By North Carolina Health News staff
COVID’s ascent in rural areas sheds light on longstanding disparities
The pandemic may have begun in cities and population centers, but as the months wore on, it took hold in rural areas across the state in various ways. The first shockwaves of the pandemic in rural North Carolina began long before the first confirmed case there. In early spring, as bars, restaurants and hair salons closed, unemployment in some already economically depressed rural areas across the state soared.
Abrupt school closures and the move to virtual doctor’s appointments highlighted yet another disparity in rural areas: the lack of adequate broadband coverage. The pandemic also prompted a wave of innovative stopgap measures from health care providers, libraries, businesses and foundations. Some providers installed Wi-Fi hotspots in their parking lots to help people without an internet connection at home meet with their doctor safely. Other organizations gave out free phones to people with serious mental health needs in hopes that this lifeline would reduce the number of crisis-driven hospital visits in these patients.
By summer, the pandemic touched every rural county in the state. As the number of cases per capita mounted, the impact of coronavirus on rural areas became clearer. Many rural residents are older and sicker than their urban counterparts and they tend to have less access to health care and are more likely to be uninsured.
The disparities have made the ascent of coronavirus in rural North Carolina even more deadly. Rural areas nationwide have the most pandemic-related deaths per 100,000 residents, a trend that plays out in North Carolina as well.
None of the disparities that make coronavirus more deadly are new. Rural areas have struggled with provider shortages, hospital and unit closures, and economic decline for decades. But the spread of the virus gives urgency to addressing these needs sooner rather than later. The first stage of the pandemic saw many stopgap measures from sending Wi-Fi-equipped buses to rural areas to serve as hotspots to stepping up testing efforts in hard-hit areas to designating special coronavirus funds for smaller hospitals.
Rural areas are likely to need more support and resources to weather the next stage of the pandemic. -Liora Engel-Smith
COVID-19 exacerbated existing health disparities for incarcerated people
COVID-19 laid bare what people who work and live within the criminal justice system have said for decades – serving time behind bars exposes North Carolinians to added health risks.
This year, the novel coronavirus pandemic tore through – and continues to spread within – prisons, jails, and detention centers, exacerbating existing health challenges that incarcerated people in North Carolina and their loved ones face. By the end of the year, more than one in five prisoners in the state system have been diagnosed with the virus, according to an NC Health News analysis, it’s likely more have been infected, but not diagnosed.
The loss of in-person visits created added barriers for children with an incarcerated parent in North Carolina, some of whom have now not seen their mother or father in almost a year. It paused the state’s plan to bring medication-assisted treatment (MAT) to people with substance abuse disorder who are incarcerated inside state prisons this year – studies show people are 40 times more likely to overdose after release from a North Carolina prison or jail, according to North Carolina researchers who published in the American Journal of Public Health in 2018.
And there was the threat of the virus itself. Many incarcerated people in North Carolina’s federal and state prisons and county jails spoke about difficulty accessing routine medical care amid rising COVID-19 cases within their facility, as well as fears about getting testing and treatment for suspected COVID-19 infections.
Inmates are more likely to have chronic health conditions than the general population, making them more at-risk for the worst outcomes of the virus. The structure of many carceral institutions, where many people live in relatively tight spaces and have little control over their ability to social distance, heightened the risk of spread.
To date, 29 people incarcerated within the state prison system, 27 people in North Carolina’s one federal prison, Butner Correctional Complex, and at least one person in jail have died of COVID-19-related causes. Two inmates who were transferred out-of-state to Immigration and Customs Enforcement detention centers also died shortly after contracting the virus. – Hannah Critchfield
Covid-19 races through North Carolina’s meat and poultry processing plants
In the tiny town of Tar Heel, people began paying close attention in early April to what was happening at a Smithfield Foods hog-processing plant 1,400 miles away.
There, in Sioux Falls, South Dakota, nearly 1,000 plant workers had contracted COVID-19 and two had died. On April 14, the plant temporarily shut down.
Workers and management of a Smithfield Foods slaughterhouse in Tar Heel, near the Cape Fear River in Bladen County, began to wonder whether the same fate could await them.
It didn’t take long to find out. By late April, meat and poultry processing plants in North Carolina reported that a total of 118 workers had tested positive for COVID-19. Two days later, that number had jumped to 190.
By the end of April, the coronavirus had infected so many workers at Smithfield’s Tar Heel plant that it almost shut down. The plant may well have closed if not for President Donald Trump’s order that the nation’s meat and poultry plants stay open to protect the nation’s food supply.
