key: cord-0047983-me4w3m6k authors: Suttle, Allison title: Letter from South Dakota date: 2020-07-03 journal: NEJM Catal Innov Care Deliv DOI: 10.1056/cat.20.0323 sha: ff6b1bf1c651c826ba3fc5478b5357cd1155de3a doc_id: 47983 cord_uid: me4w3m6k The CMO of a large rural health care system reflects on Covid-19’s impact in her region, including delayed preventive care and lost hospital revenues, and the urgency of finding sensible solutions to living with a long-lasting pandemic. The slower progression of Covid-19 throughout the region has allowed time to refine our responses by talking with health systems across the country. Many colleagues have shared their heroic learnings with us, including around effective emergency medical practices, the importance of early social/physical distancing, aggressive testing, ramped-up ICU operations, personal protective equipment for health care workers, and the biology of the disease. 6 We are indebted to the countless doctors and nurses serving on the frontlines and to researchers around the world who are contributing their time and expertise to understand how this virus works. Hospitals in New York City were unequivocally overwhelmed by this disease in ways others just were not. While New York City has suffered nearly 21,600 deaths and 215,000 Covid-19 cases, South Dakota, in contrast, had 75 deaths and 5,898 cases as of June 14.7 Looking at it a different way, the entire state of South Dakota has reported 667 cases per 100,000 residents, while just one neighborhood in the Queens borough of NYC has reported 4,014 cases per 100,000.8 South Dakota's per capita death rate is 8 per 100,000. That same neighborhood in Queens saw a death rate of 351 per 100,000. In fact, some counties in South Dakota still have not seen a single case, and hospitals in South Dakota have not come close to filling the beds we prepared for the pandemic -at least not yet." In fact, some counties in South Dakota still have not seen a single case, and hospitals in South Dakota have not come close to filling the beds we prepared for the pandemic -at least not yet.9 , 10 We were ready for a surge at least two times our capacity at any one of our major medical centers. At our peak, we filled only about 5% of available beds with coronavirus patients. As of June 16, Covid-19 patients are not even taking 3% of our total bed capacity. We worked out detailed triage plans in case our ventilator supplies were exhausted. We will keep these plans for next time -and there will be a next time. Out here in America's heartland, far from the large metropolitan areas hardest hit by the virus, we must sort through what we know, keep investigating what remains uncertain, and continue searching for clarity. Now we have an opportunity to reflect and assess the path forward. We gain a little more clarity every day. We are now bracing ourselves for a different surge. Patients have been delaying care for heart irregularities, strokes, undiagnosed cancers, kidney dialysis, and routine childhood vaccinations.11 At Sanford Health, immunizations have already dropped by 64% from where they were just one " year ago. Will we start to see the scourge of measles rip through our communities again? And consider the cancellations we have seen in mammography appointments: Sanford Health usually diagnoses eight breast cancer cases every week at our medical center in Fargo, North Dakota, but we haven't seen a single case surface since Covid-19 hit our region because women have been putting off these preventive health visits. If these patients wait a year to come in, their cancers will be much more advanced and life-threatening. Another, but hidden, surge is already upon us. It is not the pandemic but the wave of unemployment rolling now across the landscape, bringing with it a steep incline in the number of uninsured and underinsured individuals and families. A Kaiser Family Foundation report found that nearly 27 million Americans may have already lost their employer-sponsored health insurance as a result of losing their jobs during this pandemic.12 Unfortunately, some people have had no choice but to delay care as health care organizations were forced to suspend routine appointments and elective procedures to comply with statewide executive orders. Worse, some people faced life-threatening health problems during this pandemic but avoided visiting the ER out of fear of contracting Covid-19. In one of the communities we serve, a physician recalled having to convince a woman who was showing obvious signs of a stroke (her speech was slurred and one side of her face was drooping) to immediately seek help. As a result of all of this, a less healthy population will inevitably follow. Like in times of war, where permanent losses of limbs and unshakeable traumas mark the era, Covid-19-related delayed care will likely have lasting consequences. Patients who have not managed their chronic conditions may face life-threatening complications. We are already seeing patients with uncontrolled diabetes -which could have been prevented if addressed earlier -now requiring amputations and dialysis for the rest of their lives. The pandemic will also expose new mental health challenges. Rising demand for uncompensated care will only add insult to injury to financially stressed health care delivery systems." Rising demand for uncompensated care will only add insult to injury to financially stressed health care delivery systems. We will need to make even tougher choices in the months ahead: Do we shrink services and the brick-and-mortar infrastructure of rural hospitals and clinics to match the drop in the number of insured people seeking care there?13 Medicaid spending will soar, but it already offers a bare-bones, unsustainable reimbursement for the actual cost of care delivered, and many health systems had already faced massive losses long before the pandemic hit. The federal CARES Act approved in March included important stimulus relief for hospitals and health systems to offset some of the lost revenue and costs related to Covid-19 response, including protective equipment, testing supplies, and other urgent needs. However, this relief is by no means a windfall, as it only partially covers the losses incurred during the first few months of the pandemic. While the CARES Act is an important step forward, health systems will need more " support as we deal with the unprecedented challenge of this virus, including the cost of long-term poor health outcomes. The advantage rural America has had so far against Covid-19 is its head start on social distancing, an established way of life long before a significant crop of cases showed up in hotspots here and there.14 Consider the absence of mass transit across most of our region, an essential mode of transportation in many U.S. metro areas that puts asymptomatic Covid-19-positive people near