California’s rural hospitals can’t handle a coronavirus wave. ‘People will die,’ doctor warns

Mammoth Hospital’s chief medical officer Dr. Craig Burrows didn’t hold back as he urged the 8,234 people living in his Sierra ski-resort town to stay home and avoid crowds.

“Try to imagine 100 people getting sick all at once tomorrow,” Burrows said in an unscripted video message the Mono County hospital posted on YouTube. “If that happens, our small hospital, our small community, will be completely overwhelmed and people will die.

“Let me say that again: People. Will. Die.”

Mammoth Hospital has 17 beds. If COVID-19 sweeps through that community, there won’t be room to treat everyone and doctors will have to make hard choices. It’s a grim reality that Mammoth shares with 33 other federally designated “Critical Access Hospitals” in California that have 25 or fewer beds.

Scattered across the vast rural areas of the state, often hours from major cities or the midsize towns that serve as rural “medical hubs,” these small facilities inhabit the quietest corners of the state.

There’s one in Lone Pine, the gateway to Death Valley. There’s another in Tehachapi, southeast of Bakersfield. Farmworkers are treated at Orchard Hospital in the Sacramento Valley city of Gridley. The Surprise Valley Community Hospital serves a small town in Modoc County’s cattle country in California’s far northeastern corner. Redwood Memorial Hospital doctors treat patients in the small coastal city of Fortuna.

Experts say that on a good day, these facilities — often serving populations that tend to be older and infirm — lack the staffing and resources to handle a sudden influx of people needing critical care. They’re particularly at risk of getting swamped with COVID-19 patients if the predictions hold true in the coming weeks.

More than 320,000 people globally have tested positive for the coronavirus, with limited testing confirming over 1,500 cases in California as of Sunday morning, according to Johns Hopkins University and the California Department of Public Health. There have been nearly 14,000 deaths related to COVID-19, including at least 28 in California.

Research published this week by Harvard University predicts hundreds of thousands of people in California will require hospital treatment in the coming months. Gov. Gavin Newsom’s administration said some models indicated 25.5 million Californians would get infected in the next eight weeks if drastic measures weren’t taken.

In all scenarios, experts say, critically ill patients will likely outstrip rural hospital resources.

The big problem with any small healthcare system is they quickly get overwhelmed even when a few patients show up at once, said Dr. Mark Deutchman, associate dean for rural health at the University of Colorado’s medical school.

“I practiced for 12 years in a town with 2,000 people and, you know, if you have a car accident with four victims, all of a sudden all the beds in your ER are full and everybody is occupied,” Deutchman said. “So it’s a limited workforce and limited resources. … And if those personnel are at risk of getting sick, it dramatically reduces your ability to respond.”

Small hospitals have agreements with larger regional medical centers to send them their most seriously ill or injured patients. But officials in rural counties are worried about what happens if those facilities also are overwhelmed and run out of ICU beds, ventilators and staff to keep the most serious COVID-19 patients breathing.

In 2015, officials from across California conducted a “tabletop exercise” designed to simulate the impacts of a major flu pandemic. Local emergency planners were given various projections of how many people would get sick and die and how many ventilation machines each county has to keep severely ill patients breathing.

The results were sobering for Shasta County (population 180,000) and its county seat Redding, a regional medical hub: Anywhere between 39 and 445 people would need ventilators.

State figures show that Shasta County hospitals have 86 ICU beds equipped with ventilators, including beds for newborns. Most beds are in Redding, home to two regional hospitals that receive patients from across the rural north state.

The numbers are even bleaker at the three hospitals along the foggy north coast in Humboldt County, population 136,754, said Rex Bohn, a county supervisor.

“We’re very fortunate (the hospitals) all work together really well, but with that, I think we have a total of maybe 22 ICU beds and 250 beds total,” Bohn said. “So if it comes time for us to push that red button (and request help from regional hospitals) … there’s no guarantee they’re going to answer because they’re already stretched.”

He said the county is trying to prepare by renting rooms at local motels to house and isolate COVID-19 patients who don’t require critical care.

“We are behind the Redwood Curtain, and 90 percent of the time that’s probably the biggest blessing about living here,” he said. “Times like this, that might be the biggest curse.”



In the remote Humboldt County community of Orleans along the winding Klamath River, Clarence Hostler, 69, and his wife, Deborah, have chosen to keep the gate on their driveway closed to any visitors except for Hostler’s daughter, Allie, who’s been making the more than 200-mile round trip to buy them medication and groceries.



“Once it hits our neck of the woods, I believe the hospitals in Humboldt County .... their beds would be full before we got hit in rural, rural areas,” said Clarence Hostler, a member of the Hoopa Valley Tribe. “We’re pretty much saying, ‘If the gate is closed, don’t come through the gate.’ We’re both at that age where we’re at risk, so people who want to be out and about, they can stay out of our gate.”

‘We can’t lean on Big Brother’

There are 2,000 rural hospitals in the U.S. Nearly half of them are operating at a financial loss already, said Alan Morgan, CEO of the National Rural Health Association. About 1,300 facilities have 25 beds or fewer. Close to a thousand have just one ventilator.

And as small facilities work to empty beds in preparation for a surge in COVID-19 patients, that means they’re also losing out on revenue that can help keep the hospital running in normal times.

Another challenge: many critical-access hospitals are independent and locally operated, meaning they can’t call on larger hospital chains if they need more resources.