Trump’s order was met with harsh criticism from union leaders and other advocates of plant workers, who are predominantly Black and LatinX.
The advocates complained of unsafe working conditions in an industry in which workers stand close together on processing lines for hours at a time. Companies did install Plexiglass partitions on the lines and in cafeterias. They initiated many other safety precautions, as well, including taking workers’ temperatures every day and spacing them farther apart on the lines.
But worker advocates said the companies didn’t respond quickly enough or rigorously enough to fully protect the workers.
By May, a ZIP code that encompasses a Mountaire Farms poultry-processing plant in Chatham County had the highest per capita rate of COVID-19 of any of the more than 1,000 Zip codes in the state.
“When this pandemic started, Mountaire was doing nothing. They just started giving employees face masks/shields & putting up glass between people about two weeks ago,” a worker told NC Health News in mid-April. “The distance between people on the lines is literally elbow to elbow. The risk of the virus spreading is extremely high because of this.”
In mid-December, North Carolina’s meat and poultry processing plants reported 4,180 cases of COVID-19, according to figures from the state Department of Health and Human Services. That is far higher than any other category of COVID-19 clusters recorded by DHSS, including religious gatherings and colleges and universities.
A study released in July by the Centers for Disease Control and Prevention found that 87 percent of the 16,233 COVID-19 cases reported in meat and poultry processing plants were among racial or ethnic minorities. — Greg Barnes
Disproportionate impact on LatinX residents
COVID-19 has had a disproportionate impact on communities of color, highlighting how many Black and LatinX workers are essential to keep grocery stores, meat processing plants, construction projects, farms, nursing homes, long-term care facilities, hospitals and other engines of the economy and health care systems humming.
North Carolina’s LatinX residents represent nearly 10 percent of the population, but early in the pandemic, they had more than 30 percent of the lab-confirmed cases of COVID-19.
Outbreaks in meat processing plants infected workers who then brought COVID-19 into multi-generational homes.
As the case numbers grew through the end of 2020 to more than 520,000, LatinX residents continued to test positive for COVID-19 at a disproportionately high rate, now representing 25 percent of the state’s cases.
The pandemic has highlighted systemic racial disparities to health care access and underscored how many LatinX residents fear seeking the attention of a physician or nurse for fear that personal information might be passed along to immigration officials.
Advocates for LatinX workers and families have worked the past 10 months to bring free community testing sites to neighborhoods, churches and trusted community centers to eliminate some of the barriers.
They have stressed the importance of communicating public health messages in Spanish and tried to tackle thorny questions as transparently as possible to assuage fears of seeking care and treatment.
LATIN-19, a group formed in March by Duke physicians Gabriela Maradiaga Panayotti and Viviana Martinez-Bianchi, has been instrumental in highlighting longstanding disparities in the LatinX communities. They also have been the force behind many initiatives designed to close such gaps.
After a LatinX child died from COVID-19, LATIN-19 shared stories of parents not wanting to bring their sick children to the hospital for care because of pandemic visitation policies that could separate them from their parents.
Duke Health changed its visitation policy afterward to all the parents or caregivers of children to join them inside pediatrics facilities.
Now, as COVID-19 vaccines become available, there are efforts underway to show LatinX leaders being immunized on social media platforms and the network Univision to try to head off any hesitancy about their safety. – Anne Blythe
Another epidemic – childhood loneliness
When the pandemic lockdown was new enough to be somewhat novel, 11-year-old girls, Evyn and 12-year-old Vivian talked about their struggles with isolation and loneliness. Their intense longing to be with friends and classmates took a toll on both. The virtual classes allowed them to see their teachers and classmates but didn’t allow them to engage.
A rapid review in the Journal of the American Academy of Child and Adolescent Psychiatry (JAACAP) concluded that loneliness is associated with mental health problems for young people aged 4 to 21, including depression and anxiety, potentially affecting them years later. In fact, young people who are lonely might be as much as three times more likely to develop depression in the future. They also concluded that the impact of loneliness on mental health could last for at least nine years.
“As school closures continue, indoor play facilities remain closed and at best, young people can meet outdoors in small groups only, chances are that many are lonely (and continue to be so over time),” said lead author, Maria Loades, senior lecturer in clinical psychology at the University of Bath, UK.
Even before the COVID-19 pandemic, health experts were concerned about what they termed an epidemic of loneliness. she gained a new appreciation for the toll that could take on her overall mental health. While isolation takes a toll on all of us, it may be particularly hard on children still learning to regulate their emotions.
