HANOVER — Given the challenges rural communities and health care systems in the Twin States faced even before COVID-19, Dartmouth College researchers said they were surprised to find that they have so far adapted well to the additional challenges of the pandemic.
“Poor outcomes are not inevitable,” said Anne Sosin, who directs the Center for Global Health Equity program at Dartmouth and co-authored a recent report on COVID-19 and rural health equity in northern New England.
As COVID-19 hit the region in March, Sosin and co-author Elizabeth Carpenter-Song, an assistant professor of anthropology at Dartmouth, began interviews with 50 people representing health systems, social service organizations, public health groups, mutual aid agencies and municipal governments across Vermont and New Hampshire. The research focused on four geographic areas, including the Upper Valley, the Greater Sullivan/Windsor County area, the Northeast Kingdom of Vermont and the North Country of New Hampshire.
“We went in thinking that we would be revealing gaps,” Sosin said in a Zoom interview earlier this month. “Our research really showed that was not the case at all.”
Through these interviews, the researchers learned that health care organizations partnered in new ways to prepare rural hospitals to care for the critically ill. Social service organizations also stepped up to identify groups who were especially at risk of contracting the virus or of side effects related to mitigation efforts.
For example, groups focused on the problem of homelessness worked to identify those in need of housing and find space for them in motels. And schools have used their bus routes to get food to families.
Carpenter-Song credited the region’s culture for protecting its most vulnerable so far during the pandemic. For example, she pointed to neighbors taking the time to check in on each other, especially older residents or others with underlying medical conditions who are at a greater risk of developing serious symptoms should they contract COVID-19.
“The frontline is really the communities,” Sosin said. “It’s not the health systems. Health systems in many ways are the last line of defense.”
But it also is important that the hospitals have worked with community groups in their response, which helped people understand the importance of and how to comply with stay-at-home orders and other social distancing measures, she said.
Despite the collaborative response, the researchers noted that the region is still facing substantial challenges, including health care providers’ ongoing difficulties obtaining personal protective equipment and issues ramping up testing and contact tracing, especially in New Hampshire where the state health department does not have regional offices as Vermont’s health department does. Without local offices during the pandemic, Sosin said “the capacity of the state is strained” in New Hampshire.
The pandemic also has highlighted the region’s shortage of primary care providers, she said. Especially early on when testing supplies were limited, primary care providers who are in short supply in the Twin States were tasked with determining who should and shouldn’t be tested.
But Carpenter-Song noted that medical practices of all kinds have largely moved to telehealth during the pandemic, which has effectively removed the previous barrier of transportation to medical appointments that is often a challenge in rural areas. She said they were especially excited to hear that mental health providers saw a huge drop in no-shows.
This helped to answer one of their driving questions: “What are the lessons we could learn from this and carry it forward?” she said.
In the case of telehealth, she said the “genie is out of the bottle.”
The report does note, however, there are limitations to telehealth, including caring for people early in their recovery from an addiction, people struggling with severe mental illness and helping people cope with isolation. It also is limited by people’s access to broadband Internet connections.
The researchers also pointed to resiliency shown by the local business community in setting up curbside shopping options and customers opting to shop closer to home, including at nearby farm stands.
The pandemic and the increasing reliance on telework has underscored an opportunity to grow rural communities, but that will be dependent on broadband access, Sosin said.
This is the first of a series of reports the researchers plan to issue on the response to the pandemic. Moving forward, they will look at secondary effects such as rates of domestic violence and child abuse.
The researchers also plan to continue to examine the resiliency and sustainability of rural health systems in the face of COVID-19. The hospitals will need to remain prepared to treat people with COVID-19, while at the same time working to reopen their other services and make up for the losses of as much as 50 percent of their service volumes during the first few months of the pandemic.
The Dartmouth-Hitchcock health system, for example, received nearly $89 million in CARES Act funding from Washington and tapped tens of millions of dollars in other federal supports to help it weather a loss of patient revenue from the pandemic.
Sosin said she’ll also be closely watching the numbers of cases in the region as time goes on.
“We need to be worried if numbers start to rise again,” she said.