“We can’t lean on Big Brother to bail us out,” said Michael Madden, an assistant administrator at Fairchild Medical Center, a 25-bed critical access hospital in Yreka, a city of 7,600 people near the Oregon border. Fairchild has just four ICU beds and six ventilators. Madden said patients routinely travel two hours one-way to get to Fairchild.

Most of the time, the most serious patients are transferred to other larger facilities in Southern Oregon and Northern California.

“Those tertiary centers are already concerned and limiting transfers,” Madden said. “So critical patients coming here … we have transportation available for them, but they have to be accepted at these other facilities first. Our concern is we’re going to be having patients that we’re not able to transfer out to other facilities to the appropriate level of care.”

An outbreak in a rural community also could quickly cripple emergency medical ambulance and patient transportation services that would transfer critical patients to larger facilities with more resources.

The vast majority of people who staff ambulances and transport patients in rural areas are volunteers, Morgan said. If one provider gets sick, they’ll be knocked offline.

“In a rural context,” Morgan said, “there just isn’t the room for error that you would have in a large health care facility.”

Local hospitals, meanwhile, are doing what they can by erecting temporary treatment tents and freeing up space in other departments.

But rural areas aren’t likely to receive much help in the form of new temporary, state-run emergency medical centers. Newsom has requested the Trump administration dock a 1,000-bed military medical ship at the Port of Los Angeles. Newsom announced Thursday night that his office is leasing a bankrupt hospital in Daly City, and said it will also lease another in Southern California.

He also said that he’s talked with the federal Department of Defense to provide some resources in the far north of the state and in the Central Valley, but did not give specifics.

Experts say the good news about rural areas is people tend to live farther from each other and gatherings are usually smaller, so the risk of community transmission of the novel coronavirus perhaps isn’t as great as in a city.

But there’s another challenge to contend with: In some of the state’s farthest-flung corners, residents may be less likely to trust media outlets and government institutions urging them to hunker down and stay home.

Earlier this month, an Economist/YouGov survey revealed that 67 percent of Republicans were “not too worried” or “not worried at all” about catching the coronavirus, or the actual “seriousness of it.”

Most of rural California, particularly in the Sacramento Valley and the eastern part of the state, tends to lean Republican in its politics.

Later surveys have shown that concern among Republicans is rising after President Donald Trump declared a national emergency last week, and conservative media outlets like Fox News changed their tune on the risks from COVID-19.

This week, a YouGov survey found that nearly four in five Americans are at least somewhat concerned about a national epidemic emerging from the coronavirus spread, including 71 percent of Republicans. The concern has risen 12 points in the last week.

But in Susanville, a city of 17,974 people in the high deserts of Eastern California, some remain skeptical the outbreak is as serious as they’re being told.

Seventy-three percent of Lassen County voters voted to elect Donald Trump in the last election — the largest percentage in the state. Susanville’s hospital, Banner Lassen Medical Center, has just 25 beds.

“You look at the death toll — what are we? A hundred people or something like that in the whole nation? And, I don’t know, 10,000-something people with the disease in a country of 300-plus million?” said Joe Egan, a Susanville rancher. “It just completely derailed the whole economy, and to me that just doesn’t make sense. There are probably more people dying from nosebleeds than coronavirus.”

Egan said that while more people are washing their hands than usual, and local kids have been sent home from school, he doesn’t expect a “shelter-in-place” order to have much of an effect.

“I don’t think most people would even recognize that directive, probably out of necessity,” he said Thursday before Newsom issued a statewide order to stay home. “I went to the grocery store last night and, hell, everybody was out with their kids, and it was just a regular day.”

Distrust of institutions

There’s a long and dangerous history of people politicizing science and an erosion of trust between researchers and people who identify as extreme conservatives, said Lawrence Hamilton, a professor of sociology at the University of New Hampshire’s Carsey School of Public Policy. That’s especially true since the 2016 election.

Hamilton has spent years studying how political ideology informs how much people believe in risks posed by threats spanning climate change to the Zika virus. His team is now surveying people about how much they trust infectious diseases experts who for months have sounded alarms — sometimes on deaf ears — about the dangerous spread of the new coronavirus.

A large number of people in conservative communities are not at the ideological pole, Hamilton said. While images of overwhelmed hospitals in Italy are enough for many people to fear what could happen, others won’t take the threat seriously until it hits closer to home and their friends and family contract COVID-19.

“It’s less the government orders because you can have a conspiracy theory about them, than it is having people you know get sick,” Hamilton said. “That may start with celebrities but then may quickly spread to your neighbors. I think that’s the key thing.”

Other experts like Deutchman, the rural health physician at the University of Colorado, said to overcome rural skepticism, it’s going to be imperative for local doctors like Burrows, the Mammoth Hospital physician, to speak out.

“Doctors mostly still have pretty good reputations, and the people who are our patients and our neighbors need to hear us basically say some pretty simple, straightforward things,” Deutchman said. “I think any rancher would understand that calculation: ... We’ve got 17 beds and one ventilator. If five people get sick, who gets the ventilator?”

Morgan, CEO of the National Rural Health Association, said the clock is ticking, even if some in rural, remote areas choose not to believe it.

“Unfortunately, over the next week, I think that is rapidly going to be a concern that we no longer have to worry about for all of the wrong reasons,” he said. “Rural America is not immune to this pandemic at all.”

This story was originally published March 21, 2020 at 5:00 AM with the headline "California’s rural hospitals can’t handle a coronavirus wave. ‘People will die,’ doctor warns."