored the patient’s blood gas levels, adjusted her ventilator settings, and hoped for the best. They ultimately determined that the patient had an infection.

On Tuesday afternoon, Patterson’s phone dinged, and she called up a read-out of the woman’s gas levels.

“Oh, wow,” Sandquist said, eyebrows up. “That looks pretty OK to me. Yes?”

“It looks great,” the doctor said. “And look at her electrolytes.”

Sandquist flashed a bright smile. “It’s looking better and better!”

Little moments like this had cemented her decision to become a rural doctor. Someday soon, she hopes to start practicing in a place like this. When she does, she’ll be a single fish swimming against a crowded current. Since the beginning of the pandemic, in the six Southern states hit hardest by the delta variant—Alabama, Arkansas, Georgia, Louisiana, Mississippi, and Tennessee—at least 6,800 hospital professionals have either transferred to other states or quit their jobs.

Patterson, who’s 47, moved to Indianola 14 years ago to work at South Sunflower County Hospital. She sat in the parking lot on her first day, crying, worried she’d made a huge mistake and steered her life into a dead end.

Since then, she’s experienced plenty of days that even someone with the sunniest disposition would struggle to describe in positive terms. Several have come during the past year, thanks to the pandemic. Like the day she came down with Covid. Soon all four of her sons got it, and then her husband, whose case devolved into serious pneumonia.

The worst came after she’d recovered. One weekend, she was tending to about two dozen Covid patients spread around the emergency room, the ICU, and the Covid floor. Eleven of them slipped into either respiratory or cardiopulmonary arrest. These people weren’t just names on charts; many were faces Patterson recognized. Friends and neighbors she’d known for years. “It takes a beating on the soul,” she said.

She intubated some of them and hooked others to a less-invasive bipap ventilator. She administered medications to elevate their blood pressure and steadily increased their oxygen levels. Nothing seemed to work. “When you’ve done everything you can possibly do and the outcome is not what you desire it to be, that’s tough,” she said. “It’s really tough.” Of those 11 patients that weekend, 9 died.

As of mid-January, Mississippi was one of only four states where fewer than 50% of residents had been fully vaccinated, according to the Centers for Disease Control. Patterson has successfully urged many of her patients to get the shots. But the pandemic has stripped away some of her feelings of control, and she said she’s learned to live with that. She processes the trauma of the pandemic in the same way many of her patients do. “It’s faith,” she explained. “Knowing there’s a higher power that controls the motions of this world. To know that we are all only human, and science is only finite.”

When she sat down to lunch recently at the Crown Restaurant, a couple of blocks from the hospital, a stream of people approached to say hello. They asked about the school football games, where she can be found on the sidelines, serving as team doctor. Or about the youth soccer league she helps run.

A few years ago, she might have finished her lunch undisturbed. Locals might have assumed she’d be like the thousands of other rural providers who come into towns like Indianola, practice for a time, and leave. “It took a while for this to happen, but they now know that I’m permanent,” she said. “I’m not going anywhere. I’m putting down roots, my family’s here, and I’m here to serve. There’s that trust.” She sometimes runs into the families of patients who died at the hospital.

As she was finishing her salad, a woman in a navy blue smock walked up to the table. She worked for a home health agency, and Patterson had directed a few hospice patients to her. “I got your lunch,” the woman told her, and nodded to the waiter. “It’s on me.”

In rural areas, patients are more likely to be taken to hospitals for non-urgent care, driving up costs for both hospital and patient. Staffing the hospitals all day and night with doctors and nurses is expensive, especially considering hours can tick by without a single patient visit to an emergency room. Closing hospitals and increasing the number of smaller, basic-service health clinics would be far more cost-efficient—and more effective for the vast majority of health problems residents experience. The trade-off is that for specialty care and emergencies the clinics couldn’t handle, trips to the nearest urban center might be necessary.

Community clinics can already be found in the Delta. In fact, the region was the birthplace of this model of care: In 1967, the first federally funded community health clinic opened in Mound Bayou, Miss., a community founded in the 19th century by ex-slaves. Since then, about 1,400 such Federally Qualified Health Centers—at least one in every congressional district in the country—have opened.

Mound Bayou is surrounded by flat farm fields of cotton and soybeans. Early last fall, the bolls began flashing white, and combine harvesters dragged across the dry bean fields, raising dense clouds of dust. Some of those airborne particles drifted across Bolivar County and into the breathing passages of a 7-year-old boy, triggering a severe asthma attack. His gasps were violent, frightening. Just after 5 p.m., his mother rushed him to the town’s clinic, the Delta Health Center. Inside she found Dr. Braveen Ragunanthan, a new staff pediatrician who was in the final hour of his second day on the job.