others, with any number of shared surfaces. Contact tracing is also easier here. On any given day in South Dakota, we can generally count the number of people we came within six feet of on one or two hands. The steadiest stream of our hospitalized patients with Covid-19 can be traced back to those local meatpacking plants and long-term care facilities. The surge here so far looks more like a sequence of rolling rain clouds, rather than a single large and fast-moving tornado." The surge here so far looks more like a sequence of rolling rain clouds, rather than a single large and fast-moving tornado.15 But the emergence of a rural hotspot here must still be treated with all the urgency of frontline responders in New York City. Is a tornado coming our way, or is it just heavy rain and high winds? And if a health care tornado is coming, should we not factor in the price of universally restrictive responses that impede the lives and livelihood of people who are at lower risk of infection? Can we focus our tightest controls on high-risk groups, like the elderly and those with underlying health conditions who could potentially overcrowd our hospitals if they all became sick at the same time? There is still time here in the rural Midwest to get ahead of this, to find solutions to these and other pressing questions, including: • Do we have to broadly shut down all meat-packing facilities like Smithfield Foods -or can we creatively manage and control emerging hotspots while they stay open, through aggressive serial testing, antibody testing, and other best practices learned from hard-hit population centers?16 Before its closure, Smithfield Foods in Sioux Falls alone supplied nearly 130 million servings of food per week, or about 18 million servings per day, and employed 3,700 people.17 More than 550 independent family farmers in our region supply the plant. We need to figure out a way to keep these plants open while protecting lives. • Can we allow visitors back to nursing homes through a national, cohesive phased reopening plan? We need unified, consistent leadership at the federal level that provides definitive implementation guidance to states so families can begin to safely visit their loved ones again. There is a human cost to isolation. • Can we double down on protective measures in the workplace by providing ongoing testing, contact tracing, scrupulous sanitizing, and physical distancing so that millions can safely return to factories and offices long before a vaccine is developed and distributed? Forced poverty and unemployment threaten to shorten livelihoods, too. • Can we continue to ramp up telehealth services to counter patient anxiety about in-person visits, prevent further spread of illness for vulnerable populations like those who are immunocompromised, and focus on getting people healthier to avoid consequences down the road? Routine preventive health saves lives and dollars. • Can we accelerate research for treatments and vaccinations to give us successful solutions in months, not the years it took to conquer and contain polio? Twenty-first century biomedicine innovations should give us a considerable speed advantage over the polio years. This much seems certain at this juncture: We cannot eliminate Covid-19 in the short term on the prairie or in urban America.18 As communities tiptoe back into standard operations here, more cases surely will come our way. I believe Sanford Health is now ready. Using the experience of others and our own knowledge from H1N1 exercises back in 2009, we can accurately predict how many hospital admits we're going to have seven days out, how much PPE to have in stock, how many respirators will be needed, and where we go to quickly refresh those supplies and plans if needed. However, we can't lose sight of other social priorities that enrich and sustain people's lives at the low end of the risk spectrum. Will children in under-resourced but low-risk rural communities be able to make up for lost time in the classroom? How much longer will small business owners and their workers be able to keep doors open (with limited capacity) and still put food on their tables? Can we address the high end of risk while relaxing the low end? There is understandable impatience -from big cities to small farms and everywhere in between -to get back to normal." If we can determine precisely who has the virus through testing, trace their contacts, isolate the disease vectors, and quarantine those who have been directly exposed, we may be able to mitigate the spread of the virus in the weeks and months ahead.19 , 20 There is understandable impatiencefrom big cities to small farms and everywhere in between -to get back to normal. But the ubiquitous " wearing of masks and distancing in public places won't go away anytime soon until an effective vaccine is broadly available -certainly not soon enough to save summer 2020 or provide complete escape in the year ahead. That is the new normal. Until that liberating moment, we must live with the unknowns, constantly advancing our understanding of Covid-19, continuously refining our responses, and carefully guiding the patients in our care to safety as best we can as trained medical professionals, always keeping those most vulnerable sheltered from avoidable harm.21 latest map and case count. The New York Times COVID-19 now reaching into rural America Smithfield Foods in Sioux Falls reopening Facility location determines COVID outbreaks, researchers say Making sense of COVID-19 fatality rates. Star Tribune Some ironclad best medical practices tossed out the window in face of COVID-19's chaotic destruction. Kaiser Health News New York City coronavirus map and case count South Dakota coronavirus map and case count COVID-19) updates and information. South Dakota Department of Health South Dakota's 'flattened curve' is based on need for hospitalization. Keloland News Now some are dying of preventable illnesses. Argus Leader Eligibility for ACA Health Coverage Following Job Loss. Kaiser Family Foundation Small-town hospitals are closing just as coronavirus arrives in rural America. National Public Radio Social distancing a different phenomenon for rural Americans. Fox News Rural America is reopening for business, with COVID-19 largely still a distant threat. Chicago Tribune Meat processing plants across the US are closing due to the pandemic. Will consumers feel the impact? CNN Business Smithfield Foods closes plant after nearly 300 employees test positive for coronavirus Even finding a covid-19 vaccine won't be enough to end the pandemic. The Washington Post Progress on COVID-19 testing, treatments critical to resuming American life. PBS News Hour What is contact tracing and how can it stop the pandemic? National Public Radio video Leading with the unknowns in COVID-19 models Disclosures: Allison Suttle, MD, has nothing to disclose.