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COVID-19 is straining rural Southern West Virginia’s skeletal healthcare infrastructure.

“We’re watching our neighbors get sick,” said Steve Browning, who heads the Logan County Health Department. “It’s difficult, and ... it’s personal.”

Logan County began September with 493 cases and 30 virus-related deaths, triple the 133 cases and three deaths to start August. With a population of 32,000, the county’s per-capita rate shot past the rolling seven-day average limit of 25 cases per 100,000, pushing Logan into the red, the highest level in the complicated color-coding system state officials use to monitor the virus.

“It happened quick, all at once,” Browning said. “It would have been a large hit for anybody, but for a small county like us, it was an avalanche.”

Browning attributed the increase to outbreaks at Logan Regional Medical Center and a long-term care facility and community spread from people traveling.

It’s not unusual for outbreaks to compound on top of each other. Kanawha County is currently handling outbreaks at five long-term care facilities and a jail and from community spread. But in areas with less robust community health resources, outbreaks like the one in Logan expose gaps in systems already stretched to the breaking point.

“It’s showing us where we’ve failed and what we need to do better, at an unfortunate cost,” said Dr. Anna Allen, an occupational medicine physician and associate professor at the West Virginia University School of Public Health. “With prevention [care] and public health, if it’s doing the job, you don’t know it’s there. You don’t realize you’re standing on the ground until it shakes. Right now, it’s shaking a bit more for some more than others.”

Fewer than 100 physicians work in Boone, Lincoln, Logan, Mingo, McDowell and Wyoming counties, according to the West Virginia Rural Health Association. The combined population of those counties is 135,327. Three of the four hospitals in the six counties are short-term facilities where specialized services have been cut over the years.

Access to care is limited in normal circumstances. Communities are far-flung and some people don’t own automobiles. Limited mapping on GPS systems and poor road conditions push average ambulance response times to 40 minutes in some places. The national average is seven minutes, according to the Journal of the American Medical Association.

“That’s the problem of geography and resources and population density. When people are spread out in that way, like in rural West Virginia, it’s hard to know where to put your resources,” Allen said. “Here, five miles isn’t five minutes. Things aren’t right across the street in most places. Hospitals and clinics are located in places in order to survive, which brings up the access issue: Who gets the health care and who doesn’t? Who can pay for access?”

The coalfields counties are among the state’s least healthy, according to state Health and Human Resources data. Diabetes rates in the region are the highest in the state. Rates of asthma, cardiovascular disease, cancer and obesity all are higher than the state average. Those conditions put people at higher risk for the worst effects of COVID-19.

“The first thing is, we haven’t been doing much with prevention in these areas, so we have people who are sicker. If we put more emphasis on prevention, we wouldn’t have as many people in our high-risk groups to begin with,” Allen said. “This could have helped us identify problems at different times, but it’s not possible now.”

Other factors feed the crisis. COVID-19’s rapid spread in Logan wasn’t altogether surprising given the nature of the community, Browning said.

“You know everybody so you associate with everybody, and that is difficult to manage,” he said.

That problem is common in rural communities, said Dr. Randall Longenecker, the assistant dean of Rural and Underserved Programs and a professor of family medicine at Ohio University.

“The important thing for people to understand is [the pandemic] just plays out differently in a place that is sparsely populated and has less connection to the outside,” said Longenecker, who also is director of the RTT Collaborative, an organization focused on sustaining health professions and education in rural places. “In rural places, there are fewer people but more connections. It’s a close-knit community. ... Once things really get going, everyone’s got it.”

Scenarios like the one in Logan have played out in other rural areas, which might have had an advantage over more densely populated places when the pandemic began, Longenecker said.

“There were some rural communities, where there’s a meatpacking plant or similar, that led to super-spreader events, but that wasn’t the case everywhere,” Longenecker said. “Rural places, in part because of their isolation [compared] to urban places, were somewhat protected. People don’t go in and out as often, so there was less chance of exposure unless it was already there.”

When the virus arrived, its impact was swift. Many people in rural areas drive across county or even state lines for work, opening up the potential for spread, Allen said. While social networks differ from those in urban areas, the effect during a pandemic is the same, Allen said: more COVID-19.

Poverty plays a significant part. The median household income in Southern West Virginia is the lowest in the state while the number of people living below the poverty line is the highest.

“There are whole counties and swaths of land that are impoverished through years of economic extraction where the money has been taken out ... so local resources have been depleted, and poverty is one of the things that has become very clear [that] fuels the problems,” Longenecker said. “It’s just like, suddenly, we’re seeing our unsightly underbelly. Suddenly, we’re seeing all of the cracks in our infrastructure. It’s like when a hurricane comes. Well, the bridges with the cracks are the first to go down.”

The effects ripple and show no signs of lessening.

“It’s not just health care resources that make a response so difficult and highlight the social disparities, it’s more. It’s nutritional resources, a lack of good places to go shopping and have jobs, all of these issues that are a reflection of that area,” Allen said. “There aren’t many medical experts or resources capable of covering larger distances to get to people. We used to focus on that outreach, but now people are scattered, the rail lines that used to bring in supplies — people — aren’t there. It’s more difficult today with less support for such efforts.”

Rural locales by nature compound poverty’s harsh realities. Close to urban centers, needed resources are just a few miles away, Longenecker said. In isolated communities, the resources are both strained and farther from reach. Nor can the burden of responding to COVID-19 be easily shared with health agencies in urban areas already coping with outbreaks.

“The more that those small critical care centers, or smaller hospitals, fill up, the more we will fill up,” said Sherri Young, health officer at the Kanawha-Charleston Health Department. “If something is going on in another hospital, another county, we check in and see what’s happening. That’s our responsibility here. We help where we can and we are affected sometimes by what happens elsewhere.”

More beds have been needed at St. Francis Hospital in Charleston, the state’s designated surge hospital, as patients in recent weeks have streamed in from Southern West Virginia because of outbreaks at long-term care facilities in Logan and Mercer counties, said Dan Lauffer, president and CEO of Thomas Health Systems.

Cases began to slow recently in Logan, Browning said, but Mingo County has been hit harder. The school superintendent and staffers at Mingo Central High have tested positive.

Schools statewide are scheduled to start Tuesday, the day after Labor Day, another holiday weekend that could trigger more travel and more cases.

“You have to go on, life has to go on. I get that,” Browning said. “But you have to do it in a manner that protects your neighbor, your family and your community. We need to wear our masks, do everything we know we need to do, what we’ve been told to do for six months now. If that’s what it takes to solve this issue, that’s what it takes. It shouldn’t be that big of an ask.”

Reach Caity Coyne at, 304-348-7939 or follow @CaityCoyne on Twitter.