Ragunanthan had just moved to the Delta with his wife, Nina, also a doctor, and their newborn daughter. They’d met at Duke University, and as undergraduates they both spent a summer in Mound Bayou tutoring children as part of a scholarship program. He got a medical degree at Virginia Commonwealth University and a master’s in public health at Johns Hopkins; she got her medical degree from Harvard. The experience in the Delta stuck with them. This was where they wanted to practice, they decided, where they could do the most good.

This boy was a case in point. He was suffering, and Ragunanthan knew exactly how to help: a dose of dexamethasone, some additional steroids, and albuterol. In his office, the boy slowly settled down and took control of his breaths. Ragunanthan gave his mother a prescription for an albuterol inhaler and a spacer device, which attaches to the cannister and helps children, particularly, better absorb the medicine. He sent them home, planning to check in on them later to make sure all was well.

Ragunanthan loves the concept of the rural health clinic. His work leaves him feeling a vital part of an adopted community that, in racial and income demographics, is a world away from Akron, where he grew up. “William Faulkner said you can’t understand the world until you understand a place like Mississippi,” he said.

In his first week on the job, the Delta was teaching him that rural hospitals, as inefficient as they might sometimes be, can also be indispensable. The asthmatic boy had a relapse the morning after he visited the clinic. For whatever reason, the family hadn’t gotten the spacer device when they got the albuterol inhaler. So instead of being absorbed in his lungs, the medicine had accumulated uselessly in his mouth.

At 7 a.m., the clinic had yet to open. His mother had to speed him to the Bolivar Medical Center, a hospital in Cleveland, Miss. Coincidentally, Ragunanthan had just arrived there to do morning rounds with the newborns. Because of the limited number of doctors in the Delta, he regularly fills in at the hospital, which is labeled at high risk for closure. Ragunanthan admitted the boy and administered medications to restore normal breathing. If he hadn’t been treated, the doctor said, the asthma attack might have killed him.

If you talk to administrators at other hospitals in the Delta, they’ll freely disclose their sneaking suspicion that North Sunflower sold its soul. They don’t go so far as to call it a deal with the devil, but—and this is just the Delta grapevine talking—maybe a handful of politicians and regulators pulled a few strings.

One reason North Sunflower has weathered the rural hospital crisis better than most others, and attracted considerable professional jealousy in the process, is that the Centers for Medicare and Medicaid Services labeled it a “critical access” facility. That means it gets reimbursed at 101% of the cost for treating Medicaid patients. As a result, North Sunflower is guaranteed to profit from providing services that other hospitals almost always lose money delivering.

These days, critical access status can be given only to a hospital at least 35 miles from another. North Sunflower is 10.2 miles from the nearest hospital, having earned its status under a previous, less stringent qualification. A few years ago, when lawmakers were talking about stripping critical access status from all hospitals that had been grandfathered into the program, North Sunflower’s executives lobbied hard in Jackson and Washington against the move. They prevailed.

The administrators at North Sunflower say it’s a disciplined business plan, not favorable legislation, that’s at the root of its success story. They’re bulldogs when going after insurance reimbursements, for example. The hospital is constantly revising its contracts with insurance providers, making sure it’s not getting stiffed on reimbursement percentages for key services. It’s also created a spoke-and-hub system of care, creating a network of profitable satellite clinics that complement the hospital.

In late September, Joanie Perkins, the chief compliance officer at North Sunflower, was working off campus. “The executive director told me, ‘Don’t go into the hospital, it’s just rampant with Covid right now,’ ” she said. So during those weeks she spent much of her time trying to keep track of the federal aid the hospital had received.

Most of that money was narrowly targeted, and it was deposited directly into the hospital’s bank accounts. “But a lot of those were deposited in the wrong accounts,” she said. Untangling the confusion, she believed, was another way North Sunflower could rise above the rural hospital crisis. One day, the hospital’s account for hospice care received money that should have gone to its nursing account. It could have been a costly mixup. If hospitals don’t meet deadlines for itemizing exactly how aid money is spent, they can be forced to return it. “I promise you that there are hospitals out there that don’t know this and are having to pay that money back,” Perkins said.

Every little bit helps, she said, especially this year. In 2021, for the first time, North Sunflower’s rural health clinic, which normally adds at least $1 million to the hospital’s bottom line, lost money. Now the Little Hospital That Could finds itself in unaccustomed territory: on the list of rural hospitals at risk of closure, right alongside all the others in the Delta. “I don’t think any hospital can take their eye off the ball now,” Perkins said. “You’re acutely aware of cash flow at all times. Everyone’s in the same boat. You’re not on solid ground.”

North Sunflower has a foundation, she said, that can provide a cash infusion if closure is imminent—a rainy day fund of sorts. As the pandemic heads into its third year, the forecast for rural hospitals has never looked more threatening.