The role of public health in COVID – 19
1. Explain the function of public health in a community.
2. List five essential public health functions and services. Include three that are related to disease research and prevention.
3. Explain the meanings of the terms outbreak, epidemic, endemic, and pandemic. Give specific examples of each.
4. What exactly is a case definition?
5. Describe the requirements for disease reporting in public health.
6. What are the five mandatory reportable diseases in your state?
7. How would you contact your county’s public health department?
8. How many Covid-19 cases are there in your county? How many people died? How does this compare to the total number of cases and deaths in the United States?
9. What are three of the reasons for the rapid spread of Covid-19?
The role of public health in COVID – 19
As the country responds to coronavirus disease 2019 (COVID-19), the role of public health in ensuring equitable health care delivery in rural communities is underappreciated. Such crises have a disproportionate impact on rural racial/ethnic minority communities. A declining population, economic stagnation, physician and other health care provider shortages, a disproportionate number of older, poor, and uninsured residents, and high rates of chronic illness are all factors that contribute to the problems identified in rural areas. This commentary describes the challenges that rural communities face in dealing with COVID-19, with a focus on the issues that southeastern US states face. The commentary will also discuss how the COVID-19 Community Vulnerability Index, based on six clearly defined indicators, can be used to identify communities at high risk for COVID-19.
Rural communities are diverse. In 2010, 19.3% of the US population lived in rural areas, compared to 54.4% in 1910, with the southeastern United States having the highest concentration. Alabama, Arkansas, Florida, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, and Texas comprise the southeastern region, and racial and ethnic minorities account for 19% of the total rural population (1). The risk of infection with severe acute respiratory syndrome coronavirus 2 is influenced by socioeconomic factors (SARS-CoV-2). In Mississippi, for example, approximately 20% of the population is impoverished (2). Mississippi, Louisiana, Arkansas, and Alabama were named the country’s least healthy states in 2019. (2). This statistic is significant because the less healthy the population, the more likely the epidemic will be fatal. Furthermore, the virus is more difficult to contain the weaker the health system.
The majority of the states in the southeastern United States are rural (Table 1). In the face of the coronavirus disease 2019 (COVID-19) pandemic, rural communities face a unique set of challenges. They are frequently in areas with high levels of poverty, limited access to quality health care, low levels of health literacy, and social stigma. Many factors contribute to these issues, including a declining population, economic stagnation, physician and other health care professional shortages, a disproportionate number of older, poor, and uninsured residents, and high chronic illness rates. This commentary will discuss the challenges and issues that rural communities face in dealing with the COVID-19 pandemic. It will also demonstrate how the COVID-19 Community Vulnerability Index (CCVI) (4) can be used as a tool to identify communities most vulnerable to COVID-19 based on six clearly defined indicators (Table 2).
Top Rural Community Challenges
As the COVID-19 outbreak continues to put a strain on hospitals across the country, there is growing concern that many hospitals, particularly rural hospitals, may lack the financial reserves needed to remain fiscally viable. Most rural hospitals have limited resources and rely on high-profit services like elective surgery to stay in business. Cancelling these profitable services to deal with the COVID-19 pandemic may result in financial disaster for many rural hospitals (5).
The closure of rural health care facilities or the discontinuation of services can have a negative impact on rural communities’ access to health care. When people in rural areas become ill with COVID-19, there are fewer hospitals to treat them. Rural hospitals are smaller than urban hospitals, have a higher proportion of primary care physicians on their medical staffs but a lower proportion of board-certified physicians, fewer intensive care beds, and are less likely to have contracts with health maintenance organizations and preferred provider organizations.
People living in rural areas are more likely to contract COVID-19 because they are less likely to be employed and have lower incomes than people living in other areas. They also face significant barriers to care, such as provider shortages, recent hospital closures in rural areas, and long travel distances to providers. Local rural health care systems are vulnerable; when one facility closes or a provider leaves, it can have an impact on care and access throughout the community. Furthermore, when a hospital closes, access to nonhospital care may decrease because many specialists congregate around hospitals. Rural hospitals face severe financial challenges and are more likely to close than urban hospitals. For example, 15 of the 21 hospitals that closed in the United States in 2016 were in rural communities, and nearly 90 rural hospitals have closed in the United States since 2010. (6). Another financial challenge for rural hospitals is population decline, which means fewer patients to fill beds. Although population in urban counties has increased since 2000, population in half of rural counties has decreased, resulting in a decrease in revenue for rural hospitals. The majority of recent hospital closures have occurred in states that chose not to expand Medicaid under the Affordable Care Act, which means that a significant portion of their health-care costs remain uncompensated, posing a financial burden on these states (7).
Given the unique challenges that rural communities face, which are exacerbated by a deteriorating rural health care infrastructure, a shortage of health care providers, and the closure of rural hospitals, monitoring and control plans must be developed to ensure that the extent of illness and death in those communities is assessed. Solutions that take into account the rural nature of these communities, as well as the social determinants of health that influence health care outcomes, must be developed.
COVID-19 Community Vulnerability Index Leader
Community-level social disadvantage and disaster vulnerability can influence the occurrence of COVID-19 and its negative outcomes in a variety of ways. Lower socioeconomic status (SES), for example, is associated with poor health care access, which may increase the risk of adverse health outcomes. Labor inequalities, a lack of workplace protections, and family overcrowding may make it difficult to follow social-distancing guidelines. Furthermore, racial/ethnic minorities and immigrants are less likely to have timely and appropriate health care. Evidence suggests that these disparities aided disease spread and severity during the H1N1 pandemic (8–11).