Experts say that while kids are generally resilient, mental health and behavioral issues can be exacerbated by the stress, strangeness and stagnation of the pandemic that mandates continued school closures with no end in sight. – Melba Newsome
Seniors bear the brunt of COVID mortality
By Christmas Eve, 2,356 people had died of COVID-19 in North Carolina’s nursing homes this year — making up more than one in three of pandemic deaths across the state. For the sake of comparison, that’s about the population of the rural/suburban town of Green Level, in Alamance County, population 2,386.
More than 69,000 people aged 65 and older had contracted the disease by late December, according to the state Department of Health and Human Services. That meant older people made up 15 percent of the total state COVID caseload of 516,828, not far from the 16.7 percent of population they make up across North Carolina.
But as of the same time period, people older than 65 represented about 36 percent of North Carolina residents’ deaths from COVID.
Early on in the global pandemic, state residents and caregivers had trouble getting information on the diagnosis and lack of treatment for people with the frightening new disease.
Andrea Hummel, of Huntersville, was allowed little contact with Stanford Hummel, 88, her father, after he had moved into Autumn Care of Cornelius to recuperate following treatment for pneumonia. After he received a COVID-19 diagnosis, Korean War veteran Hummel was sent to a nearby hospital, where he died in March.
“I got a phone call from them, telling me that he had to go to the hospital because his oxygen levels were down to 60,” Andrea Hummel told NC Health News. “And he was having a hard time breathing.
“So I asked them, ‘Did you guys get his COVID results?’ And they said, ‘What? Nobody called you? It was positive.’”
Hundreds of more deaths among nursing home residents have kept coming, from every corner of the state. Chances to get the disease rose calamitously as staff, health professionals and caregivers may have introduced infections to nursing homes without knowing it.
That means lockdown or masking programs in the greater community help nursing home residents, too.
The virus, marked by a scary resilience, from the first cases attacked older people in nursing homes and other congregate living sites across North Carolina. By early April, COVID-related deaths were occurring in nursing homes.
However, in the months since, the proportion of older people among the fatalities has declined as treatment has improved and young people have begun dying at higher rates. – Thomas Goldsmith
COVID treatment – hypes and successes
As the pandemic ripped through the state, North Carolinians, along with other Americans, sought for treatment and relief from the ravages of the disease caused by COVID-19.
Even as North Carolina-based researchers were racing to get approvals for remdesivir, a drug developed and tested with significant input from scientists based at the University of North Carolina at Chapel Hill, others sought treatment with an old malaria drug, hydroxychloroquine.
That medication received a boost from an unlikely quarter, President Donald Trump, who latched onto early reports out of France that the drug could be useful in fighting the disease.
David Kroll, a pharmacology professor who made his name studying biologic-based pharmaceuticals such as hydroxychloroquine, said that the mechanism of action of the drug made it potentially useful against a variety of viruses. But he also disparaged the by-the-seat-of-your-pants touting of medications.
“For a leader of a country to say something like that,” Kroll said, “the data are not there.”
”Unless you’re studying it, you don’t know if the drug really was effective or not,” he added. “When you do that, open the flood gates, collecting and interpreting that data really depends on the other things that people are getting.”
Nonetheless, the genie was out of the bottle. Soon, members of the public were scrambling to obtain prescriptions of the drug, and the medication became hard to obtain for many lupus patients, who depend on it. At NC Health News, we fielded an angry call from one physician who criticized the publication for disparaging the use of the drug. She finished the call by stating that she would be getting hydroxychloroquine for herself and her husband.
Actions such as those by physicians across the state prompted the North Carolina Board of Pharmacy to issue emergency rules to stop the hoarding of the drug by physicians.
Meanwhile, by May, the Food and Drug Administration issued an emergency use authorization for remdesivir, an antiviral medication developed at the UNC lab of Ralph Baric in conjunction with pharmaceutical company GIlead. While not a slam-dunk, remdesivir is most effective in reducing viral loads in patients if given early in their COVID infections.
Researchers at the state’s academic medical centers also collaborated with intensive care researchers across the country to pool data to find answers for what treatments work best. For instance, that collaborative approach quickly found that an old drug, dexamethasone, was effective in treating people with severe cases of the disease.
“If there’s any change that has happened that should continue going forward, it has been these large, rapid, start-up platform clinical trials, like the ones that informed the use of dexamethasone and discouraged the use of hydroxychloroquine,” said Shannon Carson, an ICU physician who is head of pulmonary medicine at UNC Hospital in Chapel Hill.