The Surgo Foundation’s (4) CCVI can be used to identify which communities may require the most assistance during a pandemic or other public health emergency. The CCVI scale runs from 0 to 1, with higher scores indicating greater vulnerability. A given geographic unit, such as a census tract or county, is ranked in relation to all similar units across the country based on six themes: 1) socioeconomic status (SES), 2) household composition and disability, 3) minority status and language, 4) housing type and transportation, 5) epidemiologic factors, and 6) health care system factors. The generated score can then be used to assign a level of vulnerability. In the United States, each designation corresponds to a quintile of that geographic unit type. For example, a county score of 0 to 0.20 would indicate very low vulnerability in comparison to all other US counties, a score of 0.21 to 0.40 would indicate low vulnerability, and so on until the final category of very high vulnerability and a score of 0.81 to 1.
The CCVI is not intended to predict who will become infected with SARS-CoV-2. It can, however, provide information about the expected negative impact at the community level. This data can assist decision-makers in allocating resources where they are most needed. The index could aid in the development of a community risk profile for SARS-CoV-2 infection, which could be used to target and tailor control efforts. The CCVI data show that each of the nine southeastern states has a CCVI score of very high vulnerability. Scores for each state also indicated extremely high vulnerability on all six indicators used to calculate the CCVI (4,12–14). Mississippi, for example, has a score of 1 for socioeconomic status, household composition, and disability, and a score of 0.92 for epidemiologic factors. Mississippi’s overall CCVI score is 0.92. This score indicates that Mississippi is particularly vulnerable and prone to poorer COVID-19-related outcomes, particularly in communities with lower socioeconomic status and overall poor health.
Health-care delivery has changed dramatically since the outbreak of COVID-19. The United States has modified its technology and policies to accommodate remote health care delivery. However, while telehealth use increased during the pandemic, the regulatory changes that allowed for this increase are not permanent. Furthermore, the technological advancements required for remote health care delivery can be difficult to implement in rural communities. The terrain can make it difficult, if not impossible, to install fiber or other infrastructure, and low population density is the most significant barrier to obtaining broadband internet service in some areas of the country.
Furthermore, the cost of telemedicine for rural health clinics is an issue because many rural patients are covered by Medicare or Medicaid, and reimbursements from these government health care programs, as well as private insurance companies, do not cover the full cost of virtual medicine.
The Southeast’s rural communities have had varying degrees of success in implementing these virtual systems. In some communities, unreliable access to at-home technology, broadband internet service, and cellular phone reception has prevailed, while financial obstacles abound. The COVID-19 pandemic has highlighted the limitations of these outlying areas (15).
Top Rural Community Special Concerns
Health care affordability is a significant challenge for rural areas in the southeastern United States. However, several of the country’s most rural states chose not to expand Medicaid under the Affordable Care Act, leaving 59% of rural residents uninsured (16). Lack of insurance affects access to care because people without health insurance may delay seeking care even if they have symptoms for fear of incurring expenses they cannot afford (16).
Aside from a lack of good health insurance, many people in the southeastern and rural states face a geographical barrier (17). Geographic isolation and related challenges, such as a lack of transportation and extreme weather conditions, make it more difficult for people in rural communities to travel for care than people in urban communities, and services are typically farther away (18). Some patients, for example, travel 45 miles to Sunflower Medical Center in Ruleville, Mississippi, to receive care (15).
Infrastructure shortages are not limited to roads and highways; in rural areas, health care infrastructure may be severely limited, health care resources scarce, and clinical providers scarce. Only 9% of physicians and 16% of registered nurses in the United States work in rural areas. Dentists and pharmacists are also in short supply in these areas (18).
Top Public Health Implications
Community health centers play an important role in rural and remote areas, forming one of the most extensive health-care systems available to rural populations. Community health centers now serve one in every six rural residents (19), making them critical components of the rural COVID-19 response strategy. Because health centers can be found in almost every community across the country, they are uniquely positioned to respond to COVID-19. They can aid in increasing community access to and availability of COVID-19 testing.
Despite increasing testing and virtual visits, health centers are reporting steep drops in patient visits, and many staff members are unable to work due to COVID-19-related issues. These issues include having to juggle work and parenting obligations due to school closings, as well as not being able to find appropriate child care due to day care closings. Another issue is the temporary closure of health care facilities as a result of the pandemic. Although the federal government provided $1.98 billion in rapid response grants to health care centers, more financial support may be required to sustain services (20). Personal protective equipment and testing supplies are also in short supply in health centers. Personnel to assist with contact tracing for COVID-19-positive individuals is also required.
The CCVI is a valuable tool that can be used as part of a coordinated response to identify communities that are most vulnerable to COVID-19, allowing resources to be strategically deployed to those areas. In conjunction with targeted testing and contact tracing, this tool has the potential to flatten the COVID-19 curve and ensure that the most vulnerable communities have access to health care resources. It is also critical to develop a comprehensive profile of people at risk of SARS-CoV-2 infection. To target and tailor control efforts, the southeastern region requires a comprehensive risk profile, including geographic hotspots.
Stakeholders who work with underserved populations should be involved in emergency response planning and enlisted to assist in reaching disadvantaged and marginalized communities. The CCVI data can be used to develop a coordinated, comprehensive approach to addressing the pandemic that is unique to rural communities in the South. Hospitals, health care centers, insurance providers, policymakers, community-based organizations, and faith-based organizations should all be considered stakeholders. This collaboration would be beneficial in emergency response planning, identifying areas of greatest need, developing culturally appropriate messaging, and disseminating information throughout